ML20141D647
| ML20141D647 | |
| Person / Time | |
|---|---|
| Site: | Prairie Island  |
| Issue date: | 06/17/1997 |
| From: | Grant G NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | Wadley M NORTHERN STATES POWER CO. |
| References | |
| NUDOCS 9706270293 | |
| Download: ML20141D647 (36) | |
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TAHf June 17, 1997 Mr. M. Wadley, Vice President Nuclear Generation Northern States Power Company i
414 Nicollet Mall Minneapolis, MN 55401
SUBJECT:
PRAIRIE ISLAND MANAGEMENT MEETING
Dear Mr. Wadley:
On May 20,1997, the NRC met with Northern States Power (NSP) management at the Region til Office in Lisle, Illinois.
The purpose of the meeting was to discuss the declining operations performance at Prairie Island Nuclear Generating Plant. Enclosed are copies of the agenda and handout provided by NSP staff at the meeting.
in accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2, Title 10, Code of Federal Regulations, a copy of this letter and the enclosures will be placed in the NRC's Public Document Room.
We appreciate NSP's cooperation in this matter.
Sincerely,
)
Orig, signed by Ronald N. Gardner for Geoffrey E. Grant, Director Division of Reactor Projects Docket No. 50 282 Docket No. 50-306
Enclosure:
Agenda and Handouts from May 20,1997, meeting Uplumppsu Document: R :\\Ltrs 2lic\\N S P\\Prai\\ pra 06107.d r p To receive a copy of this document, indicate in the box "C" = Copy without attach /enci "E" = Copy with attach /enci "N" = No copy
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OFFICIAL RECORD COPY 9706270293 970617 V
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Plant Manager,' Prairie Island John W. Ferman, Ph.D.,
Nuclear Engineer. MPCA State Liaison Officer, State of Minnesota State Liaison Officer, State.
of Wisconsin Tribal Council l
Prairis Island Dakota Community Y
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NSP-NRC MANAGEMENT MEETING May 20,1997 Agenda i
i Conduct of Operations issues Dick Lindsey, General Superintendent Safety Assessment Operations Human Performance Imorovement Initiatives l
Terry Silverberg, General Superintendent Plant Operations j
Operations Self Assessments Joel Sorensen, Plant Manager i
PIl Report Dick Lindsey, General Superintendent Safety Assessment I
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CONDUCT OF OPERATIONS i
ISSUES ESF ACTUATIONS IN 1996 INTENTIONAL ENTRY INTO i
i TECHNICAL SPECIFICATION 3.0.C EXCESSIVE DRAINING OF THE REACTOR COOLANT UNINTENTIONAL DILUTION OR POSITIVE REACTIVITY ADDITIONS
o NUMBER OF ACTUATIONS a
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-l ESF ACTUATIONS IN 1996 i
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TWO IN THE THIRD QUARTER, ONE IN THE LAST QUARTER l
ERROR TYPE -
SKILL BASED ERRORS - INADEQUATE SELF CHECKING CORRECTIVE ACTION -
SELF CHECKING CULTURE IMPROVEMENT SURVEILLANCE PROCEDURE UPGRADE PROGRAM i
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- -l INTENTIONAL ENTRY INTO TECHNICAL SPECIFICATION 3.0.C 1
ERROR TYPE -
RULE BASED ERROR CORRECTIVE ACTION -
SUPERVISOR TRAINING l
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EXCESSIVE DRAINING OF THE REACTOR COOLANT ERROR TYPES -
RULE BASED ERROR - PROCEDURE COMPLIANCE i
SKILL BASED ERROR - VALVE MISPOSITIONED l
CORRECTIVE ACTION -
COMPREHENSIVE ASSESSMENT OF PROCEDURE i
COMPLIANCE ISSUE & IMPLEMENT RESULTING IMPROVEMENTS PROCEDUREIMPROVEMENT I
INDIVIDUAL COACHING AND COUNSELING k
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UNINTENTIONAL DILUTION OR POSITIVE REACTIVITY ADDITIONS ERROR TYPE -
RULE BASED - PROCEDURE COMPLIANCE CORRECTIVE ACTION -
lMPROVE PROCEDURES COMPREHENSIVE ASSESSMENT OF PROCEDURE COMPLIANCE ISSUE & IMPLEMENT RESULTING IMPROVEMENTS i
EVALUATE SWl-O-10, OPERATIONS MANUAL USAGE, for ' PROCEDURE IN HAND' REQUIREMENTS l
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PRE-JOB BRIEFS 1
1994 INSTITUTED AS A SPECIAL j
PROCEDURE I
INCORPORATED INTO STANDING i
PROCEDURES STRESSED IN TRAINING SUPERVISION BELIEVE IN IT
- DEMAND IT BECOME OUR CULTURE
~
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COMMUNICATIONS 1995 OLD STANDARD CONFUSING
- NOT ENFORCED 4
DEVELOPED NEW STANDARD
- COMMUNICATION TRIANGLE i
TRAINED AND PROMOTION 1
- FILM SUPERVISION BUY-IN
-SUPERVISION DEMAND IT BECOME PART OF OUR CULTURE
~
SELF-CHECKING 1996 HUMAN PERFORMANCE DECLINE l
l
-SKILL BASED ERRORS STRESS OF MANAGEMENT 1
l EXPECTATIONS DROP IN SKILL BASED LER'S MORE TO DO--Pil RECOMMENDATIONS BECOMING CULTURE i
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PROCEDURAL COMPLIANCE i
1997 h
ERTF CREW SOLUTION MUST BE i
- PRACTICAL
- EASILY UNDERSTOOD
- BELIEVED IN MUST BECOME PART OF OUR CULTURE!
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OPERATIONS TACTICS CREW SIMULATOR LISTS
-STARTING POINT FOR MANY INITIATIVES REDUCE OPERATOR STRESS
- GSPO VISION MEETINGS
- OUTAGE WORKING HOURS l
PROMOTING E&A VISITS
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OPERATIONS TACTICS DEPARTMENT STAFFING i
-YEAR ROUND WORK CONTROL CENTER
- SRO'S TO TRAINING UTILIZATION OF CREWS FOR j
PERFORMANCE ISSUES ISSUES RESPONSE COORDINATOR i
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1 l
Operations Self Assessments
" Assessment of Operations Outage Implementation and Related Human Errors"
- Requested by GSPO j
- Organizational and Programma:ic Study j
- Completed 4th Quarter of 1995 by NSP ERTF
- Looked at O oerator Inappropriate Actions from 1989 to mid 1995 1
- CCA, survey, and interviews
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o Percentage of Inappropriate Actions by Human Error Type from 1989 to mid 1995 by NSP 80%_
70%.
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" Assessment of Operations Outage j
Implementation and Related 1
Human Errors" Corrective Actions Taken
- Outage Shift Manager (Shift Outage j
Coordinator)
- SRO on floor for critical outage evolutions
- Management expectation for supervisors' responsibility for causes of operator inattention to detail (alertness, reduce time pressures, distractions, etc.)
-Individual S':atus Report (ISR) used to i
prioritize SM/ Crew work commitments l
~l NSP Nuclear Generation Excellence in Human Performance Survey Completed in August,1996 i
4 Survey of employee work place attitudes and perceptions t
First attempt at leading indicators Surveyed all departments including Ops 1
Surveyed areas of j
- Individual Behaviors i
- Leadership Behaviors l
- Organizational Behaviors
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~l Excellence in Human Performance Survey Areas for Improvement i
Individual Behaviors
- Methods to check co-workers Leadership Behaviors l
- Address personality conflict to minimize impact r
Organizational Behaviors
- Eliminate jury rigs l
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Why did PI need outside opinion ?
1 Study done by NSP in 1995 showed excessive rule based errors
-Yet events in 1996 showing excessive skill basec
- Were inappropriate actions being categorized correctly ?
- SAC recommended outside look similar to Monticello Validate Human Performance Survey l
t 4
y FPl/Pil Common Cause Analysis of Operations Human Performance Concerns 1
Requested by GSPO, GSSA, PM t
Organizational and Programmatic Study Look:ed at Operator Inappropriate Actioris in 1995 and 1996 CCA, survey, and interviews I
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-l Percentage of inappropriate Actions by Human Error Type from 1995 &1996 data by Pil 80b1 70%_ --
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Skill Based Rule Based Knowledge Based i
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Pil Common Cause Analysis of Operations Human Performance Concerns General Conclusions
-Ina apropriate actions were being i
categorizec correc:ly
- But, industry " norms" were incorrect in our j
1995 study
- Further comparison of leading indicator surveys needed l
- -i Percentage of inappropriate F
Actions by Human Error Type 1st Quarter 1997 by NSP i
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l WHAT WERE Pil's CONCLUSIONS?
1 HUMAN PERFORMANCE IN THE OPERATIONS GROUP IS DECLINING i
THE DECLINE IS NOT ISOLATED TO OPERATIONS SEVERAL FACTORS EXTERNAL TO THE OPERATIONS GROUP HAVE COMBINED TO INCREASE THE BASE ERROR RATE, WHILE AN EFFECTIVE MANAGEMENT CONTROL LOOP (CONTINUOUS IMPROVEMENT LOOP) IS NOT IN PLACE j
THE EXTERNAL FACTORS CAN BE COLLECTIVELY
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CONSIDERED AS " WORK STRESS" j
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1
" Changes in the industry due to utility deregulation
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have led to NSP initiatives to reduce cost. The i
department experiences some of these in the form of; l
staff reduction via attrition and hiring freezes, changes in work hour.s to reduce overtime, increased j
work load due to the same (or fewer) Operators performing more work, increasingly unpopular bargaining unit contract proposals, etc."
l "The Nuclear Industry continuously focuses more i
attention on human performance, with less tolerance j
for errors, increasing the " fear of failure"."
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"Several management changes have occurred.
The new management is perceived by the staff as being q
very technically competent, though less humanistic than previous management teams. This induces work stress, while limiting the ability of the staff to deal with the existing stress."
" Prairie Island has a long history of recognition as a j
top performer by the NRC and INPO. This adds j
further to the " fear of failure" factor in work stress, as j
no operator wants to be the one whose error leads to ending this recognition."
"The first symptom of long-term work stress is a high rate of " inattention-to-detail" human errors."
We had I
this symptom.
1 j
Pil conclusions, cont.
"....... the following conclusions can be made Prevention Human error prevention / avoidance skills of workers and supervisors are not l
comprehensive in nature.
i Weaknesses exist in implementing the accountability program for human error reduction.
Detection Trending and Monitoring capabilities for the department's human performance are weak.
Only " Lagging" indicators for human performance are used. " Leading" and "Real-Time" indicators are not utilized.
Correction i
j Root cause analyses do not always address the organizational and programmatic contributors to the events."
i Note the similarity to the Continuous improvement model-of Plan, Do, Check, Adjust t
1 Pil's RECOMMENDATIONS 1
ENHANCE SELF-ASSESSMENT, ROOT CAUSE ANALYSIS AND PERFORMANCE MONITORING & TRENDING.
t PROVIDE INTEGRATED HUMAN ERROR PREVENTION t
TRAINING
?MPROVE SHIFT SUPERVISION ACCOUNTABILITY FOR CREW ERROR i
PREVENTION / REDUCTION VERTICAL COMMUNICATION
[
SHARE THE RESULTS OF THE REPORT WITH OPERATORS i
PLANS FOR IMPLEMENTING HUMAN PERFORMANCE IMPROVEMENT BASED ON Pil ANALYSIS PROMPT ACTION IMPROVE WORKER ERROR PREVENTION SKILLS Pil 1 day course Optional PI Instructor certification IMPROVE SUPERVISOR ERROR REDUCTION SKILLS Pil 2 day course Optional PI Instructor certification IMPROVE MANAGEMENT ERROR REDUCTION SKILLS Pil 1 day course l
Pil has been asked to submit a new proposal that includes Monticello and Prairie Island j
ASSESS ADMINISTRATIVE LOAD ON LPERO, SS, SM and OTHERS l
f
=
INTERMEDIATE TERM ACTIONS UTILIZE LEADING INDICATORS AS A PREDICTOR OF PERFORMANCE t
Option A - Have Pil do their Culture Assessment on a
[
yearly basis t
Option B - Develop our own Leading Indicator based on j
the Human Performance initiative survey - to be done on a l
yearly basis Compare and contrast the HPI survey with the one f
given by Pil i
i Compare and contrast the HPI survey results with l
Pil results l
See if an integrated (HPI, new INPO fundamentals course & Pil) approach to corrective actions is feasible i
l I
i i
REFINE OUR LAGGING AND REAL-TIME PERFORMANCE INDICATOR PROCESSES l
Refine Employee Observation Report (EOR) system to l
provide the needed information Increase the use of the EOR process for problem reporting -
I IMPLEMENT SUPERVISORY TRAINING PLANS l
i THESE PLANS WERE DERIVED FROM THE HPI SURVEY CONCLUSIONS 6
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I LONG TERM ACTIONS l
CONTINUING (REFRESHER) TRAINING OF THE ITEMS IN j
THE ' PROMPT ACTION' SECTION DEVELOP AND USE CONTINUOUS IMPROVEMENT MODELS FOR PLANT WORK GROUPS i
TRAIN PLANT PERSONNEL IN HUMAN PERFORMANCE FUNDAMENTALS This is a new INPO course. Monticello and Prairie Island are sending two people each to ' Train the Trainer' courses this year
- Monti in May and PI in August j
CONTINUE SUPERVISORY TRAINING PLANS I
I