ML20135B810
| ML20135B810 | |
| Person / Time | |
|---|---|
| Site: | Crystal River  |
| Issue date: | 11/22/1996 |
| From: | Beard P FLORIDA POWER CORP. |
| To: | |
| Shared Package | |
| ML20135B807 | List: |
| References | |
| PROC-961122, NUDOCS 9612060050 | |
| Download: ML20135B810 (60) | |
Text
I 1
j e
e MANAGEMENT CORRECTIVE ACTION PLAN i
PHASE II Statement from P. M. Beard, Jr.
to Nuclear Operations Personnel This is the Crystal River Unit 3 (CR-3) Management Corrective Action Plan, Phase II (MCAP II).
It charts the course for bringing our plant to the standards the owners, regulators, and public expect and deserve. MCAP II will not be an easy task to accomplish. We have learned to live with and accept certain conditions and ways of doing business. Changing these ways, changing these conditions, and changing what we expect of ourselves and others, is what this document is all about.
Safe plant operation is our first and foremost obligation.
The plant and its equipment must be operated in a manner that minimizes the potential for adverse safety consequences.
A cornerstone of safe operation involves conservative decision-making, practiced in all aspects of plant operation and management. Any potential problem related to safety must be promptly identified, evaluated, communicated, and resolved. Some recent issues have necessitated an examination of how well we are meeting this obligation.
i As you are aware, several assessments have been conducted over the last few months.
These assessments were conducted by our staff, the Nuclear Regulatory Commission, as well as teams of highly-qualified, experienced, nuclear industry professionals.
I have used these assessments to help me determine what needed to be fixed and, more importantly, whether the plant should be operated while we make the fixes.
I have evaluated these assessments and concluded that certain design and configuration issues must be resolved during our current forced outage in order to assure that the plant will be operated with appropriate design margins while we make further improvements.
How we got where we are today is useful only in pointing out what we need to do to improve and assure ourselves we won't repeat those mistakes tomorrow.
In my assessment of CR-3's past performance, I conclude that management was the key ingredient to the shortcomings. As you read this MCAP II document, it should be no surprise that many of the corrective measures relate to enhancing management effectiveness.
I and my management team are committed to providing the leadership and management necessary to take CR-3 to the top.
There is one area that I particularly want to stress because it is so critical to the successful operation of a nuclear power plant.
I am referring to oversight.
At CR-3, as is the case at all nuclear plants, there are multiple -
groups that serve the purpose of monitoring all phases of the plant's performance. There is external oversight such as the NRC and INPO, and there is internal oversight such as QA, NGRC, PRC, and NSAT. While those responsible for CR-3's internal oversight activities cannot be blamed for the plant's shortfalls in performance, they can be criticized for failure to recognize and help assure 1
- g2ogggganaagga P
J
l they were corrected.
However, oversight organizations can not be effective if line management fails to respond appropriately to critical appraisals. There is some indication that this has occurred at CR-3.
Accordingly, I emphatically affirm that it is my policy to support the proper functioning and effectiveness of all internal oversight activities. All levels of management will look upon oversight as a positive and beneficial attribute and will respond accordingly.
For a number of reasons, some design margins of the plant are at a level where there is little or no flexibility to resolve emergent issues. We intend to aggressively address this problem.
As we restore the design margins of the plant, we will be putting in place an effective program which will ensure the margins and configuration are maintained.
There.is no reason CR-3 cannot become the best plant in the United States.
Although it may take time, I am convinced we can rise to the occasion.
I encourage each and every one of you to work
,gether.
If you think of ways to improve areas that are not being addressed, tell your supervisor.
If you don't think you are getting through, come and talk to me.
We need everyone to be a part of this program.
s: W apii.Jm
. M. B ard, Jr.
4e w3 WMr P
A W w4 %S.
.I o ke
.A1r/94in Mr&~t b
rM
~
1 Ab
>6 4m
- y w;/y p
a.
.x u4 4
A
+ <.
p 2
Resision Date Significant Change 0
10/31/96 Original 1
11/22/96 Incorporates recommendations of Independent Design Review Panel (IDRP) as Appendix B to Section C (Configuration Management and Design Basis). Incorporates recommendations of Nuclear General Review Committee (NGRC) Special Subcommittee which resiewed MCAP 11 November 8,1996.
i l
l
[
Rev.1 1
Nov. 22,19%
i
1 j
l 1.
Introduction and Overview:
This document is the Florida Power Nuclear Operations Phase li Management Corrective Action Plan I
(MCAP 11). It is the follow on plan to the Management Corrective Action Plan (MCAP) initiated in the Spring of 1995 to address specific performance issues arising from events that had occurred in late 1994.
ibe Management Corrective Action Plan Phase ll redirects improvement efforts to incorporate the results from numerous internal and external assessment and evaluation activities during 1996. The MCAP 11 identifies the root and contributing causes (barders) to achievement of excellence, assigns responsibility to an appropriate management or supervisory level individual, and establishes completion dates for specific corrective actions to address the identified root and contributing causes. The original MCAP has been completed. Several individual issues have been transferred to MCAP li for completion. Further, where analysis of completed MCAP issues has indicated that previous corrective act.Wns did not achieve the desired results, additional actions have been incorporated in MCAP ll.
These are shown in Appendix A.
The MCAP ll communicates management expectations and provides direction to the entire Florida Power Corporation Nuclear Operations Organization. It supports the fundamental" Performance Triad" of Safety, Production, and Cost. The MCAP ll is predominantly directed at the safety aspects of the triad. It is principally focused upon improvement of the safety culture of Crystal River Unit 3 using the broadest definition of safety culture.
Nuclear Operations line management has developed the MCAP 11 with two fundamental principles in
]
mind: (1) to identify the maior issues and deficiencies in Crystal River 3's performance and to (2) direct action to resolve those deficiencies. The MCAP 11 consists of five major areas, all bearing directly on the safety culture, that were identified during the evaluation process:
Leadership Oversight and Involvement Configuration Management / Design Basis Regulatory Compliance Engineerir.g Performance Operations Performance A specially designated subcommittee of the Nuclear General Review Committee;(NGRC)l chaired b~y the NCRC Chelrman. reviewed Revision 0 of M_ CAP 11. This group believdd the focus prescribed in the frve ateas above was too narrow and did not. address the four following fundamental root causesj Focusing more intensely on cost and prodtiction'~than safety.
Management not listening to or acting upon.information available to them; A strong' sense of denial witly regard to' performance; A family organizational culture rather than a self-critical. team:
Specific root and contributing causes are identified within each area as are comprehensive action plans to correct the root and contributing causes. Specific Managers and Supervisors have been assigned completion date and content accountability. Measures of monitoring progress and effectiveness have been established.
Rev.1 2
Nov.22,1996
.. _.._ _ _ _.. _. _ _ _._ _ __ _... _ _ _ _ _.___. _ m.. _._._ _ __... _. _
4 1
2.
Expected Results 1-This plan begins the process of bringing Crystal River 3 into the community of top performing nuclear j
power organizations. It is a road map designed to provide the basic performance competencies which j
will permit rapid progress along that road. It will provide the fundamental foundation to enable subsequent plans to complete the journey to excellence in all areas of the ' Performance Triad."
l j
3.
Planning Assumptions Several key assumptions guide plan development, including:
The overall objective is to reach (and maintain) top performance.
The planning horizon extends through the end of FY 97 (December 31,1997).
The plan needs not only to address issues identified in assessments, it must also include 1
strategic initiatives necessary to achieve the overall objective.
The plan assumes that necessary resources (people and money) will be available. It includes resources required over present level of effort to accomplish goals.
j Meaningful measures of effectiveness are required to monitor and communicate progress both j
internally and externally (e.g., NRC).
j Continuous improvement on the part of inaastry is assumed in developing where CR-3 needs to be at the end of FY 97.
i 9
a:
3 i
i
)
2-i e
s 1
k o
l 4
i 1
l Rev.1 3
Nov. 22,1996 4
9
~/
SECTION A 1.
Area of Concern and Management Sponsor:
Leadership Oversight and involvement Sponsor: P. M. Beard, Jr.
11.
Problem
Description:
Leadership oversight and involvement in plant issues has been inadequate in emphasizing its safety culture role. This has occurred in areas ranging from communication and reinforcement of core values and expectations to site processes and priorities. Further, where assessments have been conducted, they have neither focused on elements from the safety culture perspective, nor have they been sufficiently self-critical to enable assessment of root or apparent causes.
lH.
Present Condition:
In response to plant events over the past two years, several initiatives have been implemented, including:
Establishment of a formalized self-assessment and performance monitoring program.
Restructuring the NCRC, including an annual review of the self. assessment program by the NCRC.
Establishment of a Nuclear Safety Assessment Team (NSAT).
Creation of a Management Resiew Panel (MRP) to review the effectiveness of a corrective action taken in response to more significant events (those involving NOVs, LERs, and other significant management concerns).
Increasing the emphasis of on-shift oversight, including redefining the role of the Shift Manager and adding a position (Operations Manager) directly over the Shift Supervisor.
Despite these efforts, a difference in performance standards exists between CR-3 and INPO 1/SALP 1 plants in areas such as safety culture, procedural adherence, event investigation, root cause determination, sensitivity to operability issues, adherence to design bases, QA organizational effectiveness, and implementation of the corrective action process for emergent issues. These differences should have been determined through leadership oversight and involvement, but were not.
IV.
Corrective Actions to Address the Root Causes of the Problem:
The following are the root causes of the problem and the corrective actions that have been/will be taken to achieve top performance in leadership oversight and involvement.
I Rev.1 4
Nov.22.1996 i
)
i l
i Root Cruse 1 Site leadership has not been effective in carrying out its safety culture role because it has not:
Clearly and consistently communicated and reinforced core values and expectations with emphasis on safety 1.
culture.
2.
Implemented site processes with appropriate emphasis on safety culture.
3.
Established site wide priorities with proper emphasis on safety culture.
4.
Implemented balanced accountability with respect to safety.
5.
Established constructive self criticism and self improvement as an integral way of doing business.
6?
Fixed things that were wrong.
Corrective Actions:
Target Action Responsible Completion Date A RC1-1; a) Independently assess the senior site P. M. Beard 12/20/96 management team and determine "best fit" roles for carrying out transition to the new safety culture.
b) Make changes to reflect this assessment.
f-RC1-2; Evaluate and revise mission statement, J. S. Baumstark 12/6/96 core values, and expectations with emphasis on safety culture; the j
evaluation will include a review by a cross functional / level team.
A-RC1-3. Establish a self-critical view from the P. M. Beard 3/28/97 top down that accepts identification of problems and takes action to address them rather than rationalizing it away.
Incorporate this attribute into supervisory / managerial performance appraisals.
A-RC1-4; Establish site wide priorities which P. M. Beard Completed emphasize a safety culture.
10/31/96 A-RC1-5. Conduct a Safety Culture Index.
J. S. Baumstark Completed Evaluate the Culture Index at periodic 11/12/96 intervals.
Rev.1 5
Nov. 22,1996
Target Action Responsible Completion Date A-RC14 Plan a Supervisor's workshop which J. S. Baumstark/
2/21/97 emphasizes:
R. C. Widell a) Lessons learned from the Safety Culture index b) Manager /supenisor role in implementing a safety culture c) The relationship between accountability,
{
authority, and responsibility i
d) Behavioral expectations related to a safety culture
)
- Explains the seriousness of the problem
- Explains the benefits of self-criticism j
- Provides positive reinforcement for self-identified criticism i
A-RC1-7; Conduct the Supenisor's workshop Mgmt. Team 3/28/97
)
discussed in 2 above.
A-RC1-8. Communicate, advertise, coach, and P. M. Beard Contin'ui~ng constantly reinforce our Mission Statement, Core Values and Expectations down throughout the organization.
a.
Advertise b.
Establish performance standards in Mgmt. Team 12/3y96 writing for each department Stand down to launch the program l
c.
d.
Directors and Managers recruit each individual (Core Values to a personal level and expectations to a job specific level) e.
Measure results f.
Conduct periodic reinforcement sessions with employees g.
Hold management sessions to discuss progress and problems
)
A-RC1-9. Conduct human error reduction training for R. C. Widell 4/25/97 selected site supen>isors (90).
Rev.1 6
Nov. 22,19%
4 ACTION RESPONSIBLE TARGET COMPLETION DATE A-RC1 10. Conduct human error recognition R. C. Widell 4/25/97 and reduction techniques training for selected site workers (120).
A-RC1-11. Ensure appropriate management level attendance at NRC and QA Mgmt. Team /
12/5/96 entrances and exits.
L C. Kelley.
A-RC1-12. - formally enhance the Operating Experience Review Program'-
J. S. Baumstark 1/31/9{
which identifies emerging industry issues (both equipment and organizational
& programmatic).
J 1
)
I I
Rev.1 7
Nov. 22.1996
koot Cause 2:
1 Excessive and ineffective organizational and programmatic changes have increased human error rates.
Corrective Actions:
ACTION RESPONSIBLE TARGET COMPLETION DATE A-RC2-1 Develop a change management J. S. Baumstark 3/2_8/97 process for significant organizational and programmatic changes to include:
Communications plan including new standards expected.
Evaluation of personal / personnel impacts.
Workload assessment prior to and after the change.
Monitoring the effectiveness of the change.
Required training or re-training.
A-RC2-2 Monitor and control the number Mgmt. Team 1/3/97 of significant organizational and Business programmatic changes being Plan implemented simultaneously, a
Rev.1 8
Nov.22,1996
- - - ~ -. -
Root Caos.J:
- An inadequate root and.ommon cause analysis process inhibits management from addressing the right issues in the right 8
priority..
3 Corrective Actions:
I j
ACTION RESPONSIBLE TARGET COMPLETION i
DATE I
A-RC3-1 Redefine the corrective action J. S. Baumstark Completed process to include a single J.1]20[96 j
graded approach for 1-development of root and apparent causes as well as corrective action plans.
A-RC3-2 Establish a core group of in-depth J. S. Baumstark Completed root cause analysis experts.
11/1/96 A-RC3-3 Establish apparent cause J. S. Baumstark Completed reviewers in each line jt/14/9Q department.
A-RC34 Develop training package on R. C. Widell Completed corrective action program 11/8/96 changes for delivery by site simrvisors.
A-RC3-5 Conduct training for site Site Supervisors /
Completed personnel on changes to Mgmt. Team 11/12[96 corrective action program.
1 Rev.I 9
Nov. 22,1996
\\
l Contributine Cause 1:
Inadequate performance monitoring and trending which inhibits proactive identification of emerging issues and results in an excessive number of investigations with httle value added.
)
Corrective Action:
i ACTION RESPONSIBLE TARGET COMPLETION
~DATE '~
i A-CC1-1 Establish centralized monitoring D. Wilder febl2861997 and trending of "real time" process inputs for performance indicators and repeat events / failures. : Develop inethodology for. measuring appropriate real. time and leading indicators that preclude recurrence of significant lagging indicators.
O Contributine Cause 2:
Inadequate analysis of performance monitors has resulted in ineffective detection of adverse trends related to site programs, processes, and procedures.
Corrective Action:
ACllON RESPONSIBLE TARGET COMPLETION I
DATE A-CC2-1 Establish a method for identifying D. Wilder feb.28,1997 trends needing further analysis with respect to root cause.
\\
Rev.1 10 Nr>v.22,1996
Contributine Cause 3:
An inadequate feedback process has resulted in self-assessments not being controlled by the corrective action process and consequently, missed opportunities to improve.
Corrective Actions:
ACTION RESPONSIBLE TARGET l
l COMPLETION DATE A-CC3-1.
Establish standards for self.
R. Yost Completed assessment performance.
11/20/96 A-CC3-2.
Formally incorporate results R. Yost (NOD-45) 11/29/96 obtained thru self-assessments D. Wilder (CP-111)
Completed into the corrective action process 11/20/96 for follow-up, tracking, and trending.
4 Contributine Cause 4:
Inadequate adjustments (corrective actions) have resulted in frequent ineffective changes that may cause additional problems.
)
l Corrective Actions.
i ACTION RESPONSIBLE TARGET COMPLETION DATE i
A-CC4-1.
Establish line management P. M. Beard C6mpi.eted accountability for corrective 11/20/96 actions which:
a.
Ensure changes are j
supported by and directly i
relate to root cause analysis.
b.
Will reduce recurrence rate significantly and in a timely manner without creating another undesirable condition.
c.
Can be implemented within a management control.
- d. Are consistent with industry standards.
e.
Can be implemented cost-effectively.
Rev.1 11 Nov.22,1996
Contributine Cause 5:
The Quality Assurance process has not effectively communicated or followed up on issues.
Corrective Actions:
ACTION RESPONSIBLE TARGET COMPLETION DATE A-CC5-1.
Establish new management in J. S. Baumstark Completed QA.
10/1/96 A-CC5-2.
Provide new guidance for the R. E. Yost Completed conduct of audits.
11/15/96 A-CC5-3.
Establish 18 to 24 month J. S. Baumstark/
Dec.13,1996 rotational assignments in QA for R. E. Yost approximately 30% of assigned positions.
A-CC5-4.
Recruit new talent for QA from J. S. Baumstark/
Jan.10,1997 both on-site and off-site assets.
R. E. Yost V.
Measures of Effectiveness The following rneasures will be used to monitor progress and gauge the effectiveness of corrective actions in addressing the problem:
1.
Number of LERs attributable to human performance errors.
l 2.
Number of NOVs attributable to human performance errors.
l 3.
Self-identified issues on NRC plant issues matrix.
4.
Percent of violations that are not cited.
5.
Percent of problem reports that reflect a recurring problem.
6.
Number of CR-3 NOVs compared to regional / national NOVs (per unit).
7.
Number of CR-3 LERs compared to regional / national LERs (per unit).
l i
Rev.1 12 Nov.22,1996
Appendix A Acti:n itsms Carri d Over from Przvious MCAP Submittals and Meetings i
Section A: Leadership Oversight and Involvemot Action Responsible Target Completion Date A-FU-1:
Ensure appliccble elements of the Event Free Operailon Prog am continue to be a focus of the day-to-day way we do business with emphasis on:
Direct observation of work in progress B. J.1Hickle J/3/97 Audits and surveillance J2 Sf Baumstark 1/3/97 Independent review group oversight Jj S.LBaumstark
]/3/97 (NCRC and PRC)
A-FU-2:
Establish a single user-friendly action tracking J. S. Baumstark 9/26/97 system.
A-F U-3:
Determine the most effective role for Issue Gl LI Boldt 1/31/97 Managers. Coordinate this effort with establishment of responsibility for managing site Top 10 Prionty elements.
A-FU4:
Probabilistic Safety Analysis (PSA) - identify D. Wilder May 1,1997 enhanced applications.
Rev.I 13 Nw 22,19%
SECTION B ENGINEERING PERFORMANCE I.
Area of Concern and Management Sponsor:
The Engineering Department has not supported plant operations well, particularly in maintenance and application of the plant design basis.
Sponsor: G.L. Boldt II. Problern
Description:
The focus of the concern in engineering is primarily on design and analytical work, configuration management, and teamwork with other departments. The systems engineering area is generally perceived to be satisfactory, although some performance problems have been noted here too.
Overall, the engineering department has had an inconsistent record of performance. Over the last several SALP periods it was rated SALP 3, SALP 2, SALP 2 (and IMPROVING), and SALP 1 only to decline back to SALP 2 in 1995.
Although inspection reports identify some engineering strengths, they are overshadowed by weaknesses in the following areas: timeliness and accuracy of deAgn and analytical support for plant operation, adequacy of regulatory correspondence, quality of 10CFR50.59 evaluations, planning and prioritization of work load, and maintenance / communication of the plant design basis.
Ill. Present Condition:
The engineers were challenged to self-identify the key factors contributing to the problems described above. Their input is summarized below:
1.
For the first eighteen years of plant operation there was a heavy reliance upon A/E, contractor, and NSSS resources for performance of design activities. Corporate engineering personnel served as project managers over these resources and were not intimately involved with the details. As a result, there was ineffective technology transfer from the external resources to CR3 engineers.
2.
Ineffective management of change within the engineering organization had a negative affect on its performance. The combined effect of downsizing, relocation of corporate personnel to the Crystal River plant site, implementation of the business process improvement (BPI) recommendations to the design processes, and the reduction in reliance upon external engineering resources, negatively influenced productivity and product quality, frustrated personnel, and increased engineering work backlogs.
The reduction in reliance in external resources, although recognized by all as a potentially positive move, was performed in a more aggressively than the FPC team was prepared to accommodate given the existing level of engineering knowledge and skills.
In response, several initiatives have been implemented over the last two years, including:
Recombined systems engineeringwith design engineering, configuration management, procurement engineering, a.
and engineering projects under a single engineering director.
b.
Increased management oversight within engineering by creating a new manager position and group to control engineering programs [ inservice inspection; new/ finite term programs (e.g. GL 96-01, setpoint verification, tank calculations); and continuing life of-the-plant programs (e.g. boron corrosion, erosion corrosion, maintenance rule, charcoal testing, and tendon inspections)].
l Rev.I 14 N m 72,1 W
Increased teamwork among departments by:
c.
' Teaming operations and engineering personnel in calculation development, design inputs, and
-l assessments of impact on documents and procedures, i
Teaming licensing, operations, and engineering personnel in system and equipment operability
?
assessments, and
- l i
Implementing the use of Project Teams for conceptual design (alternatives), final design, construction, f
and startup of significant plant changes.
I Despite these actions, developed as an integral'part of the nuclear operation's Management Corrective Action Plan (MCAP) beginning in March of 1995, performance differences remain between CR-3 and SALP 1 plants.
l l
The actions described above, dealt with symptoms in many cases rather than root cause(s). To correct this condition, FPC teams working together with Failure Prevention incorporated (FPI) conducted a structured root cause determination of the engineering j
performance problem.
i IV. Corrective Actions to Address the Root Causes of the Problem:
The following are the root and contributing causes determined by the FPC/IPl team along with the respective corrective actions to achieve top performance in engineering effectiveness:
Root Cause 1 An appropriate safety culture was not effectively emphasized. As a result, activities were not given a level of safety attention commensurate with that given to production or cost priorities. This led to design basis concerns being primarily resolved through analytical means in lieu of physical means (such as plant modifications and equipment testing) directed at maintaining -
- or improving design margins.
i l
Rev.1 15 Nov. 22,1996
Corrective Action:
Responsible Target Action Manager Completion Date B-RC1
-1 Implement a " stand down" in Nuclear F. X. Sullivan Complete Operations Engineering to emphasize the 9/30/96 importance of improving safety culture. Stress the need to enhance safety sensitivity, quality, and attention to detail in the performance of 10CFR50.59 safety evaluations and the lessons learned from the recent USQ experience.
-2 Institute an interim change to require 50.59 F. X. Sullivan Complete evaluations be performed for engineering 10/15/96 activities in lieu of a screening evaluation. This action is to remain in place until formal training and establishment of qualified reviewers for 50.59's are completed.
i l
l
\\
i i
I i
l l
i Rev.I 16 Nov. 22,1996 a
Corrective Action (cont'd)
Responsible Target Action Manager Completion Date B-RC1
-3 Incorporate improved safety sensitivity into R. Widell Complete 1
50.59 evaluation training in the Technical Staff 10/30/96 and Management continuing training curriculum.
-4 Hold a special meeting with NOE (design)
F. X. Sullivan Complete personnel to further increase safety sensitivity to 10/15/96 50.59 reviews. Use industry experience (FP&L, Cooper, and FPC) to reinforce the points made.
-5 Extend the current outage to achieve FPC Management Complete immediate, near terrn improvements in plant Team 10/7/96 safety / design margins.
i
-6 Evaluate personnel in managerial and G. Boldt interim Actions supervisory roles.
Engineering Complete Managers
-7 increase authorized engineering staffing level.
G. Boldt Interim Actions Seek engineering talent from outside FPC that Engineering
- Complete,
/
can bring in fresh ideas, practices and increased Managers Continuing to design competency.
Hire
-8 issue a directive to restore system design G. Boldt Complete 4
margins primarily through physical means 10/7/96 (modification or testing) as opposed to VPNP96-0052 analytical means.
Rev.I 17 Nov.22,1996
Root Cause 2 insufficient communication of management expectations - particularly with respect to safety culture.
Corrective Actions:
Responsible Target Action Manager Completion i
Date B-RC2
-1 Establish a cktar departmental mission G. Boldt 12/31/96 staternent with emphasis on plant safety, and a concise set of expectations for engineering managers.
-2 Develop a department wide Administrative G. Boldt, 3/1/97 Instruction " Conduct of Nuclear Engineerina, and Engineering j
Projects" and supporting instructions in each
- Managers, departmental group to promulgate management Supersisors, expectations to each engineering employee.
and Work Group Employee Teams
)
-3 Communicate, coach, and continually reinforce G. Boldt, Interim Actions adherence to mission and expectations through Engineering Complete frequent department wide meetings, balanced Managers and accountability, and site wide teamwork.
Supervisors
-4 Establish and promulgate the top ten plant Gl tlBoldt Complete priorities for Nuclear Engineering and Projects.
10/14/96
-5 Ensure resources are provided to achieve quality G.? L Boldt interim Actions
[
engineering support for plant operations in Progress commensurate with established priorities, goals, and expectations.
4 a
i a
i 1
j Rev.1 18 Nov. 22,19%
4A--
r--
Contributine Cause 1 inadequate performance monitoring, trending, and self-assessment within engineering which precludes:
Early identification of equipment reliability problems.
Highlighting repeat failures.
Identification of organizational and programmatic issues.
Corrective Actions:
l Responsible Target Action Manager Completion f
Date i
1 B-CC1
-1 Establish an engineering tracking and trending K. Baker 1/1/97 program that includes:
Measures of the resources needed versus J
workload (including that necessary to address MAR /REA/ precursor backlog).
Organizational and Programmatic (O&P) indicators.
)
Equipment reliability, end-of-life, and repeat i
failure indicators (for human events and systems / components).
-2 Implement a program of engineering self-G. Boldt 1/1/97 assessments that detects and corrects problems All before the NRC, INPO, and other external Engineering agencies do.
Managers j
4 Rev.I 19 Nov. 22,1996
. =.
Contributine Cause 2 Inadequate deviation analysis of performance indicators which results in ineffective detection of adverse trends related to O&P issues.
Corrective Action:
Responsible Target Action Manager Completion Date B-CC2
-1 Assure the tracking and trending of measures and G. Boldt 1/1/97 4
indicators established as corrective action for All Engineering Contributing Cause 1 (above) are assessed by Managers engineering managers to uncover:
Adverse trends requiring increased management attention.
Potential common causes of both equipment and human performance issues.
Contributing Cause 3 Inadequate root and common cause analysis process precludes engineering from addressing the right issues in the correct priority.
Corrective Action:
NOTE: Corrective action for this item is addressed under Root Cause 3 in Section A, Leadership oversight and Im'olvement, of this plan.
Rev.1 20 Nov. 22,19%
o j
C
~
Contributine Cause 4 Inadequate communication among managers, supervisors, and engineering personnel which leads to:
Lack of common awareness of problem extent, Expended effort to resolve problems at too low a level in the organization, l
Focus on inappropriate priorities, Denial, or rationalization, of problem existence.
I Corrective Actions:
Action Responsible Target Manager Completion Date B-CC4
-1 Conduct a series of small group meetings G. L Boldt Complete between the engineering director and the 10/20/96 engineering personnel (no managers or supervisors present) to discuss problems and concerns.
-2 Conduct a small group meeting between the G. L Boldt Complete engineering director with engineering 9/10/96 supervisors (no managers or non-supervisors present to discuss problems and concerns).
-3 Increase the frequency of engineering staff G. L Boldt Complete (manager level) meetings.
10/24/96
-4 Increase the use of engineering stand downs G. L Boldt Interim Actione and other all-hands communication and training Engineering Complete
}i forums to communicate expectations and Managers lessons learned from events.
-5 increase formal and informal opportunities for Engineering 4/1/97 improving horizontal communications at each Managers level.
Rev.1 21 Nov.22,1996
~
V.
Measures of Effectiveness:
The following measures will be used to monitor progress and gauge the effectiveness of corrective actions in addressing engineering performance:
REA, A%R, and precursor backlogs Engineering resource needs versus workload Number of ICN's per AMR Number of engineering personnel changes (absolute and as a percent of total staff)
Number of significant, active O&P changes with impact on engineering The number of precursors and problem reports that identify engineering problems as a percent of the total number of precursors and problem reports.
Repeat failures (human events and system / component failures)
Rev.I 22 Nov. 22,1996
. _ ~.
Appendix A Action Hems Carried Over From Previous MCAP Submittals and Meetings Section B:
Engineering Performance Responsible Target Completion Action Manager Date B-FU
-1 Complete a manager level review and prioritization F. Sullivan 4/1/97 of all backlogged REA's.
J. Terry (other engineering managers as necessary)
-2 Revise Administrative Instructions and/or NEP's to K. Baker 4/1/97 capture the need to review design basis calculations and procedures when either document is changed.
-3 Complete the action plan for resolution of Control S. Powell Tied to CCHE Complex Habitability Envelope issues.
corrective action plan
-4 Complete corrective actions resulting from the self-K. Baker 5/1/97 assessment performed on interdisciplinary Engineering interaction in engineering.
Managers
-5 Enhance the use of lessons learned to improve K. Baker 4/1/97 performance in engineering.
Engineering Managers Rev.1 23 Nov.22,1996
SECTION C CONFIGURATION MANAGEMENT AND DESIGN BASIS 1.
Area of Concern and Management Sponson Weaknesses have existed in implementing programs for maintaining plant configuration consistent with design basis.
Sponsor: Cary L Boldt II.
Problem
Description:
Tne NRC's expectation, as contained in the commission's policy staternent dated August 10,1992, is "..the licensee will have current design documents and adequate technical bases to demonstrate that the plant physical and (tmctional characteristics are consistent with the design basis, the systems, structures and components can perform their intended functions, and the plant is being operated in a manner consistent with the design basis."
FPC has not fully met this expectation. Weaknesses that have been identified include:
Discrepancies between the physical plant and design documentation.
Inaccuracies in the technical content of design documents including incorrect assumptions and calculational errors.
Discrepancies between operational configuration (procedures) and the supporting design documentation.
Inconsistencies among design documents and between the design basis and licensing basis.
Examples of deficiencies in these areas have been documented by FPC and the NRC. Some of these deficiencies date back to the original design of the plant. We are concerned with the number and cumulative potential effect of these issues on continued safe plant operation. The identification and resolution of these issues has impacted the workload and priorities of the entire nuclear operations organization, and in particular on engineering, operations and licensing. IPC has had to operate in a reactionary mode to address these issues as they arose.
FPC's 10CFR50.59 process is also viewed as inconsistent and examples of weak 50.59 reviews have been cited in NRC inspection reports and PRC reviews. A quality 10CFR50.59 process is reliant on readily available, consistent and accurate design information.
111.
Present Condition:
A number of actions have been taken to date which are focused on assuring future engineering design work is properly performed and all changes affecting plant design are appropriately documented. These actions are as follows:
Process changes have been implemented to correct weaknesses and eliminate problems a.
from future work.
Rev,1 24 Nov.22,1996
3 Positive controls have been added to assure modifications are not turned over to operations unless appropriate procedures have been revised.
4 A requirement to obtain an operations signoff on inputs and assumptions to calculations has been implemented.
A requirement for engineering to resiew and sign off changes to the Emergency Operating
]
Procedures has been implemented.
b.
A resiew of the potential cumulative effect of design basis issues on plant safety has been completed.
A review of the plant Emergency Operating Procedures has been completed to assure the c.
accident mitigation strategies utilized have a complete and accurate technical basis.
d.
The modification process has been revised to incorporate Project Teams to assure all groups within nuclear operations have input to the project design and can more readily assess impact of the project on their area.
Utilization of the precursor card process has been increased for documenting and resolving e.
configuration and design issues.
f.
Design Review Panels are formed to review large modifications and provide a critical, questioning assessment of the design to assure all design requirements have been addressed and the design impacts are reasonable.
The above efforts are primarily forward looking, and FPC remains challenged to complete focussed reviews of past design efforts (including the original plant design / basis). Some problems were also identified by the NRC IPAP team wah more recent engineering work. This has indicated that FPC may have taken actions based on treating symptoms rather than the root cause(s) of the problems.
For this reason, FPC formed a team to apply the methodology of failure Prevention incorporated (FPI) to determination of the root and contributing causes of the configuration management-design basis concern.
IV.
Corrective Action to Address the Root Causes of the Problem:
The following paragraphs describe the root causes, contributing causes, and corrective actions to address them to achieve top performance in management of plant configuration and design basis documentation / understanding.
Root Cause 1 Limited emphasis on nuclear safety culture in relation to more traditional production priorities, such as capacity and cost, resulting in:
Inadequate design margins that have not been addressed.
Limited definition, documentation, and on-site understanding of the plant design basis.
Lack of comprehensive plant configuration controls.
Lack of networking with other B&W plants to maintain consistent designs / design margins.
Rev.1 25 Nov. 22,19%
Corrective Actions:
Responsible Target Action Manager Completion Date C-RC1
-1 Establish an Independent Design Review Panet P.M. Beard Complete (IDRP) to review the cause and extent of CR3's 6/1/96 design basis problem.
-2 Complete review, approval, and disposition of FPC Management Co lete the IDRP final report recommendations (to be Team 11,'//96 included as Appendix B).
-3 Improve nuclear safety culture. NOTE: This FPC Management See Sections A issue is being addressed as an integral part of Team and 8 of This Leadership Oversight and Engineering Plan Performance in Sections A and 8 of this plan.
-4 Extend the current forced outage to improve G. L Boldt Completion selected system design margins by physical tied to end of plant modification or equipment testing.
the forced outage
-S Develop and implement longer lead time plans G. L Boldt Completion to further improve plant design margins and tied to end of restore consistency with " typical" B&W plant Refuel 11 configurations in Refuel 11. Establish a clear understanding of what K. Baker 4/1/97 constitutes the plant " design basis" which is
- f. Sullivan consistent with industry standards and regulatory expectations. Then promulgate through plant procedures and training.
Rev.I 26 Nov. 22,1996
1
=
e
~
Corrective Actions (cont'd);
Responsible Target Action Manager Completion Date C RC1
-7 Establish a comprehensive management K. Baker 6/30/97 control process for the design basis which F. X. Sullivan includes requirements for:
j Implementation (how to)
I Maintenance Training and qualifications Reportability/ operability 1
Prioritization/ timely action I
-8 Coordinate future design basis issues through P. M. Beard Continuing the B&W Owners Group.
R. Widell Contributing Cause 1 Inadequate self assessment which precludes comprehensive, proactive identification and resolution of design basis issues.
Corrective Actions:
Responsible Target Action Manager Completion Date C-CC1
-1 Conduct a comprehensive failure modes and J. Maseda Prior to restart effects analysis (FMEA) of LOCA, LOOP, and from the loss of DC Power scenario, current forced outage
-2 Include SSFl style self-assessments of safety G. L Boldt Each year significant systems in the next five CR3 annual through 2001 plans.
Rev.1 27 Nw 22,19%
1 1
V.
Measures of Effectiveness:
1 The following measures will be used to monitor progress and gauge the effectiveness of corrective actions in addressing the configuration management-design basis concern:
j The number of precursors and problem reports that identify discrepancies in the design basis as a percentage of all precursors and problem reports.
The number of design basis LER's compared to industry benchmarks and the trend in this measure.
Age of design basis calculation reviews.
Number of operator work-arounds created by design basis issues.
l Feedback from operability /reportability review teams.
l The number of completed and open IDRP recommendations..
)
J l
i l
l i
j l
i Rev.1 28 Nov. 22,19%
t I
_..m_
_.- _~.._.
l INDEPENDENT DESIGN REVIEW PANEL RECOMMENDATIONS 1
l l
1.
Design Basis Program 1
Responsible Target l
Recommendation Manager Completion Date 1.
FPC should recognize the importance of the Design Basis and Licensing Basis and take steps to treat i
them as major programs with defined scope, clearly I
assigned ownership, and recognition throughout the organization. (IDRP 1) l Disposition: Accepted. This recommendation will G. L Boldt 4/1/97 be resolved by creation and implementation of one or L C. Kelley
}
l more NOD's which address ownership and control of
. the design basis and licensing basis of the plant.
l 2.
Establish a clear and complete definition of what l
l documents and/or sections of documents contain
)
j the Design Basis for CR-3. Revise NEP-216, Plant l
Design Basis Documents, as required. (IDRP 2)
Disposition: Accepted. This recommendatinn will K. Baker 1/3/97
)
be resolved by creation of the design basis NOD F. X. Sullivan to complete referred to in #1 above and by revision to the interim action (s) referenced NEP. Interim action in the form of 4/1/97 i
1 guidance on the definition of design basis and a to complete final listing of the design documents which contain the procedure design basis is necessary to support ongoing work.
revisions 3.
Establish the legal and regulatory status of the I
Crystal River Unit 3 Final Safety Analysis Report in relation to utilizing the specific information for design engineering purposes. Also establish what was the l
indeper d'nt review cycle for FSAR submittals.
Review me appropriateness of page 141, Volume 1, j
paragraph 10 that excludes the FSAR as a design i
document. This may unnecessarily restrict the use of information contained in the FSAR for design purposes. (IDRP 3)
Disposition: Accepted. This recommendation will
' be resolved by:
o The NOD and NEP revisions discussed in G. L Boldt 4/1/97
- 1 and #2 above, K. Baker Creation of a nuclear licensing procedure L C. Kelley 4/1/97 o
to address the review cycle for TSAR B. Gutherman submittals, o An FSAR amendment to address the issue K. Baker 4/1/97 on page 141, Volume 1, paragraph 10 B.Gutherman regarding use of the (SAR as a design document.
l Rev.1 29 Nov.22,1996 l
)
o O
INDEPENDENT DESIGN REVIEW PANEL RECOMMENDATIONS l.
Design Basis Program (cont'd)
Responsible Target Recommendation Manager Completion Date 4.
Assure that the responsibility for assuring plant operation is consistent with the design basis is clearly defined and understood. (IDRP 7)
Disposition: Accepted. This recommendation will be resolved by:
o A combination of the NOD referred to in G. L Boldt 4/1/97
- 1 above, a new Al " Conduct of Nuclear Engineering and Projects", and within the NED standards which are sub-tier documents of the Al, Within appropriate operations department B. J. Hickle 4/1/97 o
Al(s) and OI(s).
5.
Consider including all design basis documents (See IDRP Recommendation 2) at the designated plant locations for design bases documents and electronically on FulText.
(IDRP 14)
Disposition: Accepted. it may not be possible or K. Baker 6/30/97 practical to include all design basis documents on W. L Conklin fulText due to hmitations of the software, however those documents that are compatible will be placed on fullext. Approximately 20 sets of design basis documents will be placed at designated plant locations.
6.
NOD-11, Maintenance of the Current Licensing Basis, should be revised to include specific guidance for ensuring that FSAR changes are reviewed by engineering to identify and then make any appropriate revisions to design basis documents.
(IDRP 25)
Disposition: Accepted: A revision to NOD-7 7 will L C. Kelley 4/1/97 incorporate this recommendation.
l i
i l
Rev.1 30 Nov. 22,19%
INDEPENDENT DESIGN REVIEW PANEL RECOMMENDATIONS 1.
Design Basis Program (cont'd)
Responsible Target Completion Recommendation Manager Date 7.
IPC should consider promulgating a procedure for the control of design / licensing basis information and documentation that applies to the entire Cr"stal River 3 nuclear organization. This procedure should require any change to the plant, plant documentation or procedures be evaluated for effect on design basis information and documentation. (IDR 26)
Disposition: Accepted. This recommendation will K. Baker 6/30/97 be incorporated into the NOD (s) referred to in #1 B. Gutherman above and a new CP implementing procedure.
8.
Change NOD-52, Commitment Processing and Management of Programmatic Commitments, to clearly identify Design Bases as an important element of the overall Configuration Management Program, and to require actions to ensure thorough assessment and treatment of changes, including the supporting or underlying analyses and assumptions thereto, as well as hardware issues (Structures, Systems and Components). (IDRP 38)
Disposition: Accepted. This recornmendation will be resolved by:
A revision to NOD-52 to incorporate the above L C. Kelley 2l1/97 o
- elements, Corrective action may need to be broader, K. Baker 4/1/97 (NOD),
o therefore, the above elements will also be 6/30/97 (CP) considered in development of the NOD and CP rnentioned in #1 and #7 above.
Rev.1 31 Nov. 2419%
_ _ _ _ _. _ _ -. _. _ _ _. _ _. __ _- - m
____m INDEPENDENT DESIGN REVIEW PANEL RECOMMENDATIONS
- 11. Engineering Expectations i
Responsible Target
]
Recommendation Manager Completion Date 1.
Assign overall responsibility and ownership for maintaining the Design Basis to a specific manager.
i Also assign ownership of the design basis of defined systems, structures and components to specific positions within the appropriate nuclear organization.
Make the individuals in these positions responsible to provide an independent review to ensure that any changes to procedures or hardware affecting their i
+
system or component are consistent with the design 3
basis. This would enhance expert knowledge within the organization of key design basis information.
1 (IDRP 4)
Disposition: Accepted. Overall ownership of the plant design basis will be assigned to the Manager of Nuclear Operations Engineering. Ownership of the i
i design basis for individual syste.ns will be assigned to a system design engineer. Design basis osvership will be established by:
o /OC as an interim action, G. Boldt 11/30/97 Changes to appropriate procedures (e.g.
F. Sullivan 4/1/97 o
J.
NOD's, NEP's, Al's, and/or NED standards).
K. Baker 2.
The Panel recommends that when dealing with 4
design basis issues, FPC take greater advantage of discussions with the other B&W utihties. (IDRP 12)
Disposition: Accepted. This recommendation will j
be resolved by:
Adding " design basis issues" as a standing R. Widell 2l15/97 o
agenda item for the B&WOG steering committee, Including guidance for design engineers to F. X. Sullivan 12/31/97 i
o
)
discuss design basis issues or questions K. Baker with the other B&W owners in the NED standards.
1 I
a 3
a I
i n
4 Rev.1 32 Nov.22,1996
]
INDEPENDENT DESIGN REVIEW PANEL RECOMMENDATIONS J
i
- 11. Engineering Expectations (cont'd) 4 a
Responsible Target Completion a
Recommendation Manager
- Date 1
3.
Establish additional expectations for the plant's Design Resiew Panel to ensure that design basis I
implications of the modification have been
]
adequately reviewed and considered. (IDRP 18)
Disposition: Accepted. Expectations for the Design F. X. Sullivan 4/1/97 Review Panel will be added to the NED standards.
J i
4.
To help ensure that inaccuracies in design basis j
information and documentation are identified and 3
corrected over time, establish clear expectations:
that engineering personnel are accountable o
{
for reviewing and correcting design p
information and requirements.
o that all personnel are expected to report design basis deficiencies or questions so they i
can be addressed. (IDRP 27) l Disposition: Accepted. This recommendation will i
be resolved by:
i o
incorporating the above expectations for F. X. Sullivan 4/1/97 engineering personnelin the NED standards, K. Baker Incorporating requirements for allpersonnel J. S. Baumstark Complete o
i to report design basis deficiencies or 11/20l%
questions in CP-111.
i e
i i
i:
1 i
8 l
1 l
)
j 4
i s
4 i
i I.-
i
.i Rev.1 33 N = 22,1996 t
v v
. _ ~ -
3 INDEPENDENT DESIGN REVIEW PANEL RECOMMENDATIONS
,r lit. Training 4
Responsible
. Target Completion.
~
4 Recommendation Manager Date l
1.
Develop a training program for ensuring that FPC j
nuclear employees understand what documents constitute the design basis and the appropriate change control procedures for these documents, j
particularly when plant modifications are involved.
f in addition, the training program should cover the distinctive uses of design basis information, licensing basis information and the impact of non-safety SSC's on the plant's design basis. (IDRP 5)
Disposition: Accepted. lhis recommendation will be resohed by:
i o Conducting interim training (for appropriate K Baker 3/1/97 l
personnelin engineering and other F. X. Sullivan 1
organizations) based on deselopment of the i
definition of design basis and the designation i
of design basis documents, i
Completion oflesson plans for initial and R. Widell 6/30/97 o
continuing operator and technical training
\\
2 curricula, Completion ofinitial training.
R. Widell 12/31/97 o
i i
3
)
i 4
4 1
i j
i 3
Rev.1 3-1 Nov. 22,19%
INDEPENDENT DESIGN REVIEW PANEL RECOMMENDATIONS Ill. Training (cont'd)
Responsible Target Completion Recommendation Manager Date 2.
The training on the design basis and the use of design basis information should be delivered to the appropriate individuals in organizations outside the engineering sections, and it should be covered in continuing training programs for those groups. (IDRP 13)
Disposition: Accepted. Implementation of this Addressed in #1 Addressed in #1 recommendation is included in the response to #1 above above above.
3.
Develop a station Safety Evaluation (SE) training and qualification program that will result in a consistent understanding of SE process requirements, by all personnel who perform, review and approve SEs.
(IDRP 34)
Disposition: Accepted: This recommendation will be resolved by:
Establishing an interim requirement for all F. X. Sullivan Complete o
safety evaluations supporting plant R. Knoll 10/31/96 modification to be reviewed by the safety analysis group, Revising the procedures for performance of L. C. Kelley 2/1/97 o
safety evaluations, G. H. Halnon Conducting training for appropriate personnel R. Widell 6l30/97 Training o
designated to perform safety evaluations.
Complete 4.
The plan for the annual Engineering Phase 3 (continuing) training should be broken into three or four sessions and the Curriculum Review Committee should provide topic input to each session. This would allow Phase 3 training to be responsive to current issues. (IDRP 35)
Disposition: Accepted. Engineering continuing M. D. Tidwell 1/31/97 training will be broken into more than one session so F. X. Sulluvan (revise 1997 that engineers can be kept more current on design training plan) basis and other engineering related operating experience.
Rev.I 35 Nov. 22,1996
. _... ~ _.....-
j INDEPENDENT DESIGN REVIEW PANEL RECOMMENDATIONS Ill. Training (cont'd)
Responsible Target Completion Recommendation Manager Date l
i 5.
The Phase 3 continuing training curriculum should be more reflective of current design basis and licensing basis issues. (IDRP 36)
Disposition: Accepted. The operating experience M. D. Tidwell 1/31/97 content of engineering continuing training will be K. Baker updated to include the latest information on these B. Cutherman topics.
6.
Reinforce engineering ownership of its design basis training program. (IDRP 37)
Disposition: Accepted. Engineering ownership ofits F. X. Sullivan 4/1/97 design basis training program will be emphasized in K. Baker appropriate procedure revisions.
l I
I i
1 Rev.1 36 Nov.22,1996
INDEPENDENT DESIGN REVIEW PANEL RECOMMENDATIONS IV. Procedures A. Nuclear Engineering Procedures Responsible Target Completion Recommendation Manager Date 1.
Performance errors identified during design verification reviews should be monitored and remedial training and corrective actions provided for repetitive problems (IDRP 17).
Disposition: Accepted. The verification process will K. Baker 4/1/97 be revised in NEP-261 to include tracking of M. D. Tidwell performance errors. Lessons learned will be addressed by the curriculum committee through remedial and/or continuing training.
2.
Develop specific guidance and training for engineering personnel for conducting technical reviews of procedure changes. This should include emphasis on evaluating the effect of procedure changes on design basis parameters and design requirements and on identifying possible revisions of the FSAR, technical specifications, COLR, and other design basis documents (IDRP 22).
Disposition: Accepted. This recommendation will K. Baker 6/30/97 be addressed through revisions to the Qualified R. Widell Reviewer program and Al-400 series procedures.
3.
Engineering managemer.t should clearly communicate and reinforce the need to revise design basis documents promptly following implementation
)
of a plant modification or procedure change.
1 1
Procedure NEP-216, Plant Design Basis Documents, should be revised to provide specific guidance for 7
the maximum time allowed to make temporary changes to the design basis documents and to incorporate temporary changes as permanent 4
revisions. Other nuclear plants typically require permanent revision of design basis documents within 30 - 60 days of implementing a plant change.
(IDRP 23)
Disposition: Accepted. NEP-216 wi/I be revised to K. Baker 4/1/97 reinforce the need for timely revision of the design basis documents. Other plants will be screened to establish appropriate and consistent revision times.
NEP-210 may also require revision to address revision i
of the DBD's.
)
5 i
i I
]
Rev.1 37 Nov.22,1996 3
j
INDEPENDENT DESIGN REVIEW PANEL RECOMMENDATIONS IV. Procedures (cont'd)
A. Nuclear Engineering Procedures (cont'd)
Responsible Target Completion Recommendation Manager Date 4.
Revise procedure NEP-213, Design Analyses / Calculations, to provide specific guidance or a check list for ensuring that design basis documents are reviewed and revised as necessary as a result of an analysis or calculation. (IDRP 24)
Disposition: Accepted. NEP-213 will be revised as
- f. Baker 4/1/97 recommended.
5.
Change the Modification Approval Record (MAR) process document (NEP-210) to ensure Design Bases issues are clearly considered, identified and thoroughly treated consistent with and similarly to NOD-52, Commitment Processing and Management of Programmatic Comtnitments, and Al-404h Review of TechnicalInformation, and Al-404B, Review of Industry Operating Experience. (IDRP 40)
Disposition: Accepted. NEP-210 will be revised as K. Baker 4/1/97 recommended.
l s
{
Rev.I 38 Nov.22,1996 I
i
_m INDEPENDENT DESIGN REVIEW PANEL RECOMMENDATIONS j
IV. Procedures (cont'd)
B. Administrative Instructions 3
Responsible Target Completion Recommendation Manager.
Date t
I 1.
Consider revising Al400C, New Procedures and Procedure Change Requests, to require a qualified review for all procedure changes by either nuclear i
f plant technical support (system engineering) or l
nuclear engineering design. Alternatively, consider
' adding to Al400C, New Procedures and Procedure Change Requests, more prescriptive conditions for when a qualified engineering review should be i
i required. (IDRP 19) 4 Disposition: Accepted. Al-400C will be revised to K. Baker -
4/1/97 clarify the conditions for when a qualified review by D. Kurtz engineering (systems or design) is required.
2 y
2.
Revise Al-400F, New Procedures And Procedure 4
Change Processes for Emergency Operating Procedures (EOPs), Abnormal Procedures (APs), and l
Verification Procedures 6'Ps), to require a qualified review by nuclear engineering design for abnormal procedures and verification procedures as well as for l
emergency operating procedures. (IDRP 20)
Disposition: Accepted. Al-400F will be revised as K. Baker 4/1/97 recommended.
G. Becker l
3.
Include the Enclosure 11 guidance from Al-400C, New Procedures and Procedure Change Requests, in Al-400F, New Procedures And Procedure Change Processes for Emergency Operating Procedures (EOPs), Abnormal Procedures (APs), and Verification Procedures 6'Ps), to assist the originator in determining if the procedure change affects design conditions or design requirements. Consider revising 1 to be a check-off list to ensure consideration of design basis issues. Provide guidance to identify on the check-off list the specific sections of the FSAR, technical specifications, COLR, or design basis documents that may require revision.
(IDRP 21)
Dispositiom Accepted. Al-400C Enclosure 11 will K. Baker 4/1/97 be revised and included in Al-400F as recommended.
G. Becker Rev.1 39 N a 22,1996
__.m._-.__m___m j
INDEPENDENT DESIGN REVIEW PANEL RECOMMENDATIONS IV. Procedures (cont'd) 4 B. Administrative Instructions (cont'd)
~
Responsible
! Target Completion Recommendation Manager Date s
l 4.
Change procedures Al-404A, Review of Technical j
Information, and Al-404B, Review ofIndustry Operating Experience, to ensure Design Bases issues i
are clearly considered, identified, and thoroughly treated. (IDRP 39) 4 Disposition: Accepted. Al-404A and B will be K. Baker 4/1/97 l
revised as recommended.
I.
3 I
i l
I 1
9 i
4 s
9 b.
I 1
i I
f Rev.1 40 Nov.22,1996
INDEPENDENT DESIGN REVIEW PANEL. RECOMMENDATIONS IV. Procedures (cont'd)
C. Compliance Procedures Responsible Target Completion Recommendation Manager Date 1.
Ensure procedure CP-150, Identifying and Processing Operability Concerns, has an appropriate " process" to ensure that only appropriate items are notified and reported. (IDRP 41)
Disposition: Accepted. Revisions will be made in G. Halnon 1/3/97 CP-151, " External Reporting Requirements" to incorporate this recommendation.
2.
[nsure procedure CP 150, Identifying and Processing Operability Concerns, includes appropriate guidance from NUR[G-1022 to take advantage of the allowed time frame to evaluate an issue prior to notification.
(IDRP 42)
Disposition: Accepted. This will be included in CP-G. Halnon 1/3/97 151.
3.
Revise CP-150, Identifying and Processing Operability Concerns, to be consistent with industry practice for the shift supervisor to seek assistance in determining the need to make a notification. (IDRP 43)
Disposition: Accepted. This will be included in CP-G. Halnon 1/3/97 151.
Rev.1 41 Nov. 22,1996
INDEPENDENT DESIGN REVIEW PANEL RECOMMENDATIONS i
V.
Technical Issues Responsible Target Completion Recommendation Manager Date 1.
FPC should complete its efforts to better clarify the bases and armroach to handling piping analysis and piping support design basis issues. (IDRP 6)
Disposition: Accepted. Interim action taken to bring F. X. Sullivan 6/30/97 in Ed Wais to review the current piping and support analyses.
2.
The panel recommends and CR-3 had decided to install design upgrades to the HPi system to enhance operating margin in the event of certain postulated transients. (IDRP 8)
Disposition: Accepted. fPC is planning to install F. X. Sullivan Refuel 11 l
HPI crossover pipes and cavitating venturis in Refuel 77.
3.
The panel recommends and CR-3 has decided to conduct a thorough investigation to determine why similar balance-of-plant design features are limiting at CR-3 and not at TMI-1. (IDRP 9)
Disposition: Accepted. TPC will conduct the F. X. Sullivan 6/30/97 recommended review.
j 4.
FPC should complete their review of the July framatome Technologies (FTI) report and take any appropriate action. (IDRP 10)
Disposition: Accepted. Review of the July report is F. X. Sullivan 6/30/97 directly connected with recommendation #3 above.
[PC will enter the subject report into the vendor information program to control the review.
5.
Obtain controlled copies of the framatome/B&W type 52 reference documents for use by station engineering personnel with appropriate proprietary information protection. (IDRP 15)
Disposition: Accepted. FPC will obtain site copies J. Colby 2/1/97 of(or site access to) the B&W proprietary design documents. There is an apparent error in the above recommendation in that the type 52 documents referred to should be type 32 documents.
Rev.1 42 Nov.22,1996
INDEPENDENT DESIGN REVIEW PANEL RECOMMENDATIONS V.
Technical issues (cont'd) f Responsible Target Completion Recommendation
_ Manager Date 6.
The Panel encourages FPC to continue implementation of a graded approach to instrument error calculations. (IDRP 45)
Disposition: Accepted. The graded approach to J. Maseda Setpoints - 3/3/97 setpoint calculations and instrument error
. Tank Calcs --
determinations is continuing.
7/1/97 5
i i
i Rev.1 43 Nov. 22,19%
m.
e a
INDEPENDENT DESIGN REVIEW PANEL RECOMMENDATIONS
~
i VI. Safety Evaluations l
Responsible Target Completion Recommendation Manager Date 1.
Station management should consider including within the NGRC annual assessment, the Quarterly i
4 Manager Assessment, or PRC reviews an assessment j
l of the cumulative effect of design basis and design j
discrepancies on plant safety. (IDRP 29)
I Disposition: Accepted. A decision will be made as Senior 1/3/97 to which group is best to pedorm the renew and the Management respective charter will be revised.
Team i
2.
FPC should establish a " stand alone" Safety
]
Evaluation (SE) format that requires an integrated l
discussion of the proposed change, its effect on safety, and the USQ determination. (IDRP 31)
{
Disposition: Accepted.
B.Cutherman 4/1/97 3.
A subcommittee of the NCRC should review SEs i
after the fact sufficiently to address quality, trends, and issues and report the results to the full NCRC.
j (IDRP 32)
Disposition: Accepted. The NCRC will consider Senior 1/3/97 establishing a subcommittee to review a sample of.
Management the SE's pedormed.
Team 4.
Consider limiting the number of personnel allowed to perform, review, and approve SEs. This should i
result in sustaining a level of proficiency in the 1
process and thereby improving the overall quality of J
SEs.
(IDRP 33)
Disposition: Accepted. TPC will make a decision on Senior 1/3/97 this recommendation and factor the resulting Management l
approach into the response to Training Team i
recommendation #3 above.
i l~
I 1
3 4
4 j
Rev.1 44 Nov.22,1996 i.
i
INDEPENDENT DESIGN REVIEW PANEL RECOMMENDATIONS Vll. Management issues Responsible Target Completion Recommendation Manager Date 1.
FPC should take action to have the Steering Committee of the B&W Owners Group add the subject of Design Basis to its regular meeting agenda. Significant value could be gained by developing a more standardized approach to this important, emerging issue of design basis validation and control. (IDRP 11) i Disposition: Accepted. See Engineering Expectations R. Widell 2/15/97 recommendation #2 above.
2.
FPC management should revise resource planning i
and work management practices to ensure that adequate time and priority is provided to perform high quality engineering work and reviews. This should include an effective screening process to cancel engineering work requests of marginal value and to assign appropriate priority and schedules to all engineering work. (IDRP 16)
Disposition: Accepted. This recommendation will be resolved by:
o Interim action to establish top ten priorities G. L. Boldt Complete for engineering and a revised PMRG process 10/14/96 to reduce the backlog of plant modification
- work, An integrated, resource-loaded, schedule for F. X. Sullivan 4/30/97 o
engineering work.
3.
FPC should proceed with the planned selective SSFis to further assess and ensure the adequacy of the design basis information. (IDRP 28)
Disposition: Accepted. TPC plans to conduct 7-2 Senior To be included in SSFIs on important safety sptems per year for the Management each next live years.
Team year's annual plan Rev.1 45 Nov. 22,19%
--m._.-
i INDEPENDENT DESIGN REVIEW PANEL RECOMMENDATIONS
!~
Vll. Management issues (cont'd) i Responsible Target Completion Recommendation Manager Date 4.
The assessment of recent design basis LERs (Tanguay i
report) on plant safety should be revised to include an explicit conclusion regarding the cumulative effect i
of the 44 LERs reviewed. (IDRP 30)
Disposition: Accepted. Action complete.
P.R.Tanguay Complete 11/21/ %
5.
FPC undertake a: tion to periodically assess the adequacy of the INsign Bases Program and to report i
on it in a manner thet is visible to management and j
requires organizationai response. (IDRP 44)
Disposition: Accepted. This recommendation will be resolved by:
Engineering department self-assessments, G. L Boldt Tied to Engineering o
o Quality Programs audits.
).Baumstark seif assessment
~
and QPD antal
{
audit plans 6.
The Panel's charter was " Design Basis"; however, it j
found that in some regards similar problems existed in the Licensing Basis. As implied in i
Recommendation 1, FPC should take steps to improve the definition, understanding, and use of the t
Licensing Basis and consider at least Recommendations 2,4,5 and 7 in that regard. (IDRP 46) 3 Disposition: Accepted.'
L. Kelley 6/1/97 4
7.
Develop guidance for operations' personnel that i
2 establishes expectations for their review of j
engineering analyses and calculations. It should be i
j clear that the operations' review is to validate input l
assumptions related to how the plant is operated and to review outputs for effect on plant operation, d
not to provide a full engineering verification. (IDRP 47)
Disposition: Accepted. This recommendation ai/I K. Baker 4/1/97 i
be resolved through revision to appropriate R. Davis i
operations procedures (e.g. Al-500 and/or the Ol's).
i i
I i
f i
Rev.1 46 Nov. 22,19%
I
SECTION D 3
i REGULATORY COMPLIANCE
. 1.
Area of Concern and Management Sponsor:
Regulatory Compliance i
Sponsor: Larry Kelley i
II.
Problem
Description:
i Crystal River Unit 3 (CR-3) does not have a sufficient understanding of NRC regulations and does not assign full compliance with the intent of NRC regulations a sufficiently high priority. Also, there appears to be a perception that conservative decision making regarding regulatory issues is seen as secondary to plant i
availability.
1 This is supported by the following specific concerns:
I A.
Examples of failure to report or untimely reporting of events or conditions.
j I
j B.
Examples of questionable interpretations of the regulations by both licensing and non-licensing j
personnel.
C. Examples of not meeting commitments made in licensing correspondence.
D. Examples of questionable or incorrect technical information provided in NRC submittals.
lil.Present Condition The licensing organization has been modified to infuse knowledge and skills from other areas of Nuclear Operations into the department. The Assistant Director, Site Support position was created and filled by the former operations manager. This new position is dedicated to interfacing with the resident inspectors, I
facilitating NRC inspections, and developing licensee event reports and violation responses. This dedicated resource has improved the ability to identify and respond to regulatory issues in a more timely manner.
Nevertheless, the regulatory interface in some areas of the organization is still inconsistent and more reactive than proactive.
i The Manager, Nuclear Licensing was previously a supervisor in the design engineering organization. This i
experience has improved the capability of the licensing department to review the technical information in 4
NRC submittals and more fully participate e design basis issues and operability evaluations. The focus of i
this position is on managing the NRR interface, preparing all licensing submittals (except those noted above) and supporting teamwork throughout Nuclear Operations. However, additional improvement is necessary j
in at least two aspects of licensing submittals:
l.
1.
Technical quality of submittals, which will require line organizations to take more of a front-end ownership role in submittals for which they provide the technical input.
2.
More timely and accurate root cause analyses to support LER development.
It is also apparent that the knowledge of regulations and of the general regulatory process is not to the necessary level in the other departments. To facilitate spreading this knowledge to the other organizations, j
the previous Licensing Manager was transferred to Operations Support to provide the benefit of his t
t I
f s
nov. i 47 Nov. 22,19%
experience to the procedure writers group and Operations Manager. Additionally, a three-day training course on the regulatory process is being offered to all managers and supervisors in Nuclear Operations.
The training course provides the information needed for non-licensing management to understand the foundation for the regulatory process. We expect a better understanding of the regulations and associated requirements governing nuclear power plant operation. This will result in improved compliance and reinforce the expectation that compliance is a fundamental aspect of nuclear safety.
Additional emphasis needs to be given to intemal processes that assure regulatory compliance. For example, the safety evaluation process must include regulatory compliance as a necessary condition for acceptance of an alternative. The processes that maintain the current licensing basis must have the proper checks and balances to ensure changes are consistent with the regulations. Also, processes that do not directly change the current licensing basis, but deal with the decisions and implementing documents used in the plant, must likewise have the checks and balances to ensure activities are performed within the proper authorization of the licensee.
IV.
Root Causes, Contributing Factors and Corrective Actions The following are the root and contributing causes determined by the FPC/IPl team along with the respective corrective actions to improve regulatory compliance throughout the CR-3 organization.
Root Cause 1 Inadequate communication of management expectations and priorities with respect to safety culture and regulatory compliance resulting in:
FPC positior's on some regulatory issues not meeting the safety intent of regulations.
Regulatory compliance not being considered pro-actively and with high priority when dealing with site activities.
A perception by personnel that regulatory requirements should be addressed only from a perspective of minimum cost.
Inadequate and inconsistent explanations of technical issues to the NRC.
Imprecise or unclear commitments to the NRC.
Rev.1 48 Nov. 22,19%
1 i
I
l Corrective Action Root Cause 1:
Action Responsible Target Manager Completion Date D-RC1-1. Establish a safety culture from the top P. M. Beard Ongoing down that clearly understands and values the relationship between safe plant operations and regulatory compliance.
D-RC1-2. Train managers and supervisors on the B. Cutherman 12/31/96 elements of achieving and maintaining regulatory compliance and its priority in plant activities.
D-RC1-3. Establish a method which will identify B. Gutherman 12/31/96 early on issues with regulatory impact and ensure these issues are appropriately integrated into site priorities for resolution.
D-RC1-4 Develop a site issue integration matrix G. Halnon 12/31/96 that parallels the NRC Resident's matrix. Make comparisons to ensure accuracy.
D-RC1-5. Conduct a third party facilitated self-B. Gutherman 12/31/96 assessment of Licensing.
D-RC1-6 Benchmark key regulatory processes against SALP 1 plants and revise processes as necessary:
. Safety Evaluation Process (Al-400C, G. Boldt/G.
12/31/96 NEP-210)
Hainon
. Maintaining of Current Licensing L. Kelley 2/28/97 Basis Process (NOD-11,52)
. Conduct of the On-Site Safety G. Halnon 12/31/96 Review Committee (Al-300)
. FSAR Update Process (NL-7)
B. Gutherman 12/31/96
. Operability Process (CP-150)
R. Davis 2/28/97
. Reportability Process (CP-111 B. Gutherman 12/31/96 presently)
Rev.1 49 Nov. 22,1996
Root Cause 2 j
\\
Inadequate performance monitoring and trending from a regulatory compliance perspective which preclude:
Focussing on the right issues in the right priority.
Obtaining first-hand information on issue content and sensitivity.
Obtaining real-time information on emerging issues Effective implementation of the safety evaluation process.
j l
Corrective Action:
Action Responsible Target Completion Date Manager D-RC2-1. Ensure a Licensing representative B. Cutherman Completed
)
is part of the graded precursor 10/21/96 screening team to provide regulatory perspective to the corrective action program.
D-RC2-2. Assure appropriate levels of G. Boldt 11/1/97 management meet with the SRI on L Kelley a weekly basis at his convenience B. Hickle for open, candid communication.
D-RC3-3. Identify and monitor emerging L Kelley/
2/28/97 industry issues in the regulatory J. Baumstark area using the CR-3 monitoring / trending program.
D-RC4-4 Provide periodic case studies of B. Gutherman On-going on a regulatory issues and events, both periodic basis internal and external, to help provide parallels to CR-3 expenences.
Rev.1 50 Nov.22,1996
.._..._m._____
i i
e Contributing Cause 1:
i Inadequate root cause/ common cause analysis process which precludes resoiution of long term, high visibility -
regulatory issues.
Corrective Actions:
}
See corrective actions for Root Cause 3 of Leadership Oversight and involvement section.
i j
V.
Measures of Effectiveness:
The following measures will be used to monitor progress and gauge the effectiveness of corrective actions in l
addressing the problem:
Safety Performance index CR-3 Violations vs. Region 11 Average Ratio of Non-Cited / Total Violations Ratio of Strengths to Strengths + Weaknesses CR-3 Licensee Event Reports (LERs)- Compared to the Region ll Average Rev.1 51 Nov. 22,19%
Appendix A Action items Carried Over from Previous MCAP Submittals and Meetings Section D: Regulatory Compliance Action Responsible Target Manager Completion Date D-FU-1 Review the CR.3 50.59 Program and associated B. Gutherman 2/28/97 processes to ensure it is consistent with the 50.59 rule, industry guidance, and current regulatory feedback.
D-FU-2 Review the FSAR system chapters and compare the G. Halnon 3/1/97 description information to the implementing plant documents to ensure they are consistent.
D-FU 3 Provide training to managers and supervisors on the B. Cutherman 12/31/96 i
overall regulatory process. Customize course for 3 days of training by outside professionals with regulatory expertise, facilitated by in-house Licensing personnel to answer plant-specific questions.
I i
l
)
Rev.1 52 Nov. 22,19%
j
\\'
~
s SECTION f I
OPERATIONS PERFORMANCL 1
l l.
Area of Concern and Management Sponsor:
Operations Performance /B. J. Hickle
- 11. Problem
Description:
The Operations Department has not attained a level of performance equivalent to those measured as excellent by INPO and the NRC. Recent outside and internal audits have detailed several areas in need of improvement in order to attain operational excellence.
111. Present Condition:
Although Operations has some noted strengths such as the conduct of shift turnovers, the use of STAR by l
control board operators and the use of alarm response procedures, additional effort is needed to address areas needing improvement. A number of initiatives have been undertaken since March 1995, as part of MCAP i and in response to the MUT event to address them, seas. These have included:
Implementation of the Event Free Operations Program.
i l
Establishment of a mentoring program for NSS's and individuals selected for the SRO upgrade program.
Creation and staffing of a work controls position for day shift.
Creation of an additional level of management to improve management oversight of day to day operations; especially in the control room.
Additional staffing with seven engineers including outside hires to infuse new talent into the Operations 1
Department.
i Performance of an outside team self-assessment to enhance operators questioning attitude and self-critique behaviors.
Notwithstanding these efforts, some problem areas have not been fully corrected as evidenced by:
Component mispositioning events.
Failure to follow procedure events.
Inconsistent log keeping practices.
Failure tn properly self-identify mistakes with the problem reporting process.
Consequently, MCAP ll actions to address root and contributing causes of Operations problems have been developed as described in the following.
IV. Corrective Actions to Address the Root Causes of the Problem:
The following are the root and contributing causes with the corrective actions to upgrade Operations performance.
Root Cause 1 Inadequate implementation of established standards. Supervision has not consistently reinforced operating standards and this has resulted in:
l Rev.1 53 Nov. 22,1996
%e a
s
\\
- 1. Challenges to plant safety.
- 2. Inadequate work practices.
- 3. Failure to follow operational and administrative procedures.
Corrective Actions:
Action Responsible Target Manager Cornpletion Date E-RC1-1 Present a two hour class in Event Free Operations R. W. Davis 10/31/96 which focuses on safety culture to all shifts. Specific items to be covered included: self-disclosure of problems, the need for self-assessments, conservative decision making, importance of increasing margin of safety and the fuel handling event from 10R.
E-RC1-2 Develop and implement a recurring training class on J. Lind 6/30/97 Event Free Operations with r. major focus on safety culture and self-assessment to be given annually to NLO's, RO's, SRO's and Operations management.
Special attention will be given to the need to be self-critical, self-disclosing, and to do self-assessments.
E-RC1-3 Develop and implement a scheduling / tracking program R. W. Davis 11/30/96 that will ensure increased management observation of daily shift activities.
E-R C1-4 Develop structured program for benchmarking by R. W. Davis 12/31/90 Operations personnel to ensure awareness of current industry best practices.
E-RC1 5 Develop structured and recurrent program for self D. Kurtz 12/30/96
)
assessment.
E-RC1 -6 Ensure administrative procedures are included in J. Lind 12/31/96 required reading program and in the licensed operator requalification program.
E-RC1-7 Fine tune performance indicators which will momtor R. W. Davis 12/31/96 shift to shift performance consistency.
Contributing Cause 1:
Inadequate resources within Operations.
i Rev.1 54 Nov. 22,1996
}(
s Corrective Actions:
l Action Responsible Target Manager Completion Date E-CC1 1 Recruit six degreed SRO's for the purpose of providing R. W. Davis 11/30/97 (or completes an STA/SRO Work Control Supervisor to each STA training) operating shift. This will allow the NSM to assume Emergency Coordinator responsibilities full time and j
allow the Shift Supervisor to focus solely on command and control of operating crew.
E-CC12 Reduce the operating procedure backlog to less than R. W. Davis 12/31/97 25 outstanding comments through the use of contract procedure writers.
E-CC1-3 Improve Operations ability to support Engineering by R. W. Davis 3/31/97 adding additional resources to Operations Engineer section.
E-CC -4 Reduce the abnormal procedure backlog to less than R. W. Davis 12/31/97 10 outstanding comments through the use of contract i
procedure writers.
E-CC1-5 An Instant SRO class is in progress with seven (7)
R. W. Davis 6/30/98 candidates.
1 Rev.1 55 N w 22,1996
... ~
. _.._ ___. _...- _ _ _.. m m. m
-_...-____._.m.-__._
i 4
... 1.k
< :4
-Q f
4 Contributine Cause 2:
=
}
. Vague and undear operatinE expectations or standards have resulted in operating short falls.
Corrective Actions:
A Action Responsible Target i
Manager Completior Date t
E-CC21 Benchmark through plant visits and INPO contacts, R. W. Davis 12/31/96 j
those pltnts noted for strengths in clear, concise a
expectations and standards.
E-CC2 2 Review and revise Operations administrative R. W. Davis 3/31/97 procedures to reflect the information gained through j
benchmarking.
i i
E-CC2 3 Ensure Operations standards reflect the core values R. W. Davis 12/31/96 l
and principals for conducting business of Nuclear Operations.
I i
e i
Contributine Cause 3:
1 inadequate :oot and common cause analysis resulting in management failure to address the right issues with proper priority, t
Correctm Action:
4 e
j E-CC3 See Management oversight and involvement.
J i
Contriht.%
t t ause 4:
J l
Inadequate performance monitoring and trending which precludes proactive identification of emerging issues.
i-Corrective Action:
E-CC4 See Management oversight and involvement.
i-i i
i h
1
?
i i
(
i I
J J
1-1 i
i e
l l
3-Rev.1 56 Nov.22,1996 f.
)
+ -. -, - _
y
4
.?
(
V.
Measures of Effectiveness:
The following measures will be used to monitor progress and gauge the effectiveness of corrective actions in addressing the proble Procedure Compliance Indicator Precursor Cards by Shift Watch Station Appraisals / Shift Component Not in Expected Position 1
Number of Weaknesses, Violations, and LER's I
RAD Dose / Shift TPM Signoffs/Shrft l
i l
i i
l 1
I 1
l l
Rev.1 57 Nw. 22,1996
._.-...._-_.~__.m___
__.m.
.-..-..~.,m.._~
m _. _...,... ~
i a O
0,
t1 Q
-\\
'i Appendix A Action items Carried Over from Previous MCAP Submittals and Meetings
}
1 4
3 Section E: Operations Performance a
1 4
Action Responsible Target Manager Completion Date l
A.FU-1 Nuclear Shift Supervisor (NSS), targeted NSSs, and R. W. Davis Continuing SRO upgrace mentor program established.
A-FU-2 Implemented NSS annual performance Eoals that D.deMontfort 12/31/96 address weaknesses identified by IPC/NRC/lNPO.
A-FU-3 Address all identified EOP weaknesses.
G. A. Becker 11/30/ %
i' A-FU Operations weaknesses are evider: in work practices R. W. Davis 12/31/97 i
outside the control room, self-critical attitude, and operating procedure backlogs. Operability assessments require increased sensitivity.
4 4
A-f U.S Mentor Program meetings are continuing, mentors R. W. Davis Continuing
{
receiving more frequent communications from operations personnel regarding on-shift concerns, i-i i
i I
I i
f i'
I s
4 9
4 t
3 4
I
)
i l
'l 4
1 b
1 i
j t
\\
4 I
1 5
Rev.1 58 Nov. 22,19%
i 1
i
.