ML20136E448
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nao UNITED STATES y
/ NUCLEAR REGULATORY COMMISSION REGION 88 4o 101 MARIETTA STREET N.W., SUITE 2000
- 4 b l ATLANTA, GEORGIA 33234180
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/ OCT 8 1996 MEMORANDUM TO: J. Johnson. Acting Director. DRP A. Gibson. Director. DRS FROM: Stewart D. Ebneter. Regional Administrator Q
SUBJECT:
ST. LUCIE SELF-ASSESSMENT St. Lucie has finished an internal self-assessment that spans the period from January 1994 to May 1996 (plus observations since May) The self-assessment >
re) ort has been provided to us and there are numerous references to NRC and IN)0.
1 All managers and inspectors assigned to St. Lucie should read the assessment and provide a brief written assessment of the areas they are. responsible for. !
Your assessment should address. 1 i
- a. Your view of FPL assessment: is it correct?
- b. Did NRC identify via inspections and/or SALP any indicators that should have prompted us to potential problem. .
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- c. Did we pursue any of the indicators? If yes. how. If no' why not? .
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Attachment:
St. Lucie Self-Assessment I
hl 9703130211 970306
< C .PDR FOIA-BINDER 96-485 PDR
j Florida Pow r S Light Compary. P.O. Bix 128 Fort Pirree, FL 34954 0128 October 3,1996 lllll3L, L-96-263 10 CFR 50.4 U. S. Nuclear Regulatory Commission Atta: Document Control Desk Washington, D. C. 20555 RE: St. Lucie Units 1 and 2 Docket Nos. 50-335 and 50-389 Cnmnletinn nf Kt i nele % elf Aenecament In response to a series of events at our St. lacie plant, site management directed that a self-assessment of the operations at St. Lucie be conducted. Critical self-assessments provide a good approach for an organization to return its performance to a standard of excellence. The pu.- pose of this letter is to transmit the results of the self-assessment.
The St. Lucie self-assessment was conducted from May to September 1996. It covers the areas of safety amenenent/ corrective actions, opentious, engmeering, maintenance, plant support, and management policies.
The assessment period covered approximately two and one half years of operation (January 1994 to June 1996). 'Ihe attached naramment identifies sorne fundamental issues that are being addressed. 'Ihe management I initiatives to address these issues will be finalized by October 11,1996. We will provide you with a copy of these initiatives upon completion.
Although St. Lucie remains a good performer, as noted in our last ratings from the NRC, we will not be satisfied until our standards of excellence are met. 'Ihe attached self-assessment was designed to be critical of the plant's performance and does not focus on areas of strength. Its purpose was to identify areas of improvement so St. Lucie can return to its outstanding level of performance as one of tlw best plants in the nuclear industry. We are making progress to improve our performance arx! the self-assessment has assisted us in these efforts.
A St. lacie Plant status meeting is MW in Atlanta on November 12,1996. We plan to more fully discuss the results of our self-assessment at that meeting.
Very truly yours, J. A. Stall Vice President St. Lucie Plant JAS/GRM cc: Stewart D. Ebneter, Regional Administrator, Region II, USNRC Senior Resident Inspector, USNRC, St. Lucie Plant MCMw an FPL Group company
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@ FPL. !
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PSL SeVAssessment September 30,1996 i
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Jim Scarola, Plant GeneralManager (Team ind")
David Culpepper, Chief; Engineering Assurance -
Kim Heffelfinger, Protection Services Supervisor RobertDe La Espriella, QA Supervisor (Facilitator) 9 8
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I PSL SelfAssessment
. Acknowledgment Signatures ,
This assessment was completed with the full support of plant personnel and station supersisors and managers, and was led by a team ofPSL plant staff, as acknowledged below.
PSL PLANT GENERAL MANAGER-c / , - r. - -
SELF ASSESSMENT TEAM: h z
@ w'An -
R J. Dele %praeQa, Team facihtator
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NOTE This report focuses on identifying the fundamental weaknesses at St. Lucie, and was not intended to be a balanced account of strengths and weaknesses.
While some strengths and many positive initiatives were documented, they were provided for historical and contextual perspective. To provide a b=1==d view of overall station performance would require additional efforts i to document other strengths and positive aspects of PSL performance that were not identi5ed as part of this self-assessment's self-critical mission.
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TABLE OF CONTENTS :
EXECUTIVE
SUMMARY
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 ,
. METHODOLOGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 DE, I a n NS ES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 4 I. Complacency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 II. Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
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HI. Self-assessment ................................................'15 I
IV. Corrective Actions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . '. 16 V. p_ra me .hir3 y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 VI. Programs / Processes / Procedures . . . . . . . ...........................21 i VII. Change Management . . . . . . . . ............................. . . . . 25 )
VIII. Communications . . . . . . . . . . . . . . . . . . . . . . . . . . ........ ......... 27
'l PSL ..e . . . . . ... .... ..... ...... .... ,, ..,..
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k i EXECUTIVE
SUMMARY
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i The peformance and operating history of the St. Lucie nuclear station from 1984 to 1994 earned it
- one ofthe best rq=*=tians among nuclear plants world wide. Dunng that decade, St. Lucie set world
, records for nareirmiana plant operations, receiving the highest marks from regulators and praise and
- j recognition from the nuclear industry. For example, in 1985, St. Lucie Unit 1 (FSL-1) was the first
. reactor ever to record an average annual load factor of over 100%. From 1989 to 1992, PSL-2
- successfully ran for 427 consecutive days, and following a succadd outage, ran for another 502 consecutive days which, at that time, set the world record for continuous operation. The NRC l graded St. Imcie a perfect 1.00 for the SALP evahistiari periods endmg in 1992 and 1994, noting that ,
. "St. Lucie continued its history of exceptional performance, attaining superior ratings in all SALP j fimerianal areas for the second consecutive SALP period." INPO also rated St. Lucie's performance i
-as a"1" for the three consecutive gradmg periods ending in June 1990, April 1992, and August 1995, "in recognition of the achievement of excellence in nuclear plant performance." l L .
i Beginning in August 1995, a series of mgnificant problems and events indicated that St. Lucie plant i performance had declined On August 8,1995, during shutdown conditions, an inadvenent main j armem inalatian signal (MSIS) was generated and reactor coolant pump seals were damaged, because operators did not meet procedure requirements. At this time, it was also discovered that the PSL-1
- power operated relief valves (PORVs) had been improperly assembled during the 1994 outage, and were inoperable throughout the operating cycle. On August 17,1995,10,000 gallons of borated water was sprayed into the PSL-1 containment through the contamment spray (CS) system, when that system was inadvertently cross connected with the shut down cooling system. FEcctive corrective
. areiana were not taken to preclude system rehefvalves from hfting inappropriately on three occasions in early 1995, and in August 1995, the shutdown coohng system relieflifted again, releasing 4000 gallons of reactor coolant into the Unit 1 pipe tunnel. Later in the year, the PSL-2 reactor pressure vessel O-rings failed to seal properly for approximately the fifth time in the history of the Nuclear i Division, causing significant delays in the r-R= Hag outage. The latest in this series of events occurred on Januaiy 22,1996, when an operator error resuhed in an inadvertent dilution of the reactor coolant
! system at PSL-1.
4 PSL plant managaraant determined that a critical self-assessment of the operation of PSL was needed, to determine the cause for this decline in performance, so that PSL could regain its statu's as one of the finest plants in the nuclear industry. On April 26,1996, the PSL Site Vice President directed the
- i. Plant General Manager to conduct a broad self-assessment of the operation at PSL, to identify the
, faadamantal (most limiting) weaknesses which have caused a decline in PSL performance. This assessment covered the areas of safety assessment / corrective actions, operations, angia-ing, maintenance, plant support, and management policies. It was conducted from May to October 1996,
- and required approximately 4000 man-hours to complete. The assessment period covered eyyn=# twofand a halfyears ofoperation (demaat reviews from January 1994 through April
. 1996, and observations from May through June 1996).
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- trending processes did not typically monitor the effectiveness of corrective actions,.or
- effectively identify adverse trends lastly, corrective actions were seldom provided to correct l~
self-assessment dafisacian and corrective action weaknesses when self-disclosing problems and repeat events occurmd.
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- 5. Ac==-- : *2M T *ek of ci==M aat === . - ==e mad /or enforemamat of individn=3 !
- i i accouptabilities PSL managamant did not clearly state a=aa*=+iaan and hold individuals ac==*=hle for meeting those ara-a+=+iaa= Implementing procedures were less l i
- comprehensive and,less speci6c than that required for effective establishmant of accountability. Plant persannal were not held accountable for their performance by i supervisors and managers, and as a result, waalra-a developed in the areas of attention to ,
detail, procedural adherence, configuration control, and other areas of responsibility.
6 Prom 2..:/Pic ==== /Pr.- =.+. ires: T ark of amnh==ie on. and ar-mt=hility for. ~ - - p = f nronrama - --- or nrhes. The PSL events of1995 and 1996 revealed weaknesses .
1 in a variety of the programs, processes and procedures used at PSL. Knowledge based 4
procedures were in use for many years, relying on experienced, trained personnel to properly
! perform tasks despite limited procedure detail Personnel performance and job completion
' were valued more than having cormet procedures. Inadequate procedures and processes were " worked around" r.nd were not'seen as a significant problem for the plant. Program
- performance has suffered due to a lack of program =acemtahility.
i 7. chan a Man =oament- T.== than =Aaan=t* :.. ..!=.:== tion of chanaan SipW=e organizational and administrative changes were implamaa+ad at PSL in 1995 and 1996.
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However, after years of stable operations, the PSL team was not accustomed to change, and had not developed the " change management" skills needed to assure ois.id Gonal and process changes were =MHy imalamaated. As a result, the significant changes were not i carefully evaluated and managed to ensure tint the organizations transitioned =maathly into their new areas of responsibility. In some cases, continuity was not maintained for critical i functions of the Or==ai'=* Ion.
- 8. Comnnmiratians: i >== than =daanata enmnumira'ians contribut*A to a lack of comman focus '
and cohesivena== in the oreanivatian. Communication at PSL suffered because the t
' uyoit.re of clear written and verbal communications was not empbaei ad and mathads for communicating issues and *=act=tions up and down the management chain were not well defined. ' As s' result, a number of station performance problems developed due to communications waakaa====.
At the time of this report, it is recognized that St Lucie has odertaken numerous changes in
, personnel, paw and procedures over the past year. Between August 1995 and September 1996, !
most key managers were replaced at St. Lucie, including the Site Vice President, the Plant General l.. Manager, the Operations Manager, the Work Control Manager, the Engineering Manager, the , .
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DETAILS INTRODUCTION i
'Ihe W .u. - + and operating history of the St. Lucie nuclear station from 1984 to 1994 earned it one of the best repenians among nuclear plants world wide. During that decade, St. Lucie set world records for nami=== plant operations, receiving the highest marks from regulators and praise and ;
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mcognition from the nuclear industry. Lyi- - .:-hs from the US and international nuclear l
- industry 9equendy visited St. Lucie to handunark their performance against St. Lucie nuclear plant l Operations and processes '
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L St. Lucie Unit 2 (PSL-2) began commercial operation in late 1983, and FPL received industry 4
recognition for completing its construction within six years, on time and under budget. During its
- first cycle ofoperation, PSL-2 achieved a 92.5 % capacity factor and attained a 203 day continuous i
run at power. 'Ihe NRC ranked PSL-2 first in initial power operation among new US nuclear plants during 1983-1985. This ranking was based on statistical analyses of the first 12 months of operating
, experience using reactor protection system actuations, =gE :3d safety feature actuations, safety l
system peribernance, radelogicai releases, and external events. In 1984, the first refueling outage for PSL 2 was completed in less than 38 days, which was in itself an achievement that was r~p-M
- with a cover story on Nuclear News, a national pC ;cs. In 1985, St. Lucie Unit 1 (PSL-1), which
! started conunercial operatica in December 1976, was the first reactor ever to record an average -
annual load factor of ovr: 100%, which received national recognition from Nuclear 5=p==isg-l j International From 1984 to 1986, the average NRC Systematic Assessment ofLicensee Performance (SALP) score for St. Lucie was 1.40, compared to an industry average of 1.70 (SALP scores range l
- from 1 to 3,with I bing the highest).
1 In 1986 and 1987, PSL-2 achieved a capacity factor of 98.3% with the unit on-line for all but 8 days i of a 485 day cycle. In 1988, PSL-2 never went offline, and was rep *M in Nucleonics Weekly for achieving a 100% capacity factor. The single and multiple unit ...kisgs of St. Lucie placed these i units at the top ofUS nuclear plants for capacity factor in the late 1980s. In 1989, FPL was the first j company in the world outside of Japan to be awarded the Deming Prize by the Japanese Union of j- Scientists and Fr.pr m for its achievements in Total Quahty Management. The pinnacle of St. Lucie performance occurred from 1989 to 1992, when PSL-2 successfully ran for 427 consecutive days,
! and (foBowing a =_~*==M outage) ran for another 502 consecutive days which, at the time, set the world record for continuous operation.
" *Ihe average NRC SALP scores for St. Lucie improved from 1.14 in 1989, to a perfect 1.00 for the
- SALP evaluation period endmg in 1992. The NRC again assessed St. Lucie with a perfect 1.00 SALP rating for the period endmg on January 1,1994, noting that "St. Lucie continued its history of exceptional performance, attaining superior ratings in all SALP functional areas for the second j consecutive SALP period. This contmued high level of performance resulted from a dedication to excellence and teamwork by those associated with the facility. It was fostered by proactive e
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NLsayAmmamme J-approximately 4000 man hours to complete. The assessment period covered approxunately two and '
one half years of operation (document reviews from January 1994 to April 1996, and observations from May to June 1996).
METHODOLOGY I PhaseI: Initial Assessment i The purpose of the first phase of the assessment was to develop an initial assessment of the
- . performance of St. Lucie operations.
- . From May to July 1996, the Self A=m===nt Team performed document reviews, conducted personnelinterviews, and observed various aspects of plant operations. During this phase, the team was supplemented by approximately 15 knowledgeable individuals from FPL and the nuclear industry, which allowed the team to gain independent insights of performance at PSL. The following functional areas were assessed.
l I. Operations
. II. h=i=-:ig III. Maintenance IV. Plant Support -Health Physics 4
V. Plant Suppon - Security VI. Plant Suppon - Emergency Preparedness
- VII. Site Management Policies and Ewations VIII. Safety A====e/ Corrective Actions ,
! Examples of good or weak performance were grouped together within each functional area, and assessments were developed to characterize the general performance during that time. The assessments and their supposius examples formed the basis for the overall Phase I initial assessment.
i The following references / sources were used during the document reviews, covering the period of
. January 1994 to April 1996.
, A. NRC Inspection and SALP Reports.
7 B. PSL 1 and 2 Licensee Event Repons.
C. NP-700 Problem Repons.
PSL In-house Event Reports.
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E. PSL Condition Repons.
F. PSL Plant Manager Action Items.
G. Quality Assurance audits.
H. Independent Technical Resiews.
I. Depanment self-assessments.
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i to their inherent impact on many aspects of PSL operation, these limiting weaknesses must be 3
- addressed before the overall performance of St. Lucie can unprove. i i
i i The limih., waak===*= are discussed in detail in the main body of this report.
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i PhaseIV: Corrective Actions i
l . Following the completion ofPhase HI, management initiatives were developed to address the PSL j r : :"5 waak===*a identified in this report. Additional corrective actions will be implemented by I i
each Department Head for problems identified during Phase,I and II that were not previously l
, addressed In mary cases, conective actions have aheady been taken in response to condition reports (CRs), audit findings, NRC violations, etc.
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1 Management initiatives to address the issues identified during the PSL Self-assessment are j documented in Appandiv C to this report.
i l Phmaa V: Imnlamantatian and Follow un 1 -
l FoBowing c+ pd-w of Phase IV, the management initiatives will be implemented by the assigned
- Managers and Department Heads. Action plans for broad problem areas (e.g., limiting waakna==ae) will be screened by PSL plant management for inclusion into the PSL 1997 business plan.
l To monitor the effectiveness ofinitiatives and action plans, appropriate indicators will be developed j
- l. knd maintained to monitor the performance ofidenti6ed problem areas.
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rstsemannev Ms , to high levelindicators m:nitored by regulators. As a result, plant management did not utilize all the information available to fully evaluate performance of the entire o ur rJ Jon.'
'A third effect of Re/== y at PSL was an overall raiarance to change. Site personnel and plant management were rdw* ant to accept evidence of performance wea**== unless that evidence was presented by the regulators. The plant team actively worked to minimize attention to problems id=*ifi=I by internal and external oversight activities. There was an emphasis on kW problems in-house, and problems were not typically viewed as opportunities for hnprovement An adversarial r=lariaaship between PSL Quality Assurance (QA) and plant management reduced the effectiveness of the QA organization, and QA executive management's performance standards for QA did not
=diciaely empower oversight personnel Finally, plant management's isolationist approach stifled interaction with other m===M Power Reactor licenem Nuclear Division policies and penenenmutations from outsiders were not well received or accepted at PSL. The PSL management
- team was not eager to share its problems with others and did not recognize the importance of organizational'widsg as a contributor to continuous performance improvement.
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Complacency affected key plant departments in a variety of ways. In the Operations Department, procedural and p Lews weaknesses were identified but not effectively resolved. Poor pnocedure quahty.was tolerated in some cases, and individuals who operated successfully in spite of procedure weaknesses were recognized as good performers Procedure upgrades were recognized as being manpower intensive but su8icient resources were not allocated to resolving all known procedure
- j. de6ciencies. Operator performance expectations did not foster continuous improvement and j management attention was not focused on contmuous improvement Reports issued by NRC and QA frequently praised operator response to real-time plant events and failed to identify broad based l 1 operator weaknesses, operations management did not utihze lower level indicators to reveal the need
! for performance improvements , l In the F=p- - ig Department, formal problem identi6 cation and evaluation tools and techniques 4
, were not routinely utilized, because departmental management did not set high e ++ Mons for
! effective problem identification, evaluation and correction, and problem solving skills became a low r priority. As a result, there was a lack ofrigor in problem analysis, and problem evaluations were not {
effective in identifying underlying causal factors. Underlying causes went unidenufied, corrective l r actions often addressed symptoms, and p'roblems recurred. The engineering processes resulted in l l costly and frequently ineffective solutions.
v l The Maintenance Department suffered from its inability to evaluate and resolve repetitive equipment failures and prevet repeat events. Maintenance accepted poor equipment performance, and lacked {
the ownership and resolve to correct long standmg equipment problems. The Outage Management.
Department was also hampered by complacency, and the continuation of poor outage scope control practices prevented PSL from consistently meeting outage schedule, performance and budget goals.
j Plant departments lacked discipline in adh'ering to pre-outage milestones and most outages were i
- initiated without preparations being fully completed; crisis management became a frequent outage 11 1
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rsts rAmas==t emergency and off-normal operating events However, there is some evidence that the operator training program did not keep pace with industry standards for excellence during routine operations. J Successful operator training dapaada on routine constructive communication between Training 3
. Department management and Operations Dei, Locat management. Evidence of weakness at this ,
level orcommunication was found in the' comments of on-shift operators who expressed a need for :
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. increased taining in areas ofperinnnal management +%=e, Technical Specification interpretation and Emergency Plan duties 'Ihe marginal effecseness of the STOP self-checking program indicated .
that training emphasis was needed to ensure operators recognized the value of self d=+iag and
- reinforced the management == +=+ians for operating crews Some administrative duties, such as Post Maintenance Testing coordination, and implementation of Equipment Clearances, have
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1 periodicaDy canaad problems on-shift which indicate a need for increased training emphasis. These it needs have not resuhed in timely curriculum modification. l i
Weak communications from Training Dep Lucat management to Operations management were f' indicated by the fact that inadequate operating procedures were not consistently identified by the j
i operations training group. Evaluation of recent operator performance issues led to the conclusion '
that operator simulator training was resuhs oriented and insuuctors sometunes accepted the trainees' abihty to "get thejob done" rather than insisting on procedure compliance during simulator training In general, obsavers M-- =ad that tuining has sometimes accepted the standards used for day-to-day operation in the plant rather than =ia*=iaias performance standards consistent with all
- management +-i+
- :mions. Finally, several weaknetses in Emergency Plan classification and notification noted durmg drills and NRC ia==
- ions indicate a need for added training emphasis in l
these areas. Supervisors in the Operations Department have commented that formal managerial skills
- development training would help NPSs more effective in managing their shifts, setting q+
- :" Ions and holding individuals accountable.' -
i Although the Maintenance Traimng programs continue to meet NRC requirements and INPO i awW=lan criteria, specific cuniculum waaleaaaac were mentioned by maintenance representatives. .
] Supervisory skill trainmg for first line supervisors was found lackmg and the necessity and importance-
- i. of pre-job tailboard meetings was not emph==ivad Supervisors commented that industrial safety.
issues did not receive the same training attention as maintenance production processes, which may have contributed to the large number ofinjuries reported during the first half of 1996. Maintenance
- personnel interviewed stated that less than adequate training existed for topics such as Foreign Material Exclusion, Crane Operator qualification, and materials management using the Passport system. -
. In the Engineering organization, most training was handled informally on-the-job, and Engineering Department supervisors concluded that their personnel selection and development processes were i
weakened by a lack of training resources. Supervisors indicated that the emphasis on on-the-job training (OJT) rather than formal professional' development was detnmental to the full development l
- of their personnel. Engineering supervisors stated that some instances ofless than adequate plant
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- Similarly, management -==*+an for self-manaeament were stated in late 1995, but self-assesament
- training was virtually non-existent at PSL. l
[ A key element oftraining success is formal feedback from the plant line organization to the training depnetment to alks timely idanhfemtlan ofweaknesses and new training needs, and to identify those
- training elesnents and 14 ;+im which are particularly useful In early 1996, it was racag=i=d that
, ad inadequate amount offormal faadhack was being received from Managers and Department Heads l
concerning ti.i.Jrg effectiveness for their key programs Corrective action was implemented to ensure routine feedback was provided on each of the accredited programs l
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IIL Self-assessment: Lack of emphasis on identifying and wirstirig problems at the 1
worker and supervisor levels (first and second levels of defense of i quahty). '
A sound self-assessment program is one that promotes the identification and resolution of problems l
- at the worker and supervisor levels, before problems become more significant or manifest themselves during events. There are numerous methods by which self-assessment can be performed, and i i different times when each method should be twili=d For example
- routine self-chacMng is
! appropriate when performing plant evolutions; periodic self-assessments should be conducted to evaluate the performance of a group on a contmning basis; reactive self-assessments should be l
5 performed following events or significant problems; and pre-emptive self-anaenaments should be conducted following significant changes, to determine whether new vulnerabilities were created ,
t Nuclear Division Policy NP-805, Revision 0, dated 3/15/94 states that "ench direct report to the j President, Nuclear Division shall perform appropriate self-assessments " However, self-assessment was not well defined within the Nuclear Division, and PSL plant management did not set clear -
i . expectations for the performance of routine self-assessment or emphasize the value of formal self-assessment At PSL, implementing procedures and training on self-assessment were not established l
j (with the exception of the Security Department), because the need for continuous improvement was j not r+xWi by plant management and personnel. For many years, PSL station performance was rated among the best in the country by regulatory standards, and PSL management sought to maintain i the status quo. As a result, self-assessments were mostly conducted to address significant events, and
- self-assessment was not routinely used to identify and correct problems at PSL.
! The lack of effective self-assessment was evident in many departments at PSL. In the Operations
! Department, self-assess'ments were superficial and conducted mostly by outsiders. As a result, i' opentor weaknesses in the areas of attention to detail, procedural adherence, configuration control,
- and watch standing / log keeping practices were self-revealing, or identified by internal and external j oversight we =iions. Operations dw..mt supervisors and training instructors did not recognize the value of self-checking and did not' adequately reinforce its use during training and on shift The operator self-do.kirg process (STOP) was marginally effective in preventing inappropriate operator 15 l
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i reczarrence, and were often not applied to other programs, processes, procedures, or equipment that suffered from the same weaknesses Corrective action tracking and trending processes did not typically monitor the effectiveness of corrective actions, or effectively identify adverse trends: Lastly, j
correctrve actions were seldom provided to idennfy self-assessment deficiencies and corrective action 1 weaknamaan when self-disclosing problems and repeat events occurred 4
! After receiving the Deming Piize in 1989, Nuclear Division management va+ ions to reduce adminimative burden resuhed in an emphasis on less formal approaches to problem solving, with the l
i assumption that the Nuclear Division would continue to identify and correct problems in a high
! quainy manner. PSL managesnent reduced training on the madama *=I= ofproblem solving and root cause evaluations, did not set clear expectations for effective problem resolution at the worker and l'
supervisor level, and did not emphasize tracking in-process performance indicators or tr r. ding the
- long term effectiveness of corrective actions. PSL focused on prompt action item closure, which j resulted in brief problem evaluations and less than effective corrective actions. Procedure changes
! were often accepted as a corrective action because they were the most expedient.
- Alt % ugh processes were~in place to evaluate and correct significant problems and events, PSL did l not develop its own site wide process for de
- =J g and addressing (Iow threshold) problems until i 1994. In the absence of a mechanism to capture low level problems, some departments developed their own problem documentation and correction processes However, the processes developed by
- departments were largely ineffective in preventing problems.from recurring, as they were not as i visible to PSL upper management, and lacked critical attributes such as tracking the completion of corrective actions, and trendmg the effectiveness of corrective actions.
} Site-wide processes for de:=d ;g and corrwing problems similar to the PSL Condition Report ,
growes, are highly effective awhads for capturing problems of all levels of significance The PSL CR process was implemented in April 1996. The threshold of the CR process was low, which
- provided n-.=ger = with a source orlow levelindicators of the health of plant programs, processes
! and aanipment However, plant personnel were not well trained on the CR process, which di=ininhad its effecoveness For example, problems were not always properly characterized, CR evaluations did
' not always identify the appropriate causal factors, and generic implications were infrequently considered. PSL's implementation of the CR process did not provide an effective prioritization i
method All CRs were required to be dispositioned (with corrective actions identified) within 30 days of CR issuance. The short turnaround time and high volume resulted in the need to prioritize problems according to significance. This was not initially done, and the quality of the problem evaluations suffered. In addition, the CR closeout reviews were sometunes ineffective in identifying da&4aadw As a result, corrective actions were less than effective in many cases. The CR process also trends causal factors, which is instrumental in the early identification of' adverse trends.
!' However, little guidance or training was provided to personnel performing the trending.
In the Operations Department, corrective actions were provided to reduce temporary syttem
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alterations and other hardware deficiencies that caused operators to work around problems.
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Effective assignment of seem=+=hility is accomplished through policies, procedures and quality instructions which clearly establish responsibilities. High level policies are progressively explained 1
in increasing detail down through the hierarchy of procedures. Nuclear Division Policies clearly
, defmed the a a-wiaae, performance standards, and implementation responsibilities for key Division
! prn - mas As these pohcies were further dermed for the PSL site organization through implaman+iaa procedures, the communication of responsibilities was less comprehensive and less specific than that required for effective establiah naa+ of secom*=hility. Several programs and processes which apply to all plant departments were affected by management's reluctance to clearly state q+-Mons and hold individuals accountable for meetmg those - ;-+=+iaac Correctrve actions, the Facilities Review Group (FRG), Emergency Preparedness, radiation protection, Industrial Safety, design control, overtime control, and training all suffered due to a lack of clear assignment and/or enforcement of l
acce=+=hilities.
f Operators were not held secom*=hle for their performance by supervisors and managers and as a resuh, weaknesses developed in the areas of attention to detail, procedural adherence, configuration .
control, and watch standmg/ log keeping practices. Procedure quality deteriorated because the i v=fion and ecce=+=hni+y for maintainmg high quality operating procedures was not properly l emphani=1 and strict procedure adherence was not consistently enforced on-shift and in training i
Department Heads and Managers were not held accountable for the quahty of the analysis and
, corrective actions provided in CR closures, as evidenced by many problem evaluations which were ;
not effective in identifying underlying causal factors.
j Management expectations for communications from acting FRG Chairmen and the Plant General Manager were not consistently understood by acting FRG Chairmen. FRG subcommittee reviews were not consistently performed as defined by the Quality Instructions (QIs) due to a lack of enforcement of this accountability.
PSL plant management did not emphasize individual responsibility for continuous emergency .
j readiness, and ownership of all EP problems was perceived to reside with the EP Department. l Interdepartmental issues relating to ERO assignments, performance, and program support,.were usually assigned to EP, and not to those with the authority to resolve the issues. Emergency ~
preparedness procedures did not describe all ERO positions and their responsibilities. As a result, the performance of the ERO during the 1996 evaluated exercise did not meet management arpe+stions.
i Individual accountabilities for programs such as radiation protection and hot tool control were not l adequately reinforced. Many repeat problems in the HP area were due to a lack of accountability for j l
personnel r=di=+ian exposure at the worker and supervisor level. HP was ultimately held accountable for radiological problems, even when created by other departments. Foreign material exclusion I I
. pungem requirements were not taken seriousl by plant personnel because individual accountability was not enforced.
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g rSLSeVAnnmaand PSL' plant management did not strictly enforce overtime policies !=-anaa overtime had become a
- no mal way of getting the job done, and it was not feh to have had a negative impact on plant i P*i .
VL ProgramsG.w7.dures: Lack of anphasis on, and accountabihty for, W i programs, processes or procedures.
i j At PSL, plant management designed many programs, processes and procedures to establish clear
- roles, responsibilities and performance standards, monitor performance and initiate action when ,
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needed, to ensure the plant is operated and mair*=inM in a manner which protects the health and
- safety of the public and plant workers. During the evaluation period, a variety of plant programs, i processes and procedures were evaluated by regulators and inspectors and a number of strengths I were reported in these areas. For example, the NRC SALP report issued on February 8,1996, comnanM that the overall p4v -.r.ce of the Rp+ -Lg group was superior with specific strength
- demonstrated in the area of design and installation support, the inspectors commented that the l department had produced a number of well =p-:-: ed and implemented plant modifications.
Furthermore, the dep Locr.t received praise for its-demonstrated commitment to safety and compliance with regulations as well as its support of various mamtenance programs such as Non-Destructive Examinations Fada-ing emphasis on the monitoring requirements for alloy 600/690 apphcations in plant systems was perceived as a strength, as was the maintenance specification
- program In addition, the NRC identified (NRC Ta=a-+ ion Report 96-08) a strength in the l Ergir- Lg Depanment's Steam Generator eddy current testing program and Safety Evaluations, l '
, which demonstrate a commitment to safety and compliance with regulations.
The Maintmance oiWon received positive feedback on improvements made to the preventive
- maintenance program, through reviews and evaluations of basis, scope and frequency of tasks Maintenance efforts to improve unit reliability and reduce outage work scope by using effective on-line maintenance processes were highly regarded by INPO during a June 1995 evaluation.
- Mdirianally, the INPO report identified that the PSL multi-disciplinary team working to improve air
' operated valve performance, and the diesel fuel filtration skid for new fuel, were maintenance Program strengths In 1995, INPO cited the Operation Department's use of a computer model for predicting core reactivity changes during power maneuvers as a strength in reactivity management. In addition, the
. . use ofexperienced Operations personnel in the support of daily maintenance planning was recognized as 'a strength. Operations management was recognized for cautious and deliberate decisions concerning plant operations, and on-shift operating crews were commended for their professional j response to plant off-normal events.
Operating and maintenance events at PSL bgianing in August 1995 resulted in a level of scrutiny by internal and external reviewers which effectively revealed weaknesses in a variety of programs, 21 I
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- 9. Post Maintenance Testing Process (PMT): The process for completing PMT prior to returning equipment to service was weak, and resulted in some safety related 5:omponents i being returned to service without veri 6 cation of a satisfactory PMT.' '
) 10. Facility Review Group (FRG) Process- FRG processes were inefficient and the j =M== were not effective in redudag the FRG's work load. Managers identified that personnel assigned to perform FRG adwvunmittaa reviews lackad accountability for that task, 4
- and in general, FRG members did not feel ownership for their FRG duties. PSL plant j management expawinas for coinmunications bet w acting Facihty Review Group (FRG)
' Chainnen and the Plant General Manager were not consistently understood by acting FRG i Chairmen.
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- 11. Management Review Board (MRB) Process
- The MRB was tasked with evaluating and approving plant changes and modifications. As a result, engineering work was largely j determined by MRB approval. The MRB process was less than effective hac=u=> it lacked L prioritization and integration elements for addressing improvement and cost avoidance j projects, and MRB cost benefit considerations did not suf5ciently consider benefit.
- 12. CnaMari Report (CR) Process The CR procedure provided little guidance with respect to
! what enaM effective problem solving The CR process lacked an adequate prioritization scheme, CR conective actions were sometimes unnace==ily delayed by defemng action to l
! the PMAI process, and corrective actions resulting from CRs were not clearly linked to the MRB process
- 13. F;W Performance Monitoring Process
- Procedures and processes for the maintenance ofequipment lacked m&iarit detail to adequately monitor and trend equipment performance problems.
14 Document Update Process: The process ofidentifying and updating plant procedures was inadequate to keep up with the volume ofplant modification packages. Similarly, the revision i of plant drawings to reflect as-built conditions were not completed in a timely manner, and discrepancies between drawings and field conditions existed. FSAR reviews and FSAR l updates were not routinely considered as part of the modi 6 cation package process. This resulted in numerous discrepancies between operating practices and those described in the
! FSAR.-
- 15. Identi6 cation and Analysis of Rework: Procedural guidance for this program was not well L defined and, as a resuh, the impo rtance of captunng rework data was not well understood.
In addition, the difference between rework and repetnive equipment problems was not clearly defined p
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! me, j numbers ofprocedures,like Operations, have embarked on a major procedure revision project. The i
- , upgraded procedures, along with those strong programs, processes and procedures which rammin in place, are expected to form the basis for c=*ianai improvement at PSL and a solid foundation from j i which to build future success l 1
, VIL Change Management: Less than adequate implementation of changes. j J
[ A strength of the PSL orFanivation has always been the stable, expenenced workforce, and their
{ abihty to work as a team. Many employees have been at PSL since the startup of the nucl. ear units.
The result has been many years ofconsistently safe operations, and industry recognition for its record ;
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. atting performance. Over a period of time, those successes led to a reluctance on the part ofPSL i plant management and site personnel to accept evidence of perfonnance weaknesses brought forward j by regulators and internal and external oversight organimions, as well as a reluctance to implement !
I costly modifications that could further improve plant operations. Formal feedback from regulators and oversight ora helped reinforce that the plants were among the best in the nuclear i inauny, and that PSL plant management had a winning team. The combined effect was an overall l resistance to change.
i
! In August 1995, a series of events caused PSL plant management to i+x-.a' + the need for significant
, changes in PSL management and vier L.Gons. But the PSL team had not had to make many
- changes after years of stable operations, and had not developed the " change management" skills i needed to assure organizational and process changes were successfully implemented. As a result,
. sin.L.4 organizational and admimstrative chaar implemented at PSL in 1995 and 1996 were not carefully evaluated and managed to ensure that the u p.L.Jons transitioned smoothly into their new 4 areas of responsibility. In some cases, continuity was not ==ia+=ia~1 for critical functions,of the organization.
i Since August 1995, extensve managerial and organizational changes were implemented at St. Lucie, including a new Site Vice President,10 new managers (5 from outside FPL), and over 12 new department heads / key supervisors. Extensive organizational realignments have also been made. By September 1995, a new Plant General Manager and Operations Manager were in place. The Technical Staff Department was reone...M into the new System Component Engineering (SCE) Depisiow.at,
- and a new SCE Manager was assigned. Additionally, an Operations Support Department and an i
Operations procedure group were established. By February 1996, the PSL Site Vice President was re-assigned to Juno Beach, and new Licensing and SCE Managers were appointed. A major reorganization of the Maintenance Department was implemented to establish functional groups
- (Valves, Welding, Rotating Equipment, Stationary Equipment, and Outage & Projects), with new i supervisors assigned to each group. Maintenance Managers were also established for each operating
! shift. By May of1996, the President ofFPL Nuclear Division had retired, and was succeeded by the
[ Turkey Point Site Vice President. The Operations Manager from Turkey Point was reassigned to St.
2 Lucie, and a new Site VP was hired from outside PSL. Between June and August 1996, new ,
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! In Emergency Preparedness (EP), site wide organizational changes resulted in a loss of clear ERO
> acoc==*al=h in some areas The Fall 1995 reor;=ni>=+ ion at PSL did not consider the impact on 1
! EP, as some responsibilities ofERO members were not iii.h44r,ed. Previously,'the technical support l l
nanar (TSC) was mannad entirely by the Technical Staff When the Technical Staff was reorgaaM 4 those ERO rampand=h were dispersed, but personnel did not recognize that they maintainad their ERO responsibilities associated with the previous department. Additionally, gaps in the ERO
,ofganization were not identified when personnel were ter i==M As a result, the EP exercises
- aaa%ed in January and February 1996 did not meet management -
- +2+iions.
j In the Fa-i-ing Department, the elimination of the configuration management group affected the
( configuration management function. There was an uncompensated loss ofknowledge, experience, and focus, and as a result, drawmss, procedures and licensing documents have not always been j updated to reflect modifications. Additionally, multiple organizational changes in a rela:iva!y short j period of time were not carefully managed (such as the alimia=+ ion of the Technical Staff group and f subsequent formation of the Systems and Component Engineenng group, the formation ~and
! subsequent ehmination of the Operations Support Testing group, and the . formation of a Configuration Group in the Information Systems Department), and have subsequently caused i
j instability, unclear accountabilities, and in some cases, areas of responsibility were not seamlessly j u .o.m ed.
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In April 1996, the PSL site wide process for documenting problems was changed from the St. Lucie Action Request (STAR) process, to the Condition Report (CR) process used at Turkey Point, to j
provide who@ between the two sites. However, the impact of the CR process on PSL was not ,
i carefully evalustad and managed prior to its Weion. Little training was provided on the new l 1 CR prow.e, and the process was not well understood by the staff, li=hing the effectiveness of the process The CR administrative staff was quickly overwhelrned by the high volume ofissues generated by the Unit I r+1ing outage, due to a lack of resources to adequately run the program.
In addition, the mission of personnel performing CR closure reviews was changed from processing, i- tracking and trending CRs, to include a verification of the adequacy of the corrective actions listed in the CRs, without consideration for the required level of training and resources required to successfully manage those additional tasks The same individual performing the close-out reviews was also administering the In-House Event (IHE) reporting system,.was the sole individual performing HPES (hurnan performance evaluation system) evaluations at PSL, and was the chairman of the CR oversight group (CROG). As a result, CR close-out reviews have been less than effective
. in identifying weaknesses in the CR closure documents, such as the failure to identify all underlying
- can==1 factors, the lack of consideration of generic implications, and corrective actions that do not 4
address all causal factors.
VHL Communications: Less than adequate communications contributed to a lack of common focus and cohesiveness in the orgamzation.
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O rstsaVAneunent PSL MANAGEMENTINITIATIVES The challenge before PSL management is to preserve the excellent parts of the PSL culture; those programs and behaviors that contributed to long, uneventful runs, short outages, the excellent handling ofplant transients, and world class performance As enriy as 19M,FPL ww.E management recc,yJ d the need to infuse the plant staffwith new managunent personnel that brought with them a fresh and different perspective to PSL. Historically, all ofthe key managernent positions were filled strictly from within the plant. Corporate managamant desire for a different perspective at PSL resuhed in the appaia+'aaat of new Quality and Maintenance Managers, both from Turkey Point. Following the events in August 1995, to the present, most key managers have been replaced at PSL, including the Site Vice President, the Plant General Manager, I the Operations Manager, the Work Control Manager, tim Engineering Manager, the Services {
Manager, the Licensing Manager, the Business Systems Manager, the Materials Manager, and the Training Manager. Ofthe twelve key managers replaced since 1994, all but two of these individuals have worked the majority of their careers outside ofPSL. ,
In addition to significant management changes, extensive oronnivational changes were also implemented at PSL since August 1995. The Technical Staff Department was reor==ni ad into the new System Component Fair-:---irs (SCE) Department, and a new SCE Manager was assigned.
An Operations Support Department and an Operations procedure group were established. A major reors. ids.non of the Maintenance Department was implemented to establish functional groups (Valves, Welding, Rotating Equipment, Stationary Equipment, and Outage & Projects), with new supervisors assigned to each group Maintenance Managers were also established for each operating shift. The on-site engineering groups (e.g., Reactor Knpr-:-l-g, SCE, Shift Technical Advisors, In-service Testing, In-service laWons) were consolidated under the Site Engineering Manager.
Maintenance planners and schedulers and Outage Management personnel were reassigned'to the newly formed Work Control Department, and a new Work Control Manager was =ianad- A new Operations Support Departmait was also estabhshed, and a new Operations Support Supervisor was hired from outside FPL.
These changes in personnel and organizational adjustments provide PSL the talent and experience
- needed to regain PSL's place among the best perforrners in the nuclear industry. PSL management is committed to forging a new era of success at PSL by building on past successes, capturing'the lessons to be learned from recent events, and correcting the weaknesses identified during this self-assessment. Management initiatives will be implemented to address opportunities for improvement identified during this self-assessment. The initiatives are detailed in Appendix C to this report.
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