ML20134P891

Assessment of LaSalle County Nuclear Station

ML20134P891
Person / Time
Site:	LaSalle
Issue date:	02/18/1997
From:	Durham J, Fujimoto W, Sieber J COMMONWEALTH EDISON CO.
To:
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ML20134P886	List: ML20134P884 ML20134P891
References
NUDOCS 9702260157
Download: ML20134P891 (23)

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j An Assessment of LaSalle County Nuclear Station 1

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An Independent Self Assessment

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3 February 18,1997 9702260157 970218 PDR ADOCK 05000373 P

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Mr. Ilarold W. Keiser Vice President Chief Nuclear Operating Officer 14(X) Opus One, Suite 9(X)

Comed Company Downers Grove, Illinois 60515

Dear 11arry,

We are pleased to have completed your request for an independent assessment of the perfonnance at LaSalle Station. The results of our assessment are summarized in the enclosed report, and respond to your mquest that we identify the fundamental causes or " whys" that drove declining perfonnance.

We appreciate the spirit of openness, cooperation and interest shown by Comed personnel with whom we interacted during the course of the assessment. We acknowledge Comed management for steadfastly maintaining our independence and their commitment to critical self assessment.

'Ihe decision to subject LaSalle County Station and the Nuclear Operations Division to an independent self assessment is an aggressive and credible step toward your goal of achieving superior perfonnance. We believe that the aggressive actions you have begun will address the fundamental causes that our assessment identified. We wish you the utmost success in those efforts.

Sincerely, i

The Independent Self Assessment Team WM ukh dAMA.

Wanen Fujimot/ Leader liarry KistG

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6hn Durham Fred Dacimo

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b C. W.llendrix, Jr.

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1.0 INTRODUCTION

1.1 Obiective of Independent Self Assessment De Independent Self Assessment Team (ISAT) was assembled at the request of the Chief Nuclear Officer of the Comed Nuclear Operations Division (NOD). The Independent Self Assessment (ISA) was led by a core group of seven senior nuclear consultants extemal to the Comed organization, who were requested to conduct an independent assessment of perfonnance at LaSalle County Station (LaSalle). The assessment was intended to provide Comed management with an independent perspective on major perfonnance weaknesses, with particular emphasis on the fundamental causes of those weaknesses. He ISAT was also invited to provide insights conceming the effectiveness of ongoing and planned Caned initiatives to improve identified performance issues and to recommend post-assessment steps.

1.2 Methodolony and Standards for Assessment The ISAT assessed performance at LaSalle over the past two years in five functiond areas:

Operations and Training, Maintenance, Engineering and Technical Suppon, Plant Support, and Management and Organization. He ISAT's assessment process consisted of three phases.

In Phase 1, over a three week period, the core team perfomied a detailed review of existing perfonnance monitoring and assessment documentation. Rese documents included, but were not limited to, NRC inspections, evaluations, and Comed assessments, corrective action documents and perfomlant e improvement plans. We majority of the weaknesses described in this ISA report were identified in these documents.

In Phase 2, over a two week period, the ISAT verified the Phase 1-identified weaknesses based upm LaSalle observations, interviews and further document reviews. De core team members j

were augmented by INPO and industry peers in connection with the Phase 2 work.

In Phase 3, over a two week period, utilizing the results of Phases I and 2, associated causal factors for LaSalle weaknesses in four functional areas (operations, maintenance, engineering and plant support) wem documented by the core team (Attachment A). A set of fundamental j

causes was then developed for the assessment of management and organization.

As the assessment prucceded, the IS AT determined that it would deliver maximum value by concentrating on the performance weaknesses and the underlying causes. The ISAT's emphasis was phteed on problem definition and identification of fundamental causes, rather than corrective actions. Consequently, the ISAT did not focus upon the effectiveness of ongoing and planned improvement initiatives. The ISAT acknowledges that many corrective actions were in the process of being developed, and some have aheady been implemented, to address LaSalle weaknesses.

he ISAT did not conduct detailed assessments of the perfonnance of the oversight and l

assessment functions within the Comed nuclear organization, nor did it assess the perfonnance of the regulatory assurance functions at LaSalle. In the context ofits integrated review of management and organization, the ISAT examined the end results and effects of the Comed oversight and assessment functions. Those end results and effects are described in the Fundamental Cause Assessment in Section 3 of this repon.

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t The IS ATs standard for assessment of performance reflected its collective experience and was intended to represent the perfonnance of a best-perfonning plant. Unless otherwise stated, this standard applied to all phases of the ISA. The ISAT focused on the end results of NOD decisions. The ISAT did not attempt to define the specific actions that Comed management should take to assure safety, regulatory compliance or best-performance.

The ISAT did not reevaluate Comed's historical decision making processes or the conditions under which decisions were made. The ISAT placed emphasis on communication of observations and causal factors to assist Comed in understanding and accelerating its effons to resolve the issues which are critical to achieve and sustain excellent performance at LaSalle.

1.3 Assessment Team Membership and Composition The core members of the IS AT and their respective assessment responsibilities and backgrounds are:

Member Assessment Resnonsibility Backcround Warren Fujimoto Team Leader and Fonner Vice President Management and Pacific Gas & Electric Co.

Organization Diablo Canyon 28 years nuclear power experience liarry Kister Management and Former USNRC, Region I,111 and Organization Headquarters I&E 36 yean nuclear power experience Jolm Durham, P.E.

Engineering and Technical Former Engineering ManagerImpell Support Corp.; Carolina Power & Light 23 years nuclear power experience Dr. Benjamin Dow Engineering and Tecimical -

Former Manager Nuclear Service.

Suppon Attansas Power & Light 23 years nuclear power experience C.W. Hendrix, Jr.

Maintenance Duke Engineering Services, Manager of Maintenance Engineering Services 25 years nuclear power experience Fred Dacimo Operations Former Operations Vice President, Nonheast Utilities 20 years nuclear power experience John Sieber Plant Suppon Former Senior Vice President and Chief Nuclear Officer, Duquesne Light Company 36 years nuclear power experience I

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The core ISAT members were augmented by INPO evaluators and industry peers, as follows:

AugrEDted Team Personnel Assessment Resoonsibility Oreanizational AffiljaliOD L. Thibault Management & Organization INPO Gary Peet Operations INPO Joe Kappes Maintenance INPO John Maciejewski Engineering INPO l

Paul DiRito Operations INPO

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William Garrett Operations APS - Palo Verde John Petrilla Operations PP&L - Susquehanna Dan Bost Engineering Entergy-Grand Gulf Charles Grider Maintenance TVA - Sequoyah i

Dave Barcomb Radiation Protection Niagra Mohawk - Nine Mile Point 2 De ISAT received support from Jim Abel, JoEllen Bums, and Jim Gieseker of Comed, who served as liaisons to the line organization and were instrumental in gaining prompt access to infonnation,(k)cuments and individuals.

2.0 FUNCTIONAL AREA CAUSAL FACTORS l

The ISAT's supporting observations and causal factors for operations, maintenance, engineering and plant support are summarized below.

2.1 Operations and Traininn j

The IS AT found that important attributes of operational excellence were not evident at LaSalle.

The organization was not focused on the vision of best-perfonnance and did not have an understanding of, and a commitment to, the principle that strong economic perfonnance must be driven by operational excellence. The IS AT observed a gap in management and bargaining unit relations, which was reflected in a lack of bargaining unit buy in to management expectations and operational excellence. A lack of teamwork has resulted from management tumover, limited worker input to change management, and incomplete worker buy in to the success of the

. plant. Operations management has not functioned as the gatekeeper for safe operation and nuclear excellence. In the aggregate, the operations department trainir g performance deficiencies, particularly those observed in simulator scenarios, led the ISAT to question j

operating shift crew capability. The ISAT understands that LaSalle management has been woiing to resolve the idendfied deficiencies. The ISAT and LaSalle management agree that the identified training deficiencies need to be resolved prior to restart of the units.

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2.2 Maintenance l

Large work backlogs, poor materiel condition and low system and equipment availability and reliability have resulted from issues related to the work control process, perfonnance standards, i

management expectations, first line supervisor involvement, team pmblem solving and the maintenance training program. Changes to the work control system to address the dual unit outage, Operations 1996 Plan (OP96) and emergent engineering work were not effectively implemented. Management has not provided the leadership to enforce schedule accountability and establish schedule control. A comprehensive set of maintenance perfbrmance metrics, rion&laheam%exotm2.&dPg. 3 l

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i which monitor long-term perfonnance attributes as well as production, have not been developed.

First line supervisors have not been utilized as primary agents for affecting change. First line supervisors have not maintained a presence in the field and have not held themselves or dieir l

peers accountable. Involvement of workers in problem solving and a common worker and supervisor vision were not evident. Management and the bargaining unit have not worked as a team to resolve long-standing issues that hinder maintenance department improvement.

Training has not been utilized as an effective change mechanism and a means to obtain long-term benefits.

2.3 Ennineerinn hnd Technical Suonort Engineering has not effectively addressed long-temi engineering issues involving configuration management, design and licensing basis, engineering work quality, system engineering, engineering work management and system and equipment performance. Long-standing engineering issues have apparently not been given enough priority by LaSalle and corp) rate management to alk)cate the resources necessary to resolve these issues. Primary examples are the failures to develop, make available and assum compliance with essential design basis documentation; to maintain configuration documentation current; and to upgrade setpoint calculations to account for instrument loop uncertainty, These examples, along with the large number of unauthorized design changes that have been implemented, indicate that the LaSalle engineering organization has not been effective as the design authority and technical conscience of the station. Engineering work has not always been timely, thorough and technically correct.

Engineering has not applied the resources, experienced personnel, training, and woddoad prioritization to effectively implement the system engineering function. Engineering backlogs have not been completely identified, consistently prioritized or evaluated. Engineering has not been effective in resolving long-standing materiel condition and recurring equipment problems.

Wis led the team to conclude that LaSalle management needs to continue to examine the depth and breadth of these issues and to take corrective actions in onler to provide additional assurance that the LaSalle units can be safely operated within their design and licensing bases.

2.4 Plant Suonort 1

I Plant support organizations, which consist of radiation protection, chemistry, emergency planning, fire protection, and security, have generally performed their assigned responsibilities l

adequately. Weaknesses were noted in the areas of worker radiation exposure, contaminated plant areas, meteorological tower configuration and fire protection materiel condition.

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l 3.0 FUNDAMENTAL CAUSE ASSESSMENT-MANAGEMENT AND ORGANIZATION Ugm completion of the Phase 1 and 2 reviews, the ISAT team performed a review of the causal factors for operations, maintenance, engineering and plant suppoit and conducted a fundamental cause assessment for the management and organization functional area. His collective review identified four fundamental causes that were evident from the analysis of causal factors: commitment to excellence, leadership, standards, and management skills. Under each of the fundamental causes, the core team identified a set of contributing causes. The fundamental and contributing causes are stated below.

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4 3.1 Commitnwnt to Excellence Comed has not consistently maintained focus on the vision of world class perfonnance and a commitment to the principle that strong economic performance must be driven by excellence in nuclear operations and uncompromising safety. He following factors contributed to this fundamental cause:

There has not been sufficient and consistent appreciation of the resources needed to achieve and sustain long-tem 1, best-plant perfomiance. Acre has been an overemphasis on budget control which has resulted in decisions that have hindered or climinated important improvement projects.

The organization has not continually pursued a safety culture ahead of production and budgets. Production and budget incentives appear to drive the organization.

3.2 Leadershin Senior management has not consistently provided the leadership to achieve excellence in nuclear operations and safety. The following factors contributed to this furxiamental cause:

Leadenhip has not always fostered an environment that promoted high standants, shared values, personnel accountability and conservative decision making.

Impmvement initiatives have not resulted in sustained perfonnance improvements and e

management has not been held accountable for results.

Accountability has not been consistently understood, practiced or enforced. Accountability often appears to mean discipline to the organization. To many employees, accountability is perceived as punishment rather than coaching and conununicating high standards and expectations.

Training programs have not routinely been viewed as a means to effect change and obtain results. There has been a lack of appreciation for the benefits that training provides.

Training has not been continuously evaluated and updated.

Leadenhip has not always been able to gain bargaining unit onership and commitment to nuclear excellence.

3.3 Standards Senior NOD and LaSalle management have not established consistently high standards of performance for LaSalle and NOD. Standards have been accepted by management that result in a tolerance of deficient conditions and nonconservative decisions. The following factors contributed to this fundamental cause:

Corrective actions have at times been slow, narrowly focused, deferred or incorrectly prioritized to resolve important process, materiel condition and configuration management

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Engineering has not mutinely been considered as a high priority function for the safe and

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reliable operation of the station, and themfom, resoumes have not been pmvided to correct long-standing issues.

Operations leadership has not exemplified and promulgated high standards by their tolerance of long-standing materiel condition and configuration managenient issues at LaSalle.

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3.4 Man =;.wi.t Skills l

The nuclear organization did not have the required management skills to impmve substandard l

perfonnance, to monitor and continue improvement efforts and to implement sound oversight programs. Senior management did not have a good understanding of the significance and depth of issues at LaSalle. The following contributed to this fundamental cause:

a Nuclear oversigl t organizations have not effectively evaluated the available infonnation on plant performance and therefore have not successfully influenced constructive management actions forimproved performance.

1 The budgeting prioritization process has not supported activites for improving station j

perfonnance. LaSalle was given an annual budget amount to plan work for the year, rather l

than planning the work for the year and then acquiring the necessary funds.

i Lessons leamed were fmquently not communicated, implemented and monitomd within the e

nuclear organization.

Numerous personnel changes have contributed to instability and distrust, which has hirxlered upward communication and delayed resolution of important issues. As a result, personnel changes have often not resulted in perfonnance improvement.

Management personnel selection did not always match a candidate's skills and experience with existing station perfonnance issues.

Change management has been more like a trial and ermr process rather than a process which is planned, implemented, evaluated and adjusted, as necesnry. There has been a lack of understanding of what it takes to effect change, including the buy in of personnel.

4.0 CONCLUSION

This report provides a brief summary of the ISATs findings. The ISAT's intent is to provide sufficient detail in its description of the fundamental cause assessment and the functional area causal factors (Attachment A) so that Comed management can formulate responsive and effective remedial acti(ms.

The IS AT acknowledges the excellent cooperation it received fmm all elements of the Comed organization. In addition, the IS AT mcognizes Comed management for understanding the need for an independent self-assessment, maintaining the independence of the Independent Self Assessment (ISA) and sustaining their commitment to the pursuit of vigorous self criticism.

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ATTACHMENT A LASALLE INDEPENDENT SELF ASSESSMENT CAUSAL FACTOR

SUMMARY

2.0 FUNCTIONAL AREA CAUSAL FACTORS The following discussion summarizes the causal factors derived by the ISAT for each of the functional amas of operations, maintenance, engineering, and plant suppon. As indicated in Section 1.2 of the ISA i

mport, the IS AT's standard for assessment of performance reflected its collective experience and was intended to represent the perfomlance of a best-performing plant. The ISAT's documentation review was generally focused upon the past two years and its observations were of current perfonnance. The ISAT did not reevaluate Comed's historical decision making pmcess or the conditions under which decisions were made. In addition, the ISAT was directed by Comed management to identify issues and make critical observations using a low evidentiary threshold. In other words, Comed management did not expect the ISAT to definitively demonstrate the existence, frequency or breadth of a particular problem. Instead, when the IS AT's observation and experience indicated the likely existence of a particular problem, it was expected to identify that problem so that Comed management could take appropriate action.

2.1 Operations and Trainine The IS AT review of LaSalle operations addressed seven major amas of concem. The findings describe in broad terms "what is missing" or "wht.t prevents" LaSalle from becoming a best-performing plant. Causal factors for each of th seven areas are provided below.

j 2.1.1 Operational Excellence The attributes utilized for assessment of operational excellence are the following:

Good procedum quality Strong procedural adherence Sound communication techniques Solid self-checking programs Positive operator bearing with a questioning attitude e

Conservative decision making e

Good use and acceptance of supervisory oversight Technical competence and attention to detail During the ISAT visit to LaSalle numerous algns and posters were observed which addressed being " committed to excellence" of which operational excellence is an integral pan. 'Ihis was considemd a visible sign of management's commitment to excellence and a continual reminder to employees of management's philosophy.

When individuals in operations were specifically questioned if they were personally committed to " excellence", their answer was almost invariably "yes". When funher questioned however, few individuals did a reasonable job ofidentifying any of the aforementioned eight attributes of operational excellence. Additionally, there was little recognition as to how an individual could contribute to improving operations' performance.

In fact, personnel stated that they believed previous management was not committed to operational excellence. Long-standing materiel condition issues were frequently cited to suppon this belief.

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2.1.1.1 Causal Factors Individuals interviewed by the ISAT did not recognize that a bedrock e

commitment to operational excellence and nuclear safety results in long-tenn economic performance. 'Ihese individuals also did not understand that the best perfonning plants were usually the most cost-competitive. Little recognition existed of the INPO study reganling this subject.

LaSalle was previously recognized as having sound performance. LaSalle previously had an INPO 1 rating as well as SALP 1 ratings in a number of areas.

Very few individuals recognized that comparative industry perfonnance had improved dramatically. Discussions with individuals indicated that plant and personnel performance had not really changed for several years. Complacency and acceptance of the status quo seems to have occurred and contributed to LaSalle's declining perfonnance and commitment to excellence.

Many individuals did not recognize that most of the operations manager's standards simply represented current industry norms.

2.1.2 Gan Between Mananers and Harcainine Unit As previously identified, the ISAT also determined that bargaining unit and management issues and relations require additional attention. Management and bargaining unit personnel did not appear to realize that LaSalle's success requires an interdependence of action; one gmup cannot succeed without the other. A philosophy of"we are all in this together" does not exist.

'Ihe gap between management and the bargaining unit is a significant issue confronting LaSalle.

The IS AT is not aware of a nuclear station that has achieved high levels of perfonnance without a fully engaged workforce. At LaSalle, management has pointed to the bargaining unit as the source of declining performance while the bargaining unit has pointed to management.

Both sides have not taken responsibility to resolve their differences.

2.1.2.1 Causal Factors Poor communications exist. Issues have not been completely shared.

expectations have not been continuously reinforced and communication has not been fostered.

'There was a perception of hidden agendas on the part of management and on the part of the bargaining unit. Full disclosure of the " whys" of actions taken does not always appear to exist.

A high degree of mistmst exists between management and the bargaining unit. In some cases the bargaining unit does not tmst or believe management, and management does not appear to trust the motives of the bargaining unit in certain instances.

1 High tumover in management has frequently occuntd. There has been over a 100 %

I tumover in the station's middle and upper management levels over the last three years. This tumover has caused a lack of continuity in policy and direction in the operations

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l First line supervision is not fully knowledgeable about the bargaining unit contract and agmements. The contact knowledge of higher level managers wa:;

l not assessed 2.1.3 1.ack of Teamwork hem is a lack of teamwork at LaSalle. Few groups and organizations work together effectively. Each group or individual appears to view issues on an individual basis and do not endeavor to ensure team success. It appears that teamwork issues exist within the shift organizations.

2.1.3.1 Causal Factors here have been multiple changes in the management team and little continuity e

exists. His has resulted in an atmosphere of uncertainty and mistrust which has hampered teamwork.

j Some manager and supervisor interpersonal skill deficiencies which impact teamwork were observed.

Workers have a "me first" attitude which is detrimental to teamwork. In some instances they seem to be mom interested in the personal impact of change than the positive effect it may have on station operations. His is not conducive to j

teamwork.

2.1.4 Shift Manacer Performance Shift managers have not set the standards for the station. They have not functioned as the

" gatekeepers" for safe operation and nuclear excellence.

2.1.4.1 Causal Factors Shift managers have not felt empowered to make changes or to hold individuals e

to high standards.

Shift managers are not always viewed or treated as managers by the station management team.

Insufficient fonnal training and development has been provided to prepare shift managers forleadership roles.

Discussions with senior management at LaSalle indicated that the capability to operate at a higher performance level may be beyond the ability of some shift managers.

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v 2.1.5 Deficient Trainine in the aggregate, the operations department training deficiencies have led the ISAT to question cmw capabilities. The ISAT understands that management will promptly resolve these deficiencies.

r Training is not used as a tool to upgrade station performance. Training is viewed only as a license requirement.

2.1.5.1 Causal Factors Tmining is not recognized as a vehicle to make change. Most operations management personnel have not taken a personal interest in the training prugran.

Instructor proficiency appears to be a deficiency. Objectives wem not adhered to e

or covered on a regular basis and in some cases there was a poor understanding of simulator scenarios.

Simulator fidelity concems may impact training effectiveness.

i Operations standards were inadquately enforced. For example, substandard e

critiques and untimely class attendance were observed. An uncooperative atmosphere was observed between instructors and shift personnel.

2.1.6 Inadeauate Channe Mananement Skills Operations management does not fully appreciate the complexity of change management. Therc is not a complete understanding that the organization can only accept so much change before confusion occurs. Message repetition, along with demonstrated actions by management to 1

" walk the talk", has not consistently occurred.

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Communications are in ' bquate at nearly all levels. Managers do not appear to 4

take ownership and charopion policies and issues.

inadequate follow through of previous improvement initiatives has resulted in the e

perception and attitude that certain changes will eventually go away.

1 Early and consistent buy in by operators has not been sought to foster a change O

e message and develop change champions.

4 Change is not effectively implemented. Workers' input has not always been e

solicited or included in some new and ongoing change improvement pmgrams.

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The large number of management and policy changes have overwhelmed the operations organization.

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2.1.7 Lack of Understandine of Accountability A lack of understanding exists for what accountability means. When discussed with managers, nearly all defined accountability as discipline. The elements of coaching, counseling and ownership are rarely addressed. The lack of accountability was evident during ISAT observations of day-to-day operations.

2.1.7.1 Causal Factors Many employees do not have the benefit of bmader industry experience and perspectives. Operations personnel have not interacted with role models that demonstrate the philosophy of personal, team and departmental accountability.

Individuals and supervision find it difficult to confront each other in connection with weak performance; thus many opportunities to practice accountability are missed.

I 2.2 MAINTENANCE During the assessment of the maintenance function five issues were raised which are impacting LaSalle's ability to identify, prioritize, plan, schedule and execute wort Rese issues have resulted in large work backlogs, poor materiel condition and low system and equipment availability and reliability. These issues involve substandard performance in die following j

areas:

Work contml process Perfonnance standards and management expectations e

First line supervisor field involvement e

Teamwork and accountability Maintenance training program These major concems, along with significant subtier issues, are discussed in detail below.

2.2.1 Work Control Process The work control process at LaSalle does not support the efficient identification, prioritization and execution of work. Three major concerns exist:

A firm scope control plan has not been implemented to deal with the large volume of work ackled to both unit outage schedules.

Interface problems between the workers and the work analysts delay many jobs.

Station leadership and direction of the overall work management pmcess have not supported scheduling and coordination of work during a two unit outage.

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2.2.1.1 Causal Factors L

LaSalle management has not provided the leadership required to force schedule accountability for all personnel. Implementation of changes to the work contml l

process to address the dual unit outage, OP96 plan and emergent engineering was weak. Management did not pmvide the initial direction or adequately monitor implementation. Station personnel were not held accountable for making the system work. 'The current dual unit outage coupled with the significant amount of emerging engineering work has overloaded the system.

A The station has not decided to operate as a schedule controlled business unit. The e

organization is in place and de workforce is willing to work a schedule.

Schedule control, however, has not been established and the msultant default mode is to allow first line supervisors to select work independent of the published station schedule.

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2.2.2 Performance Standards and Mananement Expectations Management has not developed a comprehensive set of maintenance performance metrics which reflect current industry practices. Some standards do exist; however, these have not been communicated to first line supervisors and workers in the form of consistently enforced

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expectations. The lack of a comprehensive set of perfonnance measums has inndered the establistunent ofimprovement goals and action plans. Without perfonnance measures progress cannot be monitored.

2.2.2.1 Causal Factors Management emphasis has been focused on short term pnxiuction. The performance indicator of importance was the short-tenn availability of the unit.

Indicato s of high quality maintenance supporting long-tenn perfonnance such as y

Iow work backlogs, low rework, training program compliance, materiel condition impmvement and staff professionalism were not emphasized. Maintenance management was not held accountable for developing or implementing standants in these areas.

2.2.3 First Line Supervisor Field involvemerit First line supervisor presence in the field is not sufficient to ensure that job perfonnance meets management expectations. Supervisors are a key ingredient in promoting change. Because they am not in the field. they are not involved in coaching, quality checking, on-the-job training (OJT) and providing technical resources required to improve maintenance department perfomlance. They are not available to help set and communicate management expectations.

2.2.3.1 Causal Factors Management has not recognized the key role that first line supervision plays in implementing the changes requimd to improve performance. Maintenance management has not established nor supported an expectation for increasing the field involvement of the supervisors. Steps have not been taken to address those problems that prevent field involvement. Problems such as work package quality and scheduling kept supcivisors out of the field.

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Supervisors have not held themselves or their peers accountable for doing their jobs. Supervisors have been content to simply do the work analysts' job rather than hold them accountable for providing a high quality product.

2.2.4 Teamwork and Accountability

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he maintenance management philosophy at LaSalle does not promote team problem solving.

De philosophy has been to direct work from the top dcwn involvement of the workers in identification and resolution ofissues has not been encouragea. Maintenance does not always address important issues as an integrated worker, supervision ano management team with the recognition that a common vision is a prerequisite for success.

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-2.2.4.1 Causal Factors Bargaining unit and maintenance management have not recognized that in order i

to succeed they must woi as a team to identify and resolve problems. Bere is a top down philosophy for problem identification and resolution at LaSalle.

i Maintenance department management and first line supervisors do not always appropriately involve bargaining unit personnel in the identification and resolution process.

Here has been a reluctance on the part of management to involve workers in developing solutions. Many managers may be uncomfonable allowing workers the freedom to solve problems themselves.

He bargaining m1it has been reluctant to fully engage the workforce in taking ownership for problem resolution. His is due to the lack of tmst between workers and management resulting in part fmm the many programs-of-the-I month, the high tumover in management and the reluctance on the pan of some employees to change.

He bargaining unit works to protect traditional bargaining unit contract positions and precedents regardless of their impact on maintenance department perfonnance. Maintenance management and the bargaining unit have not behaved as if they have a common vision for identification and resolution of problems. Taking personal responsibility for resolving problems has not been encouraged by maintenance depanment management and bargaining unit leadership.

2.2.5 Maintenance Trainine Pronram he current training program does not fully support the development and continuing

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improvement of the maintenance woiforce. First line supervision and workers do not own this program. It was recognized that the pmgram was not meeting the depanment's needs yet no actions were taken. The ineffectiveness of the maintenance training progmm contributed to the high levels of rework and work backlogs.

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2.2.5.1 Causal Factors s-i Le Management did not take full advantage of the long-tenn benefits of an effective j.

training program. He focus was on those areas that promoted shon-tenn availability at minimum costs.

Training was seen only as a minimum mquirement to meet regulatory obligations.

Management has not made a conunitment to make resources available regardless e

of competing needs. Long-term benefits were sacrificed for short-term budget i

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2.3 ENGINEERING AND TECHNICAL SUPPORT i

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4 he engineering organization was assessed to determine its performance as the design audiority arxl technical conscience of LaSalle. Also assessed was the ability of the engineering i

. organization to provide high quality and responsive engineering and technical support to die other organizations.

e he ISAT confinned that the performance of LaSalle engineering is significantly below that of best-performing plants. Engineering has not been effective as the design authority and technical conscience of LaSalle and has not always provided high quality and responsive engineering support to other LaSalle organizations. It was found that engineering is primarily focused on msolving short-tenn and emerging issues. Engineering has not effectively addessed long-tenn engineering issues involving configumtion management, design basis and equipment perfonnance. He resources needed to establish and sustain good engineering perfonnance have not been applied. De following areas were found to be in need ofimprovement:

i Configuration management e

Design andlicensing basis e

Engineering work quality.

e System engineering i

Engineering work management e

System and equipment performance Deliciencies in each of these areas have been identified previously, were validated in this assessment and have continued to recur for a number of years. Dere are several reasons for this.

Past leadership of the engineering organization has not been effective in establishing, communicating, supporting, monitoring and enforcing high standards of performance. Low standards of performance have been tolerated in that deficient conditions and less than adequate work have been accepted. Corporate and LeSalle engineering management have not provided the direction, focus and coaching needed for ti.e staff to be successful. Compounding the lack of success has been the large tumover of management, supervision and group leaders within the engineering organization.

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.Most important is the fact that corporate and LaSalle engineering leadeiship have not effectively championed engineering issues within the Comed organization. Long-standing engineering issues have apparendy not been given enough priority by LaSalle and corporate management to allocate the necessary resources _ to resolve these issues. Primary examples are the failures to develop essential design basis documentation (DBD); to assure compliance with the design and licensing basis; to maintain configuration documentation current; and ta upgrade setpoint calculations to account for instrument loop uncertainty. These examples, along with the large number of unauthorized design changes implemented through work requests, indicate that the LaSalle engineering organization has not been effective as the design authority and technical conscience of the station.

7his led the ISAT to conclude that LaSalle management needs to continue to examine the depth and breadth of these issues in order to provide reasonable assurance that the LaSalle units can be safely operated within their design and licensing bases.

Related causal factors for each of these areas are discussed below.

2.3.1 Confinurat on Management Configuration management deficiencies have occurred where the design change process has been circumvented and important configuration documentation has not been revised to be current with the as built plant.

2.3.1.1 Causal Factors Actions had not been taken to establish and maintain a sound configuration management program at LaSalle. Low standards and long-standing ' eficiencies d

had been tolerated due to the inability to obtain the requisite funding necessary to tesolve known and long-staruling deficiencies.

1 Corporate and station management had appaiently not known about or e

understood the significance and the depth of the aforementioned configuration management issues. Engineering management has not been an effective i

organizational champion for engineering issues and has not " driven home" the

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need to address these issues in a timely and complete fashion.

LaSalle organizations did not understand or embrace the importance of e

maintaining configuration management and prohibiting unauthorized changes to plant. design no matter how minor the changes may have seemed. Additionally, other organizations had been complicit in the configuration management issues in that they tolerated deficiencies for a significant period of time even though their work had been adversely impacted (e.g., incorrect instrument data sheets and air system P&lDs).

2.3.2 Desien and Licensine Basis Design and licensing basis information is not always accessible, defined or documented, j

maintained consistent and current, or understood and implemented in LaSalle activities.

j Engineering personnel have not consistently assured that the as built and as operated plant is within the design and licensing basis.

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i 2.3.2.1 Causal Factors Funding has not been pmvided to define, develop and validate the plant design basis, to develop cormct setpoint calculations, and to resolve known instrument documentation deficiencies.

4 Engineering management has not e.ffectively served as an organizational champion for engineering issues and " driven home" the need to address these

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issues in a timely and complete fashion.

Station organizations have not understood the importance of making available and maintaining accurate and consistent design basis infomiation to suppon essential station activities. Thus, these issues have not received the requisite funding and attention needed to resolve them.

2.3.3 Ennineerine Work Ouality Engineering wodc has not always been timely, thomugh and technically correct.

2.3.3.1 Causal Factors Them has been a significant amount of emerging work from L2R07 and LIF035 that has requimd design change packages (DCPs) to be developed on short notice.

Also, the move to pmvide engineering in-house in the 1994-1995 period has not been effective. Resources from the primary architect engineer were significantly mduced during the time period when DCPs for L1R07 and other LlR07 outage activities were in preparation. It was believed by those interviewed that this reduction did not allow adequate time to properly prepare for LIR07 and L2R07 and contributed to DCP quality problems.

A stmng production focus has contributed to less than rigorous and incomplete engineering and safety evaluations. Also, the lack of concise, complete and consistent design basis infonnation has been a contributing factor.

The failure to conduct proper testing appeals to be due to a lack of knowledge of correct testing methods and how to correctly interpret test results.

2.3.4 System Engineerinn The system engineering function has not been effectively implemented. System engineers have not been requimd to determine system design, operational and testing requimments and perfonn requisite monitoring and tmnding to assure that these requirements are met.

2.3.4.1 Causal Factors The mies and responsibilities of system engineers have not been effectively communicated, supponed and enforced by management. System engineering is engaged in nonsystem engineering activities such as work package preparation, initial troubleshooting, procedure preparation and coordination of field activities.

System engineering has been expected by other station organizations to perfonn nonsystem engineering duties.

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System engineering hetivities are not managed to allow fulfillment of a pmactive e

system engineering function. System engineer workload is not always priontized.

Additionally there are an insufficient number of system engineers to effectively implement the system enginecdng function.

2.3.5 Eneineerine Work Mananement Engineering is not effectively managing their workload. Engineering backlogs are not completely identified, consistently prioritized, or evaluated. The impact of the engineering backlog on system readiness is unknown. Long-tenn engineering issues are not being resolved.

2.3.5.1 Causal Factors The engineering organization has failed to effectively prioritize work for the engineering group. A lack of an effective system for the prioritization of workload dilutes the ability of the engincedng staff to resolve important tecimical issues. Problems with the lack of an effective work prioritization process were identified as early as 1993 in the LaSalle Business Development Report.

De engineering organization has not established an effective workforce management pmcess. Engineering management has not effectively established.

communicated, supported, monitomd, and enforced high expectations and standards and the correct roles and responsibilities for the engineering organization.

Management has historically established an excessively high thmshold for issues needing resolution which has thwaited efforts by system engineers to pmactively pursue and resolve many issues.

Frequent tumover in engineenng management, supervision and group leads has been a major contributor to long-tenn engineering and materiel condition issues not being resolved.

2.3.6 System and Eauipment Performance Engineering has not been effective in resolving long-standing materiel condition and recurring equipment problems at LaSalle.

2.3.6.1 Causal Factors Station and engincedng management have tolerated low standards of e

performance.

Industry operating experience has not been effectively reviewed, evaluated and implemented to resolve equipment problems.

The prioritization process used to establish the budget has had too high a threshold to address needed improvements. His leads station personnel to accept and tolerate deficient conditions that have been identified for correction but not funded.

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• Until 1996, there does not appear to have been a coordinated effort among station organizations to identify materiel condition items that needed correction.

i 2.4 PLANT SUPPORT J

j-Plant support consists of radiation protection, chemistry, emergency planning, fire pmtection, i

and security. At LaSalle, plant materiel condition and housekeeping present challenges to the

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quality of the radiation protection program and the fire pmtection program. 'Ihe radiation protection pmgram is also impacted by the poor practices of woders doing work within the radiologically posted area (RPA). All plant support functions are adversely impacted by the failure of management to prioritize and allocate the resources necessary to maintain high perfonnance in the plant support areas. Notwithstanding these adverse factors, the plant support functions have generally perfonned their assigned responsibilities adequately.

2.4.1 Radiatmn Protection 2.4.1.1 ~

Worker Radiation Exnosure 2.4.1.1.1 Causal Factors The causes of this higher level of worker radiation exposure are as follows:

I The radiation source tenn in the plant is higher than the industry median. About e

324 " hot spots" exist in the plant, of which about 72 are significant contributors to worker dose. Additional effort needs to be put toward reducing or eliminating these hot spots.

In addition, the cobalt reduction program, while initially making progress, has been slowed to the point that little progress is being made.

Finally, the use of depleted zine that has been effective in reducing source tenn at other boiling water reactors (BWRs), was inordinately delayed at LaSalle.

• Radiation worker practices are below median industry standards. Numerous examples show that radiation wo&er practices need improvement. Some ' workers may not fully appreciate the value of good radiation woiter practices in reducing individual exposure and contamination, preventing the spread of contamination and minimizing radwaste. Insufficient radiation worker training appears to contribute to improper radiation worker practices.- Additionally, managers and supervisons either do not recognize poor radiation work practices, or do not correct the ones they observe. More importantly, radiation protection technicians do not consistently use the PlF process to document, track and investigate poor -

radiation woder practices. Radiation protection supervisors are not holding the radiation protection technicians accountable for using the PIF process.

Conduct of maintenance contributes to the higher worker exposure at LaSalle.

Analysis of ALARA exposure records indicates that emergent work is a major contributor to the failure to achieve ALARA goals. While it is expected that unplanned emergent work will add dose to total worker exposure, the degree of l

emergent woi unde. mines the dose goal setting process, thus reducing the 1

i effectiveness of tly, ALARA process. In addition, emergent woi places an I

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,. 2 added burden on the radiation protection department to hurriedly prepare an ALARA analysis that might not be as effective as an analysis that was prepared 4

in ample time before the actual perfomlance of the job. Further, repeat work and rework unnecessarily add to worker exposure.

2.4.1.2 Contaminated plant area.

2.4.1.2.1 Causal Factors l

Relatively higherlevels of radioactive contamination are caused by poor materiel condition of LaSalle equipment.- This condition is caused by low standards as to what constitutes an acceptable condition of piping and components, mid a maintenance pmgram which appears unable to achieve leak tight conditions of plant systems.

2.4.1.3 Performance indicators and Henchmarkine.

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2.4.1.3.1 Causal Factors A lack of meaningful management perfonnance indicators and benchmardng at LaSalle contributes to management's inability to fully appreciate the extent to which corrective actions must be applied to become a best-perfonning plant. The development of extensive perfomiance indicators to assist in managing these areas was not considered necessary.

2.4.2 Chemistry l

i The chemistry laboratory, including the analytical equipment, techniques, quality control and expertise to perform accurate and consistent analysis has demonstrated good perfonnance.

1 2.4.2.1 Accelerated corrosion of ninine and eauipment.

The station has experienced accelerated cormsion and other problems amenable to chemical treatment. Elements of the chemistry program important to the pmtection of LaSalle systems and equipment are missing or have not been established in a timely manner. This has allowed equipment and systems to be damaged through corrosion and caused other undesimble conditions such as higher radiation levels.

l 2.4.2.1.1 Causal Factors This failure to establish proper treatment programs in a timely manner was caused by an initial failure to appreciate that accelerated corrosion could occur, and a lack of aggressive treatment once this condition was recognized.

2.4.2.2 Technical knowledee of the chemistry department has not been fully achieved.

2.4.2.2.1 Causal Factors Historically, the chemistry department at LaSalle received technical guidance from the corporate chemistry department. It was accepted that the transfer of technical knowledge would be thmugh the corporate chemistry interface.

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o o l 2.4.3 Emernency Plannine Except as noted below, the areas examined during this assessment in emergency planning at l

LaSalle appear to be satisfactory, l

2.4.3.1 Operations Sunnort Center 1

2.4.3.1.1 Causal Factors Emergency planning personnel have provided an altemate location for the OSC but the altemate location also does not take into account the consequences of a significant release of airbome radioactivity during an emergency. Emergency planning personnel are reluctant to identify and equip another altemate OSC location to prepare for the contingency of an emergency concurrent with a major release because all other available shielded, filtered locations have some other undesirable attributes.

l 2.4.3.2 Meteorolonical Tower 2.4.3.2.1 Causal Factor his reluctance to correct the nonconforming condition of the ten meter j

meteomlogical tower instruments appears to have been caused by a lack of i

priority, acceptance oflow standards and a lack of aggressiveness in resolving this issue.

l 2.4.4 Fire Protection 2.4.4.1 Materiel Condition of Fire Protection Eauipment i

2.4.4.1.1 Causal Factor Fire protection equipment has a lower priority than station equipment used to l

l produce electrical power.

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2.4.4.2 Fire Protection Program Human Performance Deficiencies 2.4.4.2.1 Causal Factors De following facton; appear to dominate the human perfonnance deficiencies in the fire protection program.

Rere have been insufficient communications to employees on specific tim I

protection requirennnts. The roles and responsibilities of individuals accountable l

for various aspects ollhe fire protection program are not well defined and understo(xi.

• Inattention to detail.

Carelessness during the performance of" hot work."

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The station (k>es not assign a high priority to fire protection issues.

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The station has low performance standards for the station staff and for station equipment.

2.4.5 Security There were no strengths or significant problems found during the assessment of station security.

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