ML20151D210
| ML20151D210 | |
| Person / Time | |
|---|---|
| Issue date: | 07/12/1988 |
| From: | NRC COMMISSION (OCM) |
| To: | |
| References | |
| REF-10CFR9.7 NUDOCS 8807250012 | |
| Download: ML20151D210 (70) | |
Text
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s UNITED STATES OF AMERICA NUCLEAR REGULATORY COMMISSION
Title:
ANWAL BF.R.*ING BY INFO Location:
ONE WHITE FLINT NORTif, ROCINILLE, MARYLAND Dat'6:
TuEso;Y, JULY 12, 1988 i
Pages:
1-48 l
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1 Ann Riley & Associates Court Reporters 1625 i Street, N.V!.. Suite 921 Washington, D.C. 20000 (202) 133-3950 8807250012 800712
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- ,;4 DISCLAIMER This is an unofficial transcript of a meeting of the. United ~ States Nuclear Regulatory Commission held on
.7-12-88 in the Commission's office at One White. Flint North, Rockville, Maryland.
The. meeting was
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open to public attendance and observation.
This transcript has not been reviewed, corrected or edited, and it may
. contain' inaccuracies.
4 The transcript is intended solely for general U-informational purposes.
As-provided by 10 CFR 9.103, i t is not part rf the formal or informal record of decision of the matters discussed.
Expressions of opinion in this transcript do not necessarily reflect final determination or beliefs.
. No pleading or other paper may be filed with the Commission in any proceeding as the result of, or addressed to, any statement or argument contained herein, except as the Commission may authorize.
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1 UNITED STATES OF AMERICA 2
NUCLEAR REGULATORY COMMISSION 3
4 ANNUAL BRIEFING BY INPO 5-
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6 PUBLIC MEETING 7
8 Nuclear Regulatory Commission 9
One White Flint North 10 Rockville, Maryland 11 12 Tuesday, July 12, 1988 13 14 The Commission met in open session, pursuant to 15 notice at 10:03 a.m.,
the Honorable LANDO W.
ZECH, JR.,
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16 Chairman of the' Commission, presiding.
17 COMMISSIONERS PRESENT:
18 LANDO W.
ZECH, Chairman of the Commission 19 THOMAS M.
ROBERTS, Member of the Commission 20 KENNETH CARR, Member of the Commission 21 KENNETH ROGERS, Member of the Commission 22 23 24 25 e
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STAFF AND PRESENTERS SEATED AT THE COMMISSION TABLE:
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2 A.
BATES, Secretary 3
W.
PARLER, OGC 4
S. ANDERSON, INPO i
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Z.
PATE, INFO j
6 T. SULLIVAN, INPO
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7 W. COAKLEY, INPO r,t '
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12 13 14 15 l
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PROCEEDINGS T
2 (10:03 a.m.)
3 CHAIRMAN ZECH:
Good morning ladies and gentlemen.
4 This morning we welcome Dr. Zack Pate, president and chief 5
executive officer of INPO and the other executives accompanying 6
him to brief the Commission on some of their current
~
7 activities.
This is an information briefing.
The Institute of 8
Nuclea_ Power Operations, referred to as INPO, has earned a 9
very strong and positive reputation throughout the nuclear 10 power industry for having provided constructive, competent 11 support to nuclear power plant operations in a broad range of j
12 activities.
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13 INPO has developed and implemented programs which 14 provide support to nuclear utilitiec in training, in 15 evaluation, in analysis of significant operating events, in 16 operational assessment and in technical assistance visits to 17 mention only a few areas of involvement.
18 INPO has and does make a difference in the successful 19 operation of nuclear power plants in our country and has also 30 contributed to the operations of nuclear power plants in 21 countries overseas, q
t 22 We at the NRC as regulators of nuclear licensees, 23 have been aware of the significant improvements in the overall 24 performance of nuclear power plants in our country.
Many of 25 the safety indicators that we look at show notable improvement.
4 4
1 Worker exposure is down.
Volume of radioactive waste generated 2
is down.
Safety system challenges, unplanned scrams, forced 3
outages are all down.
Other indicators also show a clearly l
4 improving trend.
5 As I see it, our job as regulators at the NRC is a
6 complemented by the different job that INPO does in striving to 7
provide excellence in nuclear power plant operations.
We at 8
the NRC as a government agency are charged under the Atomic l
9 Energy Act to assure that the public health and safety is 10 protected.
11 Our requirements have been developed to ensure that 12 this mission is* executed.
Recognizing that the licensee, the l
13 utility, has the ultimate responsibility for safe operations of l
l, 14 the plant, INPO strives to assure and assist with this safe and la 1
L; 15 reliable operations.
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16 Therefore, INPO acts as an arm of the industry f
17 itself, to promote improved safety and reliability of the I
l 18 operations of nuclear power plants and therefore can be and is 19 of great assistance to the NRC in carrying out our statutory
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20 responsibilities.
With these thoughts in mind, we welcome you 21 and we look forward to your presentation.
You may begin, Dr.
22 Pate.
Welcome again to the NRC.
23 MR. PATE:
Mr. Chairman.
Commissioners.
It's a i
24 pleasure for us to have this opportunity to brief you on the 25 current status of some of INPO's activities.
Let me just take
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a momsnt and introduce the other speakers at the table.
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To my right is Terry Sullivan, Vice President for 3
Analysis and Engineering.
On my far left, Walt Coakley is Vice 4
President of Training and Education.
Stan Anderson is Vice 5
President and Director of the International and Supply 6
Division.
In the audience are Angie Howard, Pat Beard and Rick.
7 Jacobs, who we may call on~for assistance in answering your y
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8 questions.
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9 Since we last briefed the Commission, we've had some 10 managemano changes in INPO and I'll cover the highlights of 11 those briefly.
For example, Terry Sullivan succeeds Pete Lyon 12
$dua retired as head of the Analysis and Engineering Group the
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l 13 first of this year.
Pat Beard who did an outstanding job for 14 us in heading the evaluation and assistance group for five 15 years has been succeeded by Ken Strahm.
Pat is now working in l
16 the government / industry relations area with Angie Howard.
i 17 Walt Coakley who had headed our Accredi.tation
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18 Division succeeds Ken Strahm as head of the Training and 19 Education Group.
20 We plan to focus specifically this morning on four 21 areas.
First an update for the Commission on accreditation.
22 Second, an update on the new World Association of Nuclear 23 operators planning and progress.
We will provide some comments 24 on maintenance and last talk, bout the professionalism 25 initiative.
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If you have questions of clarification, please do ask
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2 them as we go along.
Otherwise, we would respectfully request 3
that you hold questions until after we have completed our 4
briefs as we may well answer some of your questions as we go 5
along.
6 Now, let me ask Walt Coakley to give you that status 7
of the accreditation program.
l 8
MR. COAKLEY:
I appreciate the chance to give you an l
9 update on the status of accreditation in the nuclear utility 10 industry.
You may recall that in 1984, the nuclear utility l
11 industry made a commitment to pursue early accreditation of ten 0
12 key programs at all plant sites.
There were two parts to that 13 commitment.
First for plants that loaded fuel before 1985 --
14 that's 60 sites -- the commitment was to have by the and of 15 1986, all 10 self-evaluation reports for those programs 16 accepted by INPO, this signifying programs that were ready for 17 an accreditation review.
18 As we reported to you last year, that commitment was 19 met.
All accreditation team visits to review those 600 20 programs were completed by the end of 1987.
The other part of d
21 that commitment was to bring all 600 of the programs before the
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22 National Nuclear Accrediting Board by the end of June of this 23 year.
That goal was also met.
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24 All of the 600 programs have now been presented to 25 the Board for their review.
To give a full accounting of the
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600 presented over the past four years in this category, 598
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programs have now been accredited.
The accreditation of two 3
programs from the Nebraska Public Power District's Cooper 4
Nuclear Station was deferred.
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However, we expect tho=.e two programs to be reviewed 6
again by the Board within the next month.
Next, with regard to 7
the 16 plant sites that loaded or loaded fuel after January 1, 8
1985, the commitment for those utilities was that their 9
programs would be ready for accreditation within two years of 10 fuel load.
11 That is on schedule.
Seventy-two of those programs 12 of the total of 160 have alread'y been accredited.
Ten of those 13 16 sites in that category.
We're watching closely the progress
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14 of those plants and their training and providing assistance as 15 needed.
In the category of renewal of accreditation, the U
16 requirements are that accreditation must be renewed every four 17 years for each program and that repeats the process of self-18 evaluation, INPO team review and an accrediting board review 19 decision.
20 Forty-one programs at seven sites have been reviewed 21 by INPO for renewal.
To date, accreditation has been renewed 22 by the National Nuclear Accrediting Board for five of those, 23 for Oconee's operator programs.
Those are on schedule and we t
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24 will hold to the four-year renewal interval that we've 25 promised.
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INPO plant evaluations that the ANA group sponsors 2
are tasked to take a hard look at these accredited programs 3
between the four year renewal intervals.
They check on 4
implementation of the programs and they look at the performance 5.
of the people who have been trained by those programs.
Those t
6 results are fed back also to the accreditation program process 7
for follow-up.
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8 NRC has been closely involved with accreditation in 3
9 three ways during these past few years.
Headquarters and
,l 10 regional staffs have sont one or more observers on 24 of the 1
11 162 accreditation team visits that have been conducted.
12 Thirty-eight-of the 48 accrediting board meetings conducted to l
13 date have been observed by an NRC staff member and of course, 14 each five-person accrediting board that reviews applications l
15 for accreditation includes one member nominated by the 1
16 Commission.
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17 The first of those you nominated, Dr. Forrest Remick, y
18 has just completed over five years of service on the 19 accrediting board and is retiring from the board this month.
20 He will be honored for his dedicated service at a plenary 21 session of the board later this week.
22 We've had good cooperation and encouragement from you i
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and the staff on training and accreditation issues and look 24 forward to continuing that relationship.
25 CHAIRMAN ZECH:
Thank you very much.
Please proceed.
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1 MR. PATE:
Thank you, sir.
I'll ask Stan Anderson to L
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give you an update on the international part of INPO's work.
3 CHAIRMAN ZECH:
All right.
Thank you very much.
4 MR. PATE:
Mr. Chairman, gentlemen.
I have a few 5
slides to describe our current status of the World Association.
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But before I do, a few words of background.
After chernobyl,
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7 we at INPO looked for ways to promote the exchange of 8
information among operators.
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We have an international program currently in place q
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10 with 13 members but we thought we should look beyond that.
So,
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11 we concluded among other things, that we should organize a a
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A worldwide meeting.
13 So, with the encouragement of our Board of Directors and our 14 international participant advisory committee, we planned that 15 meeting and it was held as you know, in Paris, in October of 16 last year.
If I can have the first slide, please.
17 (Slide.)
18 The meeting was co-sponsored by INPO and UNIPEDE.
It 19 was hosted by Electricite de France and the chairman was Lord 20 Marshall of tl CEGB.
There were about 130 representatives and a
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We were quite pleased with the 22 attendance and here are the countries that did attend.
23 First, second slide, please.
24 (Slide.)
25 That's the first slide of the attendance and then the
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next one, please?
2 (Slide.)
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From'the USA, we had a strong contingent and from the 4
USSR, they were represented by Minister Loukonin from the
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5 Ministry of Atomic Energy.
We had invited 32 countries and 6
that was based on countries that had operating reactors or 7
soon-to-be-operating reactors.
The countries that did not 8
attend the meeting were the Philippines.
They sent a letter of 9
regret, and then Romania and Pakistan.
We expected Romania and 10 Pakistan to show up but just at the last minute, they changed 11 their plans.
12 At the meeting, we agreed to a resolution and if I
'13 can have the next slide, please?
14 (Slide.)
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15 This is the heart of the resolution.
That there 16 would be World Association of Nuclear Operators with regional 17 centers in Tokyo, Moscow, Paris, and Atlanta and a small 18 coordinating center, perhaps in London.
That's the basic 19 structure of the organization.
20 MR. ANDERSON:
Next slide, please.
21 (Slide.)
22 MR. ANDERSON:
I'd like to mention a few other 23 highlights from the resolution.
First of all, we recognize 24-that there were existing links in the world among operators, 25 but this was to strengthen those links.
Then the mission of
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11 1
the World Association is to maximize the safety and reliability 2
of nuclear power stations and we intend to do this by 3
exchanging information, encouraging comparison and stimulating 4
emulation.
5 Finally, that there be a steering committee 4
6 established to carry out the work of the resolution.
Next a
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7 slide, please.
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8 (Slide.)
9 MR. ANDERSON:
Some additional items from the l
10 resolution -- I've already talked to the first two bullets, but 11 let me call your attention to that last one.
The coordinating 12 conter worked closely with the IAEA.
We have been working with 13 the IAEA from the beginning very closely and we intend to keep 14 up that relationship, just as we have in this country with the 15 NRC in forming the World Association.
16 We had Hans Blix as a speaker at the Paris y
i 17 conference.
Next slide, please.
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18 (Slide.]
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19 MR. ANDERSON:
I mentioned the steering committee.
20 The mission and the main task of the committee are clear.
With 21 regard to the chairman, at the Paris meeting, Zack Pate, in his 22 remarks, proposed to the executives that Lord Marshall continue 1
23 his role of senior statesman in organizing the World 24 Associatiots and all agreed as did Lord Marshall, so he does 25 serve as the chairman at the present time.
Next slide, please.
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(Slide.)
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MR. ANDERSON:
The steering committee has met.
We've 3
met three times.
I represent the U.S.
utilities in that body.
4 The last time we met was about three weeks ago.
The countries 5
listed tnere are generally represented.
Everyone is invited, 6
however, and those that don't attend are called corresponding
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7 members and we keep them informed of the action of the 8
committee.
The INPO London office found themselves very much 4
involved in the work of the steering committee, so we've 9
t.p 10 designated them as the secretariat.
Next slide, please.
11 (Slide.)
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Regional centers -- they are being 13 organized in Atlanta.
INPO will spo..sor the Atlanta Center.
14 We have our first organizational meeting day after tomorrow.
15 In Moscow, the All Union Research Institute for Nuclear Power 16 Plant Operation will sponsor their center.
They've had a 17 meeting.
They met on the 30th of June and had five countrias 18 in the Eastern Bloc attend.
19 In Paris, they're probably the furthest along.
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20 They've had several meetings and they now have a prospective
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In Tokyo, they've had two meetings and et 22 the last one, they had, as you see, Japan, Taiwan, Korea, 23 Pakistan, the PRC and India present and we're pleased that both 24 the PRC and Taiwan were at the meeting.
Next slide, please.
25 (Slide.)
1 13
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'l MR. ANDERSON:
Finally, the date is set for the next 2
meating of the executives as a follow-on to the Paris meeting.
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It will be in Moscow.
At the Paris meeting, Lord Marshall l
4
_ proposed to Minister Koukonin that the next weeting be held in 5
Moscow and we pursued this in the months following.
We hadn't i
6 heard anything so then we also proposed that the next meeting 7
of our committee to organize the meeting, be held in Moscow and 8
they accepted that.
In April we went to Moscow to work on the 9
plans *or the next meeting.
10 The meeting was held in the All Union Research 2.1 Institute of Nuclear Power Plant Operations.
That's Dr.
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12 Abaygan's center.
I had met him before and he's the gentleman 1
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13 that when I gave him my INPO card, he said, I have the INPO in
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So that's the relationship there.
15 We were greeted at our meeting by Minister Loukonin 16 and throughout the meeting in Moscow, it was attended by both 17 the people from the Institute, Dr. Abaygan's organization and 18 the Ministry of Atomic Energy.
We held two days of meetings 19 and finished with a session with another Minister, Mini. ster 20 Vuronin down Gt the Ministry of Atomic Energy in downcown 21 Moscow and Veronin wra very en
.uiastic about having the 22 meeting and oe actually set the dates.
23 The dates for the meeting are the 15th through the tj 24 17th of May, 1989.
That, sir, completes my brief.
I'd just 25 like to say that we've appreciated the support of the NRC in
14
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1 this effort thus far and we would appreciate your further 2
support.
We currently are working on ensuring that we have 3
concurrence from the U.'J.
Government on exchanging information 4
with all ccuntries and that is very important to our 5
organization.
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In fact, it's the key to our organization, that the
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membership is open to all and when we do get information in the 8
World Association of Nuclear Operators, that it can be shared 1
9 with all.
Thank you, sir.
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l 10 CHAIRMAN ZECH:
Thank you very much.
11 MR. PATE:
Thank you, Stan.
Turning now to
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12 maintenance activities, I'll focus-on INPO programs this 13 morning as we are a ware that the Commission is scheduled for a 14 brief on August the 3rd on all industry initiative by utility 15 executives, NUMARC, EPRI and so forth..
We're also aware of the 16 special workshop NRC is sponsoring on niaintenance this week
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17 here in Washington.
18 We recognize the essential and broad role that 19 maintenance plays in safe and reliable operation of nuclear 20 plants and thus, the Commission's justifiable interist.
21 Evaluatiori of maintenance has been an integral part of our two 22 week evaluations since the first days of INPO.
Some four years 23 ago, a NUMARC working group with support from INPO, began to 24 address elective mai,ntenance issues and in late 1985, with 25 encouragement from the NUMAPC working group, we took a hard 9
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1 look at what the Instituto could do, above and beyond the 2
normal programs, to casist the industry in improving 3
maintenance.
4 Two key initiative were identified by this time and 5
in support of those two initiatives, work had already been done 6
on a comprehensive maintenance guideline.
These guidelines 7
were published to the industry in late '85.
Thus, our first 8
initiative was to request that all of our member utilities do a
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self-assessment of maintenance based on those INPO guide}ines.
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10 All 75 sites that are in operation, were included in ei 11 that initiative.
To date, 72 have completed and provided a
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12 report to INPO l'n the results of their self-assessment --
13' again, against the INPO guidelines.
Three others have 14 committed to completion dates -- Yankee Atomic, South Texas and 15 Monticello -- but haven't quite completed their work.
16 Our review indicates that most of the 72 self-17 assessments are candid and comprehensive and our evaluation
'18 team reviews corroborate this and the utilities are taking a i.
i 19 number of initiatives to improve their own maintenance 1
j 20 programs.
A second initiative was to put together maintenance 3
el assistance and review teams to visit a plant and take a focused e
22 look just on maintenance.
23 To do that, we formed a special team that went beyond 24 the historical approach INPO has used, in that the teams 23 included not only three or four maintenance people from INPO j
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16 and a team manager from INPO, but we asked the plant to 1
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designate e carefully selected person like the maintenance V
3 manager or the plant manager, to in effect, be a member of the m
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team.
We asked EPRI to designate a member who could accompany 5
our team.
6 We also asked the cognizant NSSS supplier.
If the
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7 plant was a W3stinghouse plant, we asked Westinghouse to 8
identify a knowledgeable maintenance person to accompany this 9
team.
We also added to the team, a maintenance peer from a 10 utility where we knew the maintenance program was working 11 pretty well.
So the team was a mixture of people, but all with
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12 a great deal of experts and expertise in maintenance and all i
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with a common cause.
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14 With these teams, we first conducted four visits to 15 plants that we thought had good maintenance -- as good as there 16 is in the industry.
That was to see how to do it and to let
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17 our teams be calibrated to the highest standards that we could 18 find in the industry.
We then had the teams visit 11 plants 19 Whore knew maintenance needed improvement.
We have to date 20 done 20 follow-up visits to review progress at those 11 plants.
21 Participation by the host utility or the utility that l
22 was being reviewed in this effort has been extensivt.
Fcr i)l 23 example, we held open team meetings so that when we discussed e
Y 24 the issues that our team had identified, the utility could have 25 one of their managers present.
To give you an idea of the
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extent to which the host utilities participated, we've had 9 2
vice presidents or other senior managers join these maintenance l
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review teams to help evaluata their own sites, 4
We've had 6 site directors or plant managers do the j
5 same thing and 14 maintenance managers have made themselves a a
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6 part of the team.
I think that special team visit to review a
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maintenance and those visits that have taken place over the 8
past 2 years, have been one of our most successful initiatives 9
in terms cf identifying the real root causes of some of the 10 maintenance problems and also in helping the utilities or t'te
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11 plant generate an action plan to upgrade their own maintenance.
12 Nonetheless, we follow up to these special visits.
13 We continue to evaluate maintenance during the regular plant 14 evaluations.
We're incorporating the feedback gained from this process into a revision to the maintenanco guidelines that we 15 l.
16 hope to publish soon.
We are planning to provide a summary of h
17 the key results of the self assessments back to the industry l
18 and we'll provide the NRC with a copy of that.
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19 In parallel, INPO is also involved in a number of l
20 other aspects of maintenance and I'd now like to ask Terry l
21 Sullivan to cover some of these activities.
22 CHAIRMAN ZECH:
Thank you very much.
You may 23 proceed.
24 MR. SULLIVAN:
Thank you, Zack.
The analysis and 25 engineering group's function is to analyze, gather and screen o
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1 and assist utility organizations in the application of 2
operating experience.
The Commission has previously been 3
briefed on the significant event evaluation and information 4
network commonly referred to as the SEE-IN program, so I won't 5
go into detail there, except to stress that this analysis and 6
' dissemination of lessons learned and the rigorous follow-up 7
during every plant evaluation on the implementation of those 8
lessons learned, is a primary management focus at INPO.
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9 At the same time, the industry is addressing the 10 human performance and equipment performance problems that aro
- t 11 the immediats causes of significant events.
Recognizing that 12 people have a tremendous impact on plant performance, the 13 Institute has sponsored a program called the Human Performance 14 Evaluation System and I'll refer to that as HPES.
Since 1984, 15 this program has been developed through a joint effort with 16 several of our member utilities and international participants.
17 The program's goal is to help nuclear plant personnel 4
18 minimize error in the performance of their jobs and I can
'tj 19 report that HPES is currently a part of the management effort 20 at over half of our domestic utilities and four international 21 participants.
HPES is showing that it can help manage human g
22 performance and strengthen plant team work.
23 INPO assists in training and program implemen ation 24 and we provide feedback on evaluation techniques and ccrrective 25 actions.
In addition, we publish a newsletter focusing on s
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19 1
human performance problems.
It's called "Lifted Leaves," and 7
2 I've passed out an example.
Our June. issue focuses on taggeng d.
3
- systems, of course, that's a very important station control d'
4 mechanism for protecting equipment and people.
5 Previous issues have focused on issues like 6
communications, the importance of self-verification, labaling 7
and that type of thing.
Ap important insight from the 8
application of HPES is that the cause of the those significant 9
events is similar to the causes of non-consequential events.
10 As a result, when plants correct the causes of day-to-day j.]
11 performance problems, they're also reducing the factors that 12 can contribute to significant events.
13 Since the start of HPES, we have purposely controlled
!.I 14 growth of the program to allow us to make adjustments needed to 15 gain maturity.
However, right now, all INPO members are.being 16 encouraged to participate in HPES on a voluntary basis and 17 ue're conducting workshops this year to train additional 18 coordinators.
19 If I could shift now to the area of equipment 20 performance -- of course, we recognize that this is also a 21 major factor in plant performance and the operator's ability to ti.
22 respond to off-normal events.
In that regard, the Nuclear s
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24 collection of industrywide component reliability information.
25 Right now, we receive about 1600 failure reports every month
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and in the database we have now almost 80,000 failure records.
2 That's a lot of valuable operating experience at the 3
component level.
We've done a lot of work on the software 4
associated with the use of that system.
New data retrieval 5
software on INPO's IBM mainframe is now in use by INPO members 6
and participants and also by the NRC staff.
In May, we 7
released a number of pre-formatted equipment reliability 8
reports for use by the industry.
9 Dy the end of this year, we'll have new data 10 reporting software which includes a computerized check of the 11 input data for its quality and accuracy.
We'll have that 12 rele sed by the end of the year.
INPO is systematically 13 screening NPRDS data for significant component failure trends 14 and we're also looking for differences in performance in 15 plants.
We do this in preparation for every evaluation in the 16 maintenance assistance review team visits that Zack mentioned t
17 and the evaluators are given specific follow-up leads and we 18 also provide the results to the plants.
19 When we started using these techniques in the 20 evaluation and assistance area, we found a lot of interest by 21 utilities and so what we did was to begin to invite the 22 utilities to send people to INPO to work with us on developing 23 their plant-specific analysis.
Typically, we'd get an NPRDS 24 coordinator and a maintenance or system engineer to come down 25 and work with us.
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With their help, we've been able to streamline these s
2 techniques and select the best methods and we're going to be 3
making this available to the utilities for their direct use 4
later this year.
Although few equipment problems are generic, 5
we also use the component failure analysis results to look at 6
industry-wide _ equipment performance.
We've done this in a number of cases with reactor protection systems, auxiliary 7
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feedwater, motor operated valves, check valves, et cetera, y
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Where applicable, they feed into the SEE-IN products 10 that we also measure and we also provide information to the 11 plants on their performance for these particular components.
12 And where we don't seem an improving trend, we 13 followup during evaluations.
At this point, I'd like to talk a 14 a little bit about motor operated valves, because I think it's a 15 good example of the type of equipment issue that I'm talking 16 about here.
j 17 Continuing MOV problems were identified by the i
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18 industry and the NRC beginning in the 1980's.
We had issued a
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19 number of SEE-IN products and in 1983 we issued a significant 4
20 operating experience report on motor operated valve problems 21 with a number of key recommendations.
22 We also conducted a workshop and started to look at 23 implementation during our evaluations.
However, by 1986, it 24 was becoming apparent that the failure rates were at best 25 constant and certainly they weren't improving to the extent we m _
l5 c.
-+
22 1
1 would like to see.
~
[
2 NRC noted the same thing in an AEOD caso study report bj 3
at the and of 1986.
So we began a broader INPO-wide, and 4
really industry-wide initiative to address motor operated 5
valves.
6 We sent a letter to utilities senior management 7
calling this problem to their attention.
We began working with 8
the Electric Power Research Institute and NUMARC to look at 9
technical problems that needed to be resolved.
10 We, of course, kept applying the NPRDS data that I
~
t 11 mentioned earlier, and during evaluations, we provided more
('
specific training to our evaluators and, in fact, developed a 12 13 couple of pre-specialized evaluators that we were able to send 14 to selected plant evaluations, experts on motor cperated 15
- valves, 16 We have continued to support EPRI's Nuclear 17 Maintena,nce Assistance Center in this regard and we've also 18 conducted a number of visits to plants that have good motor 19 operated valve performance so we can feed back the positive 3
20 aspects as well.
4 j
21 So I think you can see from the example that we are 22 applying NPRDS to improve equipment performance.
And an 1
23 important byproduct of this effort I might mention is that, as 24 we use NPRDS and as the NRC staff has used NPRDS, we also find 25 problems in the database which we're able to correct.
23 1
In summary, I think the number of significant events 2
with generic implications has steadily declined over the past 3
several years, but the future gains will be tougher to achieve.
U 4
So we've got to focus on the human performance and t
f 5
equipment performance issues.
INPO is taking a harder look at j
6 operating events and we're trying to integrate our events 1
~_
7 analysis activities with human and equipment performance 8
analyses.
9 The results of these efforts, along with the 10 analytichi tools, are being provided directly to the utilities 11 for their use.
12 We're not satisfied.
The reactor events, as they 13 occur, our goal is to prevent.
We want to continue to reduce 14 the number and severity of significant events and thereby i
t 15 prevent a serious accident.
ij 16 Thank you.
17 CHAIRMAN ZECH:
Thank you very much.
18 MR. PATE:
The final area that we plan to discuss 19 this morning is the professionalism initiative that was kicked 20 off at our CEO conference in November of last year.
21 We challenged the industry to undertake two 22 initiatives to enhance or strengthen operator professionalism, 23 and we have now broadened that to professionalism kind of 24 across the board.
j 25 These initiatives were as follows.
First, the d
s' 24 1
development and implementation of a set of broad principles to 2
guide management of operators and that could lead to an 3
improved climate for professionalism.
4 That's kind of coming after the problem from the top.
5 And second, development by each utility of a professional code 6
for operators coming at the problem from the other direction.
~
4 I'd like to update you on activities aimed at
{
7 ir l
j 8
implementing these initiatives, both of which have been -- a I
9 lot of have been received enthusiastically by the industry.
10 Taking the professional code for operators first, we
~
11 held a workshop for senior reactor operators in Atlanta this 12 past February.
13 Every nuclear plant in the United States and some of 14 our international participants were represented, with a total l
15 of 173 senior reactor operators.
l 16 The SRO's discussed in starting with our input, 1
ld 17 developed a list of developments they felt chould be inc'uded IL 18 in a prc!essional code.
)
19 The resulting elements, the principal product of the 20 workshop, were then distributed to member utilities.
The t
21 following seven elements were considered by the workshop 22 participants to be the most important, and I know the 23 Commission would identify with most of these elements directly.
24 Protects the public health and safety.
That's the 25 bigger part of the professional code for operators.
I know we
it'
-o Q,;
M 25 1
all applaud that.
y 2
Personal integrity.
Third, a commitment to 1.!'
3 excellence.
Fourth, maintain and improve job-related knowledge 4
and skill.
5 Fifth, accept responsibility for one's own actions.
6 Next, monitor and respond promptly to plant conditions and 7
abnormal indications.
8 And last, adhere to all applicable regulations of 9
plant procedures.
With this input over the past few months, 10 all utilities have been working on a professional code.
11 We believe it very important that the operators feel 1(
12 ownership of these codes and, thus, in every case, the work is Il 13 started with the operators.
14 To date, we have received reports along with copies 15 of the codes from 19 utilities covering 24 sites.
And by the 16 end of this month, we expect to receive them all.
17 We ask for all of them by the end of July.
Let me 18 just read an excerpt from a couple of the letters giving us 19 feedback on how this is going.
20 First is a letter from the American Electric Power
,!I il 21 and it's from the CEO, Pete White.
He says, following your r.
I i
22 lead at the CEO conference, we carried out the concept of a i
23 professional code for operators to our plant management.
24 It goes on, they were receptive and sent 25 representation to your workshop on this subject in February.
A m,_
g
~w-26 1
series of meetings at the plant with operators led the 2
appointment of a peer committee to draft a code.
d, This has gone through several revisions and we 3
lI 4
anticipate adopting an operator code pry to your suggested July b
5 1988 target.
b 6
This letter is dated April 15.
He says, I strongly ~
7 support the followup concept that a foundation should extend 8
throughout the utility and we will pursue this concept building 9
on the operator code.
10 I shall personally follow development closelv and
~
11 interject my corporate philosophy as required.
To us, that's a 12 good example of CEO involvement.
13 Here is a letter from Philadelphia Electric Company l
14 that furnishes a copy of their code and I think, in view of the l '
4 15 situation that happened at Peach Bottom some time ago that we'd L
16 all be interested in the few elements of their code.
17 The first one is, and t.his was developed by the Peach 18 Bottom operators, they call it their commitment to excellence.
19 Remain diligent in maintaining plant and personal safety by 20 identifying and actively pursuing resolution of concerns.
21 Next, constantly remain alert and maintain awareness 22 of plant status, anticipating conditions that could adversely 23 affect plant reliability.
24 Next, cooperate with independent organizations, l -
L5 recognizing the need for monitoring and review cf nuclear U
. 1',;
27
[
1 operations.
s 2
And next'and the last one I'll read but not the last 3
one on the list, be governed by and adhere to applicable 4
Federal law by complying with technical specifications, 5
procedures, and policies.
And it goes on.
6 Here's a letter from Duke Power received just a few
~_
U-7 days ago, and this is from Bill Lee and he says, regarding the I
(-
8 initiatives towards strengthening professionalism, a committee ti 9
of our operators has developed a commitment to excellence.
10 They prefer this handle rather than the word code 11 which has regulatory connotations.
The committee of operators 12 will present the cominitment to excellence to management at a 13 luncheon meeting later this month.
14 He goes on to say, in the last paragraph, all in all, 15 thinking about commitment to excellence and professionalism is 16 a very worthwhile process that has been stimulating to all who
?
17 have participated.
I p
18 We plan to continue high priority emphasis.
And then 19 the last one that I'll read, this is from Northeast Utilities.
20 And the first paragraph says a working group of operators 21 representing the reactor operators of our four nuclear stations 22 have done a splendid job in developing an operator code.
23 And then it goes on with some points about the 24 workshop and so on.
It says in the last pacagraph, I am j
25 pleased with the code developed by our nuclear station q
tb
I f,i.
28
.U d-1 operators.
2 I feel it' encompasses a salient point presented by 3
the various input sources, and I'm especially pleased with the 4
enthusiastic participation and buy-in by our reactor operators.
5 Those are just some examples, but they were 6
encouraging to us to see the real participation.by the 7
operators ir. the generation of codes that look like they're
-a 8
pretty sound.
l 9
The management principals, in parallel with the i
[
10 efforts to develop codes by the operators, utility executives l
i(
11 have addressed a set of management principals designed to 12 enhance and ensure the right climate for the operators, i
13 To review this background briefly, at the CEO 14 conference each utility was provided with a draft set of 15 principals for review and comments.
16 And many comments were received.
While a number of 17 respondents took exception with a point or two in the 18 principals, virtually all were supportive of the concept and 19 many commented favorably on the need.
3 20 An ad hoc industry committee of experienced nuclear i
21 power executives, Chaired by Ed Utley, Carolina Power and 22 Light, was formed to review the utility comments and to assist 23 us in refin;ng the principals.
24 And the people on that committee were com.: of the
~
25 best utility executives from around the country with a
)
r O
O 29 j,
1 widespread in geography and plant type.
a 2
The committee did considerable work and, in my view, 3
exceptionally fine work on this project.
The final set of 4
principals, entitled principals for enhancing professionalism, a) 5 was distributed to our members and to the Commission's senior i
6 NRC staff in March.
7 We have copies with us in kind of a booklet form.
I 8
think copies are in front of the commissioners.
9 Based on the Committee's input, the scope of the 10 principles has been expanded to include all nuclear personnel, l
11 maintenance, technical and engineering personnel rather than 12 limited it to operators.
?!
13 In fact, that was one of the strongest suggestions of s
14 the Committee.
The principles for these other areas are being i
15 drafted and will be distributed to utilities and copies 16 provided to the NRC at a later date.
We asked each utility, 17 beginning at the CEO level to take an in depth look at its 18 policies and practices and compare them to this set of 19 principles.
e've also asked them to share the results of this 20 comparison with us by the end of Augttst.
21 The reports of this review are already being received 22 and I'll just read excerpts from one of those letters.
This is ij 23 Baltimore Gas and Electric where the CEO, George McGowan, says l
[
24 "the commitment and professionalism of nuclear people is a key
- t 25 ingredient for success of any nuclear program and our Calvert PW
ll.
'6, 30 1
Cliffs operations is no exception."
He said "I have reviewed 2
the copy forwarde$ with your March 30 letter and fully support 3
the principles outlined in this document.
The ad hoc industry 4
committee did an outstanding job in summarizing the requisite 5
managerial precepts to maintain an enhance professionalism."
6 He goes on later to say "I have distributed the
,ii
~
7 principles with a cover letter throughout our nuclear g
organization and I emphasize the importance of epplying the 8
9 principles throughout our daily operations."
10 We.telieve that this is an important initiative as
'l 11 each utility formally adopts and puts into practice the 12 principles that promote, encourage and reward professional 13 performance of nuclear personnel.
Nuclear plants will be 14 operated ct higher standards.
I'd be remiss if I did not 15 mention that the NRC has been very supportive of these efforts.
l l4 16 Discussions with Commissioners and with senior staff
'p h
17 led to useful ideas that were incorporated into our thinking l
18 and into the principles.
We explicitly included the staff's 19 input into the guidelines for the operator codes.
We very much 20 appreciate the NRC's interest and support of this initiative.
21 Mr. Chairman, in clo :ing, we value these 22 opportunities to brief the Commission on our work.
Such 23 meetings and information exchange are vital to the industry ar.d 24 we look forward to each session.
ha'd be pleased to try and 25 answer any questions.
'i lu u
rg
. -m JE at 31 1
CHAIRMAN ZECH:
Thank you very much.
Question?
Mr.
2 Roberts?
~'
3 COMMISSIONER ROBERTS:
This is your informstfon sheet 4'
on.the performance indicators?
And the trends look /ery good, 5
but let me ask you this -- you say, talking about the very 6
first item -- equivalent availability factor.
In 1986 and 1987 7
performance in thic area was significantly affected by the a
I 8
long-term shutdown of several plants with had equivalent 9
availability factors of zero percent.
That's obviously TVA, 10 Peach Bottom, Pilgrim -- don't make the cceputation but how 11 would this numbe~. change if you eliminated them from n
12 consideration?
13 MR. SULLIVAN:
It's about 68 percent.
14 COMMISSIONER ROBERTS:
Okay.
Thank you.
The.t's all 15 I have.
l 16 CHAIRMAN ZECH:
Commissioner Carr?
Mr. Rogers?
i 17 COMMISSIONER ROGERS:
Well, yes, I'vc got a few 18 things I'd just like to hear a little bit more about if we can, 19 in various areas.
With respect to the international programs, 20 have any concrete results come out of this effort so far that h
21 actually involve the plants themselves.
I mean, this seems to 22 me you're in an organizational phase, or have been in an 23 crganizational phase up till now, have you seen anything 24 specific start to emerge that you can put your finger on in the 25 way of specific results other than agreements to work together, P
+
32 1
to share information?
2 MR. ANDERSON:
Do you mean out of the new II in 3
organization that we're trying to form?
I 4
COMMISSIONER ROGERS:
Yes.
j l
5 MR. ANDERSON:
It's really too early for that 6
although we did have a group down in Duke Power just about
~_
7 three months ago and they looked at the way Duke was handling 8
operating experience and just the way the material was being 9
handled.
Not specific material exchange, but we gained 10 something from them because there were about seven nations 11 represented in that effort so we're just getting started in 12 that respect.
But as to exchanging information, we just 13 haven't done that yet because we were waiting for all these l
14 steps to take place, so nothing has really happened.
11 15 Our goal is to have it organized by May of 1989 but 16 in the meantime, we're trying to get organized so we are ready 17 to go at that time.
18 MR. PATE:
Commissioner, I have a comment on that if 19 I may.
INPO has an international program which we've been 20 operating for about seven years and we now have 14 21 participants.
The participants are the free world countries hj 22 that operate nuclear plants.
All of them except -- that have a e
23 sizeable nucle'ar program -- all of them except Switzerland.
24 Yugoslavia has just joined our program as a participant, just a d
25 few months ago.
The other 13 have been participants for a song 4
_i.
33 l'
time.
2 It's just'a simple reality that the Eastern Bloc 3
countries aren't going to join a U.S.
institute so we weren't 4
exchanging anything with the Eastern Bloc countries, plus a lot 5
of other countries for one reason or another wouldn't n
6 participate with INPO or just couldn't due to State Department y
~
7 policies.
For example, South Africa.
So a key reason for this
!'i 8
initiative is to set up an organization that allows the 9
information flow into all countries that operate nuclear 10 p' ants.
11 With the 13, now 14, that participate with us, a good 12 healthy exchange has been going on for years and all of those 13 or virtually all of those countries maintain a guy in Atlanta 4
14 on our staff who can literally, since our products are not 15 confidential, he can siphon off and send home anything he wants 16 to.
17 Stan, we made how many technical exchange visits to 18 our existing participants, say, in the last 12 months?
19 MR. ANDERSON:
About 24.
20 MR. PATE:
And we just had a team of what, about 10, 21 in Taiwan?
22 MR. ANDERSON:
Almost 15, 14 people.
23 MR. PATE:
Fourteen people in Taiwan at their 24 request, to dc a review of their operations, so a lot is going' 25 on in the INPO international program, but nothing as Stan said,
(
I t
o L
l i
34 n
i h
1 has happened under this new association that would broaden the 2
operating experiende exchanged to the hopefully the whole 1
3 world.
In fact, one of the things that our international
{
l 4
participants stress is that they want a slow transition because 5
they don't want to give up the exchange they already have with l
6 INPO.
i I
~ _.
i 7
COMMISSIONER ROGERS:
Fine.
Just turning to the 8
maintenance area, when you started your program, review teams, 9
you picked a person on each team from a plant with a clearly 10 good maintenance effort.
So you said.
Now, the question is r
e 11 how did you decide who those folks were?
1 hat were the 12 criteria for determining that you felt comfortable with that 13 assessment?
14 MR. PATE:
That's based simply on the evaluations 15 that we've done over the years with each plant.
We've been to 16 each plant now, I think we've been to everyone at least five 17 times and many six tines, and we have for example, we have a 1
18 maintenance department of about 19 people and over the years,
-(
l-L 19 they get to know the maintenance people in the industry pretty l', [
20 well.
l.;
21 Soon, they have a sense for which plant has pretty 22 solid maintenance, maybe preventive maintenance, and so if 23 we're going to a plant where we think preventive maintenance 24 needs a lot of help, we try in a customized way to pick a guy 25 from another plant that does that well and take him with our
~
,a d
35 1
team.
It's purely a subjective choice, Commissioner.
n i
2 COMMISSIONER ROGERS:
Well, do you think there's any
'u
!j way that -- you know, what I'm trying to get at here is how one 3
f j-4
' develops measures of excellence in this area and whether 5
there's any thought being given to somehow being able to 6
distill the approach of the experts into -- who render these 7
judgments over time -- into some kind of a system.
In fact, an 8
expert system, that renders such -- pops out such a judgment.
9 It's an area that of course, we're all grappling with, how to 10 identify good programs and largely up to now, I suspect, it's being done as a matter of judgment by people who visit and look 11 12 and consult with each~other and decide, yes, this is good.
13 can that somehow be taken one more step into a little b
14 more of a structured approach -- not necessarily fully 15 structured, but a little bit more of a regularized approach 16 that could be useful for other purposes.
17 MR. SULLIVAN:
We've tried -- we have other 18 indicators that we've been looking at now for six years, at 19 least.
The problem with that we find primarily is it's -- I've 20 heard it said it's more like looking in a rear view mirror.
It 21 tells you where you've been but not where you're going.
Wo i
i
,j 22 haven't been able to come up with a way that substitutes for an r
23 experienced evaluator in the field observing work.
s; 24 So, I think our assessments still get to looking at 25 what's physically going on in the plant.
As I said, we aren't
,,w---
e 36 1
content really to just react to events or whatever happens, 2
we're trying to anticipate problems but we found that the 3
quantitative indicators that we've gathered data on really I
4 don't help us do that very much aside from looking at thing-1 5
like NPRDS which can give you a feel for where that plant's 6
equipment is performing relative to the industry, but even p
i 7
there, it's only data.
9 8
It's got to be follow-up in the field to as I said --
9 one obvious trade-off is, is it a data problem versus a real 10 problem in the field?
So, those are the kind of things we 11 follow-up in the field and on balance, we found over time the
~
~
12 evaluator in the plant is the one that gives us the best and 13 most timely information.
14 COMMISSIONER ROGERS:
Well, it's the problem e* how 15 to try to regularize something that can be looked at by the i
16 non-expert; is there a way?
It's something, I guess, we're all I
h 17 hoping can emerge eventually.
With respect to HPES, does your 18 evaluation system involve any quantitative measures for 19 evaluation?
You're talking about human performance now.
Arc 20 these again somewhat subjective and judgmental or can they be 21 somehow distilled into quantitative measures.
22 MR. SULLIVAN:
We are looking at the causes that we 23 see in these day-to-day human performance problems I mentioned 24 that we see that cause profiles are very similar to the causes 25 we see in significant events.
So, we have -- we're beginning L
h F
h' ij 37 q
V 1
to gather data and try to look at where the problems are.
I 2
guess it's not a surprise to us compared to what we see in the 3
evaluation things like procedures, communications, the 4
workplace, equipment labeling, show up.
5 The program is really emerging and I'd say just 6
beginning to mature, so we haven't tried to come up with a
~ _.
i 4
7 quantitative parformance measure of its value at this point.
]
8 COMMISSIONER ROGERS:
So far, that hasn't been part 1[
9 of it?
10 MR. SULLIVAN:
Yes.
~
11 COMMISSIONER ROGERS:
You think that you're moving 12 towards that?
Do you think that's a realistic expectation or 13 is that something that's a question yet to be answered?
14 MR. SULLIVAN:
I think it's the latter.
It's yet to 15 be answered.
Right now, in just applying the techniques and-16 looking at these day-to-day problems that occur and trying to 17 understand why they occur, that -- and you know, in all these ij 18 areas, I think it's safe to assume that the real results will il 19 show up in the overall performance indicators that we've 20 developed, equivale.nt availability, the numbers of scrams, I i
21 mean, all those things reflect on human and equipment 22 performance.
23 COMMISSIONER ROGERS:
Th'ey're all final outcomes, not 24 sort of intermediate measures along the way and that's where 25 the di ficulty comes; isn't it?
$i t
~
)
38 1
MR. PATE:
Yes, sir.
That's exactly where the 2
difficulty comes.
3 COMMISSIONER ROGERS:
Just with respect to your NPRDS 4
record systems studies, what are you finding with regard to 5
failures in instrumentation and control systems and their i
6 importance?
I know you mentioned the motor operated valve and _
l 7
of course valve problems have been, you know, legion.
8 What is your experience so far, though, with 9
equipment performance failures or component failures in the 10 instrumentation and control area?
This is one that somehow j
11 doesn't.seem to be popping up in some ways and what have you g
12 been finding in this regard?
g' 13 MR. SULLIVAN:
We have looked specifically, for h
i 14 instance, at reactor protection systems and the principal 15 conclusions were really, for instance, to lose an RPS function, j
16 the common cause failures are the things that are most 17 important and have resulted in the significant situations.
At 18 the same time and this is true 'ven in the case of motor 19 operated valves, we see a distribution of performance among the l
20 plants.
li 21 There's always someone who's having more problems itjy 22 than the average.
There are always some people who for one 23 reason or another have figured it out.
So, in the case of l
24 reactor protection systems a couple of the issues were 25 instrument drift and calibration problems w'31ch could
~
l 39 1
contribute to failure but in general, we haven't noted any 2
broad, generic problems in that area, but what we're finding q
and this is where I said it's going to be tough to make the 3
j 4
future gains.
p 5
The problems are more plant-specific.
So, we do this
'l ll _
6 analysis in advance of svery evaluation and we go into the ic 7
evaluation knowing where this plant has an adverse performance 8
trend for a particular component or where their performance is 9
different from the industry, whether it's particularly worse or
~
10 better.
11 Our sense is that che problems need to be attacked on 12 a plant-specific basis.
13 MR. PATE:
A study of reactor protection systems and i
14 that's why he is talking about that particular one.
That was 15 chosen with some care as a system as a system to study where we i l 16 have to have a good payback but in doing that analysis a few
f plants were found to be having failures of detectors that sense 17 18 power level and at the high power level lead to a reactor 19 scram.
20 A few plants were having failures in the connections 21 to the detector or the connections back in the cabinet.
That 22 takes me back 15 years to Navy experience where a lot of 23 problems were experienced with these cabling connectors where 24 you may have a dozen pins, each one picking up its own signal 25 and if those connectors fail then the inctrumentation doesn't ti*
f i.
Ji 40 1
do its function or the detector doesn't do its function, so the 2
study identified to' those plants that they are an outlier in 3
cable connections and hopefully then knowing that they could go 4
in and find what everybody else is doing to make sure their 5
connections are reliable, so that is a specific xample of i
6 something we just distributed to the industry.
~..
7 It is a little contribution but in the aggregate all 8
those little contributions add up to reliability and we hope 9
one of these days they will add up to improved availability 10 throughout the industry.
11 MR. SULLIVAN:
That's reflected in scrams too.
I 12 think that the reason Tna got interested in the RPS system wac 13 it is about 15 to 20 percent of the scrams as of 198a, but the 14 scram rates now, even this year, are running about a little 15 over 2 per unit year compared to -- I think there's a table 16 shows --
17 COMMISSIONER ROGERS:
That's an industry average?
i' 18 MR. SULLIVAN:
Right.
I i
19 COMMISSIONER ROGERS:
That's quite a substantial --
i 20 MR. SULLIVAN:
Yes, it is and I think the increased 21 care with the reactor protection systems is reflected in that 22 and that gets back to the bottom line indicators but to get 23 those results, the devils in the details, you've got to attack 24 the problens at the plants.
25 COMMISSIONER ROGERS:
And just one other area,
l ls L
P
?
41 h
0
~
1 finally, the professionalism initiatives.
How different are V
2 the elements of the' individual utilities codes that are h
1 l
3 starting.to drop in to you?
When you review them, do you see 4
any significant differences from one utility to another?
l 5
MR. PATE:
Those are due into us, Commissioner, by 6
the end of July, so we have about half and I have read them 7
every one as they have come in, but we haven't done the 8
analysis that my staff will do when we get them all, so i
9 answering your question just on the basis of my having read a
10 them, they are strikingly similar.
That is not too surprising
~
11 because they all went to that workshop and they all took home a L
12 guideline.
y h
b 13 Yet there are variations.
For example, the name of 14 the thing, as Bill Lee says, his guys want to call it 15 Commitment to Excellence.
Others have called it A Code of 16 Ethics.
We recommended they call it A Professional Code, but l
17 that was specifically a recommendation.
Some leaned more 18 toward the ethical behavior whore others leaned a littla more 19 toward a spectrum of professionalism in its full sense, but I'd 20 say most places have 8, 10, 12 elements and the elements i
j 21 usually include integrity and following up on abnormal e
L 22 indications and adhering to the regulations and procedures and 23 communicating carefully with the othecs in the control room and 24 so on.
25 So while they vary over a fairly narrow spectrum that
t 42 1-I've tried to describe, I think the most striking feature is 2
that they are quite'similar.
It would be a pleasure to talk to 3
you about that after we've analyzed the full set.
- i 4
COMMISSIONER ROGERS:
Thank you very much.
l h
ll 1
5 CHAIRMAN ZECH:
Let me just comment, first of all, on l
6 your training emphasis and your accreditation program and p
7 commend INPO for that initiative.
It certainly in my judgment 8
has shown an upgrading of training in the utilities and in the 9
plants that I'd visited I note for example that whereas three
'i 10 or four years ago when I first started visiting the plants, 11 training was mentioned but with not the enthusiasm and not the 12 emphasis that I see today.
l; 13 Your initiative regarding upgrading training I think l4 14 has certainly been a significant one and has put training on a 14 1,
g higher plane throughout the industry where it should be and I l
15 J
L 16 think that that is a very significant contribution of INPO.
l 17 On your maintenance program and the discussion we've 18 had here this morning, I agree that it is difficult to come up i
f 19 with the performance indicators in the maintenance area, 20 although I would prefer to look at it as a challenge rather 21 than an impossibility.
I think that if we continue to work at 22 it, and I've talked to our staff and they are continuing to 1
23 work on it, I would suggest that INPO continue to work on it 24 also to see if you can't come up with something that could be 25 helpful.
It is difficult.
Looking in a mirror is not a bad
)
l
=
3.
u-43 l
1 way to describe it because you can see when it is over with, 1
l 2
hindsight does show'you where you have been, but I believe it 3
is not imposaible so I would look at it as a challenge to 4
continue to see whether you can't come up with something.
3 5
We are going to do that and I believe that it could l
6 have a payback.
We may find that it takes more than one s.
7 indicator, maybe several, but it seems to me that it is not f!
8 completely impossible to come up with something that should
?
y 9
show us some measure of maintenance capability.
~l
( 1) 1 10 I think the focus we are putting on maintenance is 11 appropriate and I can't help but feel that if we focused on
~ '
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12 maintenance we will indeed be able to come up with some l
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13 measure, maybe quantifiable, maybe not, but certainly 14 approaching quantifiable and will at least give us a better
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15 measure than we have now.
I suggest that you continue to work 16 on that.
As far as the performance indicators themselves are 4
17 I
,l l
18 concerned, I know that INPO has had them for a number of years l
19 and as you well know, we are working on a program here.
I 2C think that our staff and INPO is working together on these 21 indicators.
I have recently thought that since this was kind 22 of my initiative here, for the NRC to participate in a 23 performance indicator program perhaps we should change the name 24 to Safety Indicators because our focus on them is from the 25 regulatory standpoint, as you know.
I haven't discussed it
f.
j 44 1
with my colleagues and I don't know if it would be important 2
enough to do that or not but it does seem to me that perhaps 3
that would show the emphasis that we are placing on the 4
regulatory and the safety side of trying to get some measure 5
that will assist us.
6 In any case, we are proceeding in that regard.
Our
~
~
7 indicator system is maturing and perhaps calling them safety 8
indicators would be the appropriate thing to do but we will 9
look into that in due course.
l 10 on professionalism I'd just like to comment that I 11 think that that is a very important endeavor that you are
~
12 undertaking.
I think it is particularly appropriate. that you t-13 involve the operators -- the maintenance people, I hope, as 14 well as the operators.
Those people who are on shift worA at 15 the plant in some capacity I believe can contribute to that 16 professionalism but it is encouraging to me to hear what you 17 have done so far in that regard, 18 We, too, had started a program in that regard you 19 know, to have an enhanced control room professionalism.
We T
20 will watch your program very carefully but I think that you 21 have rade an excellent start towards getting a commitment.to 22 safety and an improved operational professionalism and I think 23 that the fact you have involved the operators again and a 24 number of utilities and the people are really thinking about 25 this very seriously has to result in the positive safety as
45 I
well as reliability improvements, p
2 So that is an important program and when you get 3
these plant personnel thinking about how they can do it better 4
and committing themselves to doing it better, certainly that a
5 has got to be something that we all would applaud.
I commend 6-you-for that program and am following it carefully, as I know
~_
7 my colleagues are and the staff here is too to see that perhaps 8
we can even measure improved performan<.e as a result of that 9
program as you put it in place.
10 Those are my comnents.
Before we conclude this 11 morning, let me ask my colleaguus if they have any other last 12 thoughts.
13 COMMISSIONER CARR:
I've got one.
On your world 14 organization, how are you working the funding on that?
Who is 15 going to pay ~the bills?
- l 16 MR. ANDERSON
That's a very good question.
The 17 Coordinating Center will need funds to operate and that is why 18 we have specified that it be very small.
Each of the regions 19 will contribute to the Coordinating Center, probably in equal 20 share.
That hasn't been fully decided as yet.
21 COMMISSIONER CARR:
And the regions are expected to e
22 get their funds from their participating utilities?
23 MR. ANDERSON:
That is correct.
The regions will be d
24 self' supporting -- that is, the membership will contribute to 25 the work of the particular regions, so that's our plan thus
J y,
46 1
far.
.2 COMMISSIONER CARR:
You don't have the same sort of 3
leverage that you are used to in an international organization.
4 I don't know how you take care of the guy who doesn't pay his 5
bills.
Just curious, that's all.
h 6
MR. ANDERSON:
Well, we hope that everybody will be (j
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generous and pay their bills.
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8 COMMISSIONER CARR:
Like they do in the other world 1;
9 organizations.
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10 MR. PATE:
Well, that's inevitably why they're f
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11 challenges.
12 CHAIRMAN ZECH:
On that same subject, let me make one i
f 13 brief comment.
I know you referred to your coordinating with 14 our Government agencies and State Department and so forth.
d i
15 MR. ANDERSON:
Yes, sir.
i 16 CHAIRMAN ZECH:
It's very important that you do that lk 1
p 17 because I'm sure you're aware of that since you mentioned it.
l!
N 18 We need more leverage en that but I think that's important.
,1 1
19 I'm sure you'll follow through on that --
l 20 MR. ANDERSON:
Yes, sir.
We will.
21 CHAIRMAN ZECH:
-- very carefully.
22 Mr. Rogers, anytning further?
23 COMMISSIONER ROGERS:
Well, just to say that we 24 appreciate and I certainly appreciate very much' hearing from 25 you and the quality of the INPO products is clearly a very high
.k 4
47 i
,c l'
one that I think we appreciate seeing and hearing about and I h
2 just hope that we can always find ways of working 3
constructively together on the safety aspects of nuclear plant 4
operations.
Obvicusly INPO's interests are broader with 5
respect to performance than the NRC's in 'a certain sense but we 6
certai7ly share an overlap very strongAy in the safety area and 7
I just want to commend you for your good work in the past.
We 3
look forward to working constructively in the future.
9 CHAIRMAN ZECH:
Let me just conclude then by saying i
l 10 that we thank you very much for a very informative briefing.
- l 11 We look forward to this briefing as you do and I know I need g
12 Ivit r3 mind INPO that NRC is the Government authority.
We do 13 have the statutcry responsibilities.
Your industry group, on 14 the other hand, you can and are making in my judgnent and I'm 15 sure that of my colleagues too, a significant contribution to 16 safe operations and of course that is what we watch very 17 carefully.
18 We want to continue working with you and we hope that 19 you will recognize that this agency, the NRC, does indeed have i
i 20 the regulatory responsibilities for public health and safety.
I l
1.
Wc intend to carry them cut.
We fully recognize though that i
22 the licensees, as I mentioned in my opening remarks, do have 23 the responsibility for the safe operation of their plants and 24 we charge them with that and therefore your participation in 25 improving their safe operations does indeed support our
)
1 I,
4
48 i
1 mission.
s 2
So whereak we have the regulatory responsibilities,
,i 3
the statutory authority for public health and safety, your
- l
- 5 4
significant contribution to improved operations and safe lY l 1, 5
operations does complemerit our carrying out our 6
responsibilities.
We commend you for what you have done in the
'N 7
past.
We encourage you to continue to focus on encouraging 8
excellence and improved operations.
9 We thank you very much for being with us today.
We f
p 10 appreciate it and stand adjourned.
l 11 (Whereupon, the meeting was adjourned at 11:17 a.m.)
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CERTIFICATE OF TRANSCRIBER This is to certify that the attached events of a meeting of the U.S. Nuclear Regulatory Commission entitled:
TITLE OF MEETING: ANNUAL BRIEFING BY INPO i
~
I PLACE OF MEETING:
Washington, D.C.
l I
DATE OF MEETING: TUESDAY, TULY 12, 1988 i
were transcribed by me.
I further certify that said transcriptien is accurate and complete, to the best of my ability, and that the transcript is a true and accurate record of the foregoing events.
I i
I l8 Ann Riley & Associates, Ltd.
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[
I SCHEDULING NOTES
.,;?-
TITLE:
. ANNUAL BRIEFING BY IRPC SCHEDULED:
10:00 A.M., TUESDAY, JULY 12, 1988 (OPEN)
. DURATION:
APPROX 1-1/2 HRS PARTICIPANTS:
INPO 145 MINS SPEAKERS
~
- ZACK PATE INP0 REORGANIZATION PRESIDENT / CHIEF EXECUTIVE OFFICER ACCREDITATION UPDATE
]
INP0 MAINTENANCE ACTIVITIES PROFESSIONALISM OF NUCLEAR PLANT
~
~
PERSONNEL
- STAN ANDERSON, VICE PRESIDENT WORLD ASSOCIATION OF INTERNATIONAL AND SUPPLIER DIVISION NUCLER OPERATORS
- TERRY SULLIVAN INP0 MAINTENACE GROUP VICE PRESIDENT ACTIVITIES ANALYSIS AND ENGINEERING l
OTHER ATTENDEES
- PAT BEARD, JR.
VICE PRESIDENT i
GOVERNMENT RELATIONS
- ANGIE HOWARD VICE PRESIDENT INDUSTRY RELATIONS AND INFORMATION SERVICE
- WALTER C0AKLEY GROUP VICE PRESIDENT TRA!NING AND EDUCATION
IS22788.001 TC 11 MAY 88 Keener
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IS22788.011 TC 09 JUL 88 ANDERSON
- 10 Resolution of the Paris Meeting e To strengthen existing links and cooperation among nuclear operators by setting up a World Association e That the Association's Mission is to maximize the safety and reliability of nuclear power stations' operation by:
exchanging information encouraging comparison
. stimulating emulation among nuclear power station operators
- That a Steering Committee be established to:
J 9 implement the. Organizational Principles that form-
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1522788.012 TC 09 JUL 88 ANDERSON
- 12 Resolution of the Paris Meeting e That the key Organization Principles of the Association are:
- The organizational structure will f acilitate direct exchange, l
comparison, and emulation of member's operating experience
- The organizational structure will include Regional Centers in Atlanta, Moscow, Paris and Tokyo
- Members can participate in one or more Regional Centers e That a Coordinating Center be staffed from each region aad be iocated in a country not containing a. Regional Center
~a That the Coordinating Center work closely with the.IAEA to ensure:
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- 10 WANO Steering Committee
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To implement the organizational principles stated in the Resolution Main Task:
Set up the World Association of Nuclear l
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- 12 1
Steering Committee
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Meetings:
December 2,1987 March 1,1988
~ June 21,1988 Countries Represented:
Belgium Hungary Spain Canada Italy Sweden Finland Japan United Kirgdom France Korea USA W. Germany. Mexico USSR f ; a. '
Secr~etariat INPO London Office
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IS22788.008 hMW 09 JUL 88 KEENER
- 12 Regional Centers Atlanta eINPO to sponsor eOrganizational meeting scheduled for July 14,1988 Moscow
- All Union Research Institute for Nuclear Power Plant Operation will sponsor eMeeting held June 30,1988 in Hungary Paris
- Several meetings of Vd. European utility organizations eProspective Director assigned Tokyo
.eHeld meetings of regional utilities: Japan,. Taiwan,
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IS22788.002 TC 9 JUL 88 KEENER
- 10 Second Executive Meeting Moscow - May 1989 Decision by Executives to formally establish World Association of Nuclear Operators 4'-
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4 Principles for Enhancing Professionalism of Nuclear Personnel T he purpose of these principles is to enhance professionalis nuclear penonnel. They are principles that management in the nuclear power industry considers important for fostering professionalism of all nuclear plant and corporate support personnel. They require contin-ued management attention to be effective. This document provides examples of the types of principles that utilities should adopt and intple-ment to recognize, enhance, and maintain a climate of professionalism.
These examples should be used by utility management to examine its policies and practices and to make improvements where needed.
March 30,1988
Prindpies for Enhancing Professionalism of Nuclear Personnel
- 1. managing ror
- 1. _,o,_ _ gem
-_,y d s_,e _es me sce, nuclear manager possesses sufficient nuc! car power plant knowledge and Excellence and caperience, otne, corporate omeers, managers, and staff personnei responsible Professionalism for Supponing plant operations possess the necessary knowledge and experience to understand nuclear plant activides, problems, and events. Corporate officers and directors above the senior nuclear manager are involved with :.nd informea of plant performance and problems in sufficient detail to maintain a clear' understanding of the status of plant safety. Necessary resources and support are provided in a timely manner.
- 2. Management provides an environment that is conducive to excellence and professionalism. This includes the following elements:
- Senior management establishes an overall corporate philosophy that permeates the organization.
. Management sets the example by conducting itself with commitment and integrity.
+ Management establishes safety as a personal, moral responsibility and ensures the safety of the public, utility personnel, and the plant.
- Management maintains an atmosphere of open communication such that problems are brought to its atter2 ion undiluted.
. Management sets goals that encourage centinual improvement in perform-ance and avoid a sense of self satisfaction or complacency.
- 3. Management ensures that work is performed in accordance with c:tablished plans, schedules, and procedures to achieve maximum clarity of direction.
quality of performance, and management credibility.
- 4. Appropriate levels of management are actively involved in the d y to-day activities of the plant, including routine operations, testing, and outages.
- 5. Management provides plant personnel with a quality plant to operate and maintain by ensuring that plant systems and components are reliable and maintainable mi conform to approved design and that high standards for material condition are maintained.
- 6. Management is proactive arui responsive. Solutions to problems are pursued with the objective of correcting root causes and improving performance. Solving problems is viewed as an opportunity for making productive improvements.
j
Principles for Enhancing Professionalism of Nuclear Personnel i
- 2. managio, mene,.i Nuclear Personnel
- i. peopie and their p,oressionat capabindes are reganied as the nuclear organi-zaticn's most valuable resource. Authorized staffing is sufficient to perform all required tasks, and positions are filled with highly trained and fully qualified individuals.
- 2. Programs are established and implemented to recruit and select individuals with the qualifications and abilities to perform the jobs for which &cy are being hired and also with the ability to develop the skills and knowledge required for higherlevel positions.
- 3. Knowledge and skills are developed, maintained, and enhanced through appropriate training and career development. In addition, opportunities are provided for personnel at alllevels to work with good role models to foster development. The initial and continuing training programs for applicable plant personnel are accredited by the National Nuclear Accrediting Board. Other training programs are also maintamed at high standards.
- 4. Management practices and policies convey an attitude of tmst and an approach that is supponive of teamwork at alllevels. Dese practices and policies recognize and expect professionalism from all personnel. Policies that spell out expectations and standards of performance are well-estabilshed and documented. These policies are clearly communicated and are well understood by all personnel and are routinely reinforced in training and in the daily conduct of business.
- 5. De line organization is the principal focus of management, the principal source ofinformation, and the only source of management direction. Com-mittees, review boanis, and other activities that provide supplemental quality I
checks ofinformation sources are not allowed to dilute or undermine line authority, accountability, or credibility.
- 6. Management practices encourage communication and require teamwork among and between groups that operate, maintain, and support the plant. These practices also encourage personnel to view themselves as a part of the overall "team" with successful operation of the plant being a common goal and that conflicts between the workers and management or between groups are resolved.
Mana2ement conscientiously examines these issues on an ongoing basis.
- 7. Appropriate personnel have professional codes that set forth certain practices, including ethical practices, that they adopt as a part of their way of doing business. Rese practices embody high standards of technical and ethical performance and help build a foundation for safe and reliable plant operations.
Dese codes are developed and maintained such that individuals feel ownership and pride in their code and its implementation.
Principles for Enhancing Professionalism of Nuclear Personnel 8, Management seeks input on the development, and feedback on the effective-ness, of policies and practices. Open channels of communication are established and maintained such that personnel at all levels are encouraged to provide complete, undiluted input and feedback.
- 9. Personnel receive appropriate recognition for their achievements, both within l
their work groups and in t14 company as a whole.
)
B. Developing Management Personnel
- 1. Formal programs are estab!!shed to select and develop individuals to fill key management positions.
- 2. Managerrent development and selection practices reflect the fact that work in plent opet#.; 9:ovides the broad, integrated view of plant activities needed by nuclear m.m. n Individuals with experience in day-to-day plant operations are considerum an imponant source of management talent. The policies and practices that govem career development ensure that individuals are aware c.f the opportunity to develop into management positions and that selected indivi(uals are encouraged and provided with opportunides to pursue this career path.
- 3. Promotion and management development practices seek a balance between career operations individuals and others who obtain operations experience as pan of their career development. Operations personnel with the potential to fill key management positions are provided an opponunity for acquiring experience in other groups. Also, other personnel with the potential to fill key management positions are provided an opportunity for obtaining an SRO license or certifica-tion and operations experience. Engineers who hold bachelors degrees in technical fields are considered a key source of such personnel.
- 4. The plant manager or assistant plant manager in the line organization holds or has held an SRO license or has been certified for equivalent SRO knowledge and has extensive nuclear power plant experience, preferably in the operations depanment. The operations manager or middle manager to whom the shift supervisors report holds an active SRO license and has extensive nuclear power plant operations department experience, preferably as a shift supervisor.
In addition, in the long term, it is highly desirable that other key plant manage-ment positions be filled by personnel with plant operations experience and who hold or have held an SRO license or cenification. Examples of such positions include the following:
maintenance manager technical services manager training manager a
Principles for Enhancing Professionr.lisrn cf Nuclear Personnel j
= site manager
. outage manager
. the various assistants for these key positions
- 5. Management personnel and candidates for management positions are pro-vided approp.iate management and interpersonal skills training and experience to enable them to perform management and supervisory functions.
- 6. Candidates for managen.ent positions or for promotion to higher level management positions are provided with opportunities to work with and for individuals who can serve as role models to enhance the development of leader-shre and management capabilities.
- 7. Selected permnnel are provided opportunities in a variety of functional areas in the nuclear organization and are given opportunities to work with utility groups and to visit other nuclear stations to broaden their exposure and perspective.
C. Managing Operations Departrnent Personnel In addition to the practices and principles described above, the following apply specifically to operations depanment personnel.
- 1. 'Ik initial screening of applicants or candidates for operations positions takes into account the positions of great responsibility that these personnel are likely to fill, for example as reactor operators.
- 2. Subsequent screening, with nuclearline management involvement, is con-ducted as operators and others are selected as candidates for the senior reactor operator and shift supervisor positions. This screening focuses on leadership and management capabilities.
- 3. While a college degree in a technical field is not a necessary requirement for operations positions, operators with bachelors degrees in technical subjects have a greater likelihood of promotion to and success in management positions.
Management practices ensure that an appropriate number of personnel with such degrees, or the potential and desire for acquiring such degrees, are selected for operations positions. In addition, management assists and encourages selected opemtors Lho have the potential to acquire bachelors degrees; programs that lead to degrees in technical subjects are given preference. 'o assist in ac-l complishiry this, college credits may be sought for successful completion of I
utility training programs.
1 Principles for Enhancing Professiondism cf Nuclear Personnel
- 4. Management p.1ctices goveming the conduct of control room operations and simulator training ensure the following:
- The line responsibilities and authorities during off-normal or casualty conditions are spelled out with absolute clarity. To the maximum extent possible, the roles of control room personnel during an off-normal or casualty situation are the same as for routine duties. (A transfer in respon-sibility when things begin to go wrong is undesirable for many reasons, including the fact that personnel are often unable to detennine when such a transfer should be made.)
. Simulator practices of normal, off-normal, and casualty situations are conducted, to the maximum practical extent, with the same personnel and with the same responsibilities and authorities that are assigned in the plant control room (the team concept).
- 5. Line management, up to and including the senior manager on site, is suffi-ciently involved in all phases of the training, qualification, requalification, and simulator programs to ensure that operators are properly qualified to perform their assigned tasks.
- 6. Management policies and practices ensure that the person responsible for the plant after hours (in effect, the person who acts for the plant manager), whether this is a shift manager, shift engineer, or shift supervisor, is selected keeping in mind the great responsibility that the person assumes. The individuals selected have the training, experience, maturity, and judpent to assume this respon-sibility. In selecting and approving these individua3, it is recognized that this person enforces the professional standards and sets the tone not only for the operators but for all personnel at the plant during off-hoers. Final approval of the qualifications ofindividuals assigned to this position 10 reserved for an appropriate level of senior management.
D. Managing Maintenance Personnel E. Managing Technical Personnel F. Managing Engineering Personnel NOTE: Principles that specifically apply to maintenance, technical, and engineering personnel have been drafted and will be reviewed by utility personnel. After they have been finalized, they will be added to the management-and operations-related principles.
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Wlume 4 Number 2 June 1988
...A publication about experiences in huntan perfortnance The One That Got Away
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TAGGINGSYSTEM
,g The station tagging systemis one of A valve that was caution tagged charging pump suction valve, water the mostimportant controls for p*
open instead of being danger tagged flowed through the charging pump and tecting plant equipment and personnel.
closeN to the draining of 1300 gal-out the flange where the relief valve Problems with tagging continue to oc-lons of conta Ned waterinto the had been removed.
cur and have recently resulted in un.
auxiliary building.
Approximately 45 minuteslater a plained scrams, equipment damage.
During a refueling ( itage a tagging roving sect.rity guard notified the con-and personnelinjuries.
order that included draining the vol-trolroom that water was coming out of Thisissue of LiftedLeads focuses ume controltank wasimplemented to the room. The operators closed an iso-on tagging problems and the underly, allow repacking of volume control tank lation valve to stop the leak. An esti-ing causes of these events. Each event dischargeisolation valves nd the mated 1300 gallons of contaminated was analyzed toidentl the causes and bench testingof thechargingpu 1pdis-water hadleaked from the system, corrective actions needed to prevent charge relief valve. When the repacking The post event evaluation deter-recurrence.
was completed,a portion of the system mined that the review of tagout revi-was realigned to reestablish a makeup sions is not conducted as thoroughly as water flow path from the refueling -
initial tagouts. Additionally, the tag-water storage tank to the reactor cool-ging coordinators do not receive plant-ant system-specific systems training. The event To realign the system,the tagout highlights the importance of supervi-was revised. During the revision pro-sory attention to detail when approv-cess, the operations coordinator did not ing tagouts, notice that tbc charging pump suction Recommended corrective actions valve used as a drain path during the included revising the procedure to en-isolation was caution tagged open.The sure a more detailed review of tagging l
tagout revision to realign the system revisions and requiring systems train-was then implemented.
ing for individuals involved in prepar-When power was restored, the sup' ing tagoute.
ply valve from the refueling water stor-mu u n n i i i. j TRIP & CAL TRIR DID YOU HANG b k YEAM.
SOMEONE HERE WANTS THE TAGS FOR THE WHY?
[ TO SEE YOU ABOUT,s -
5ERVICE WATER YOUR WORK.
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s Litted Ind, Volume 4 Nrmber 2 June 1988 Case Of the Missing were not adequatelylabeled. Inade.
One mechanic was ona gratingand Tag quate communication among person-able to get away, the second was sitting nelwas a contributing factor, ona support Firder 15 feetin the air A misplaced tag resultsin a r* actor The evaluation alsoindicated a tur-and had nowhere toescape. He scram.
bine buildinginstrument airvalve received burns on his legs and face, but i
The unit wasin cold shutdown check off was not performed prior to fortunately did not fall to the concrete with a maintenance outage in progress.
unit startup. Such a review would have below.
One of the maintenance activities for identified the mispositioned root valve.
The post event evaluation revealed this outage was to remcVe and repair Corrective actionsincluded the theorderof thetagouthadtrapped l
the level control valves for feedwater proper labeling of allinstrument air steamin the pipe with none of the sys-heater SA.To support this activity a valves, revising applicable procedures tem vent ordrain valves tagged open.
l tagout wasissued.
to address the handling of missing.ags, Additionally,the system was not l
The tagout sheet did not identify ensuring that the instrument air vntve checked to ensureit had been depres-l the instrument air valves to be closed linc upcheckoff procedureis per-surized.
by number but provided the valve formed prior to startup, and discussing Corrective actionsincluded ex-name instead (e.g., "instrument air iso-the event andlessonslearned with panding the tagging system to include lation toSD-SI 128A").Since many of operations personnel.
vent and drain valve positioning as well the instrument air root valves were not as requiring positive verifica tion of sys-labeled, it was easier to identily the unm i i I : a tem status prior to opening a previous-valve by name. As a consequence, the ly pressurized system. Additionally, equipment operator assigned to tagout Hang in There requirements for the use or scaffolding the level control valve placed the tag on A deficient tagging order and anin-were discussed with maintenance per-the air header root valve for the level c rrect assumption caused a mechame sonnel-control vahe instead of the local isola-t be burned.
tion valve-e ma ntenam men were later,after the job was completed, assigned toadjust the packingon two a different operator removed the steam valves and to replace the packmg tagout. He removed all the tags except n a third.The steam system was the one on the airisolation valve, tagged out by the operations group to l
which he could not find.This was support th.is work.
reported to the shift supervisor, and an At the job site,the maintenance unsuccessful search for the missing tag men n ticed the valve requiring new QUARTERLYQUOTE was conducted. It was assumed the tag packmg was still blowing hot water and had been lost,and the tagout was can-
..Errorsjustdon't happen.
steam through the old packing.They theyare caused."
celled.
proceeded to the other two valves and Two monthslater the reactor tightened the packing as required.
scrammed from 18 percent powerdue When they returned to the first valve, to high water level in heater S A. With-they found the valve stem dry and the rmr o,,nuom. s.n, isoo. noo arti,75 r,6..
out instrument air, the level control 4o c,,i 3033,. o scio 4 co.....,6 valve n I nger blowingsteam. Assum-is..,mi,n,,,,,6. n,,n,. rersor...a im,uon sn.
valve had failed in the closed position.
The post event evaluation mdicat-ing the pressure had been relieved, they
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ed the wrong vahe was tagged because Suddenly the packing blew out the description on the tagout sheet was with a burst of hot water and steam.
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FROM:
SECY Correspondence & Records Branch l
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