ML20154R547

Refers to 981020 Meeting in Region IV Office Re Common Cause Analysis Conducted by Util Staff at Fort Calhoun Station. List of Attendees & Licensee Presentation Encl

ML20154R547
Person / Time
Site:	Fort Calhoun
Issue date:	10/22/1998
From:	Gwynn T NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV)
To:	Gambhir S OMAHA PUBLIC POWER DISTRICT
References
NUDOCS 9810270067
Download: ML20154R547 (31)

Text

{{#Wiki_filter:b q p***do i r UNITED STATES . [t. ,-j REGION IV *L ( 'j NUCLEAR REGULATORY COMMISSION 3 s 0,, -.' s 611 RYAN PLAZA DRIVE. SUITE 400 ,o' ARUNGTON. TEXAS 76011 8064 OCT 221998 S. K. Gambhir, Division Manager. Nuclear Operations Omaha Public Power District Fort Calhoun Station FC-2-4 Adm. P.O. Box 399 Hwy. 75 - North of Fort Calhoun Fort Calhoun, Nebraska 68023-0399

SUBJECT:

MANAGEMENT MEETING TO DISCUSS FORT CALHOUN STATION COMMON CAUSE ANALYSIS

Dear Mr. Gambhir:

'his refers to the meeting conducted in the Region IV office on October 20,1998. This meeting related to the common cause analysis conducted by your staff at the Fort Calhoun Station. This meeting was beneficial in providing information directly to the Regional Administrator. Most of the information had been previously presented in a public meeting conducted on October 6,1998, at the Fort Calhoun Station. In accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2, Title 10, Code of Federal Regulations, a copy of this letter wil! be placed in the NRC's Public Document Room. Should you have any questions concerning this matter, we will be pleased to discuss them with you. Sinc \\( Thomas P. nn, irec r Division of eactor ro' cts Docket No.: 50-285 License No.: DPR-40

Enclosures:

1. Attendance List

2. - Licensee Presentation

1. 810270067 981022 PDR ADOCK 05000285 P

PDR ja

~.. -. .4~ Omaha Public Power District cc: . James W. Tills, Manager Nuclear Licensing Omaha Public Power District Fort Calhoun Station FC-2-4 Adm. i P.O. Box 399 Hwy. 75 - North of Fort Calhoun Fort Calhoun, Nebraska 68023-0399 James W. Chase, Division Manager Nuclear Assessments Fort Calhoun Station P.O. Box 399 - Fort Calhoun, Nebraska 68023 . J. M. Solymossy, Manager - Fort Calhoun Station Omaha Public Power District Fort Calhoun Station FC-1-1 Plant P.O. Box 399 Hwy. 75 - North of Fort Calhoun - - Fort Calhoun, Nebraska 68023 t Perry D. Robinson, Esq. Winston & Strawn-1400 L. Street, N.W. 4 - Washington, D.C. 20005-3502 1 . Chairman Washington County Board of Supervisors Blair, Nebraska 68008 Cheryl Rogers, LLRW Program Manager Environmental Protection Section Nebraska Department of Health 301 Centennial Mall, South P.O. Box 95007 < Lincoln, Nebraska 68509-5007 E ( (

..., ~.. c . ) e Omaha Public Power District. OCT 2 2 m- ~ L l l \\ bec to DCD (IE45). l bec distrib. t'y RIV: Regional Administrator DRS-PSB q DRP Director MIS System -*c Branch. Chief (DRP/B). RIV File Project Engineer (DRP/B) Branch Chief (DRP/TSS) Resident inspector i 1 3 DOCUMENT NAME: R:\\_FCS\\FC1020MS.DRP - To receive copy of document, Indicete in box: "C" = Copy without enclosures "E" = Copy with enclosures "N" = No copy RIV:AC:DRP/B D:DRP A), DNGraves;df M. TPGwynn f V 10/ @ /98 10P,1498~'-/ OFFICIAL RECORD COPY - h y =p y ..-...v

. -... - - ~ - - - -. - - ~ y 5 I - Omaha Public Power District OCT. 2 21998 i bec to DCD (IE45) [bcc distrib by RIV:. RegiontJ Administrator ' DRS-PSB

DRP Director-MIS System

. Branch Chief (DRP/B) RIV File ' Project Engineer (DRP/B) Branch Chief (DRP/TSS) l . Resident Inspector - i i j J ' ] ) l 4 l 1 DOCUMENT NAME: R:\\_FCS\\FC1020MS.DRP I To receive copy of document, indicate in box: "C" = Copy without enclosures *E' = Copy with enclosures "N" = No copy RIV:AC:DRP/B - D:DRP A), DNGraves;df to - TPGwynn IT V 10/ @ /98 109,1498. ' /- . OFFICIAL RECORD COPY-nro.,,, q

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\\.. ) l 4 r I ENCLOSURE 1 1 Attendance List i Licensee W'. G. Gates, Vice President S. K. Gambhir, Division Manager - Nuclear Operations J. M. Solymossy, Manager - Fort Calhoun Station i K. Rackley, Director, Performanca Improvement International NRC' 'I E. W. Merschoff, Regional Administrator T. P. Gwynn, Director, Division of Reactor Projects W. B. Jones, Senior Reactor Analyst D. N.' Graves, Acting Branch Chief, Project Branch B I i l I i. 1

1 (. ' ENCLOSURE 2 ~O l Agenda i I Introductions I Process I Corrective Actions I Summary I Open Discussion O Human Error Analysis I Phase 1 1 Common Cause Analysis I Phase 2 I Underlying or Root Cause Analysis l O

l n l f.\\ j Phase 1 l l Common Cause Analysis of l Fort Calhoun events O Phase 1 Analysis E

Purpose:

1 Identify underlying organizational and programmatic issues 1 Identify focus areas for further investigation I Completed July 1998 I Used Condition Reports Beginning 1/1/97 I Levels 1,2,3 and selected Level 4 l0 l I

O Phase 1 Analysis l I Selected events involving human errors l occurring since 1/1/97 I Excluded i Errors occurring before 1/1/97 I Equipment failures l I Data base of 140 inappropriate actions i I 80% confidence level I 5% expected random error I 1 O. -. Phase 1 Analysis Process I Review Condition Reports, Root Cause Analyses and HPES investigations I Identify " Inappropriate Actions" E Categorize" Inappropriate Actions" i l L

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0% coordination of document document procedure activities (ca) preparation (dp) review (dr) preparation (pp) N._.) Classed by Type of _Misjudgement iO inappropriate Actions . in o,quoi, xas i.,,. ___ = = = - - 16 % ~ - - - - - - - - - - - - - - - ---{ 14 % _ 12%. g 4 b + _-4 O 1o% d2 w' .~ g 0% y q YL 7 _j o e%.._ e y,_ v v i,: t. ,.1 W i. 4L $1 u 1 4 4% - (:j - f;r; A l "- s u - = -

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C IAs versus O&P Failure Mode (Expected Error of 5%) 50.00 % 45.00 % -- 'V 40.00 % -- O m 35.00 % -- e h 30.00% -- 2 ~ O 25.00 % -- + v 0 20.00 % -- 15.00 % -- l ) x 10.00% -- e 5.00% -- 43 0.00% 05 O4 001 P2 P1 P4 03 OP1 PP1 PP3 P3 02 O&P Failure Mode This can be compared to the following graph from the draft report. The only significant difference between the two gaphs is that the P4 failure mode is greater than the 5% threshold value for the latest analysis. This change does not impact the focus of the Phase 2 analysis. Secondly I looked et the Inappropriate Action categories for the items classified as an Inadequate Job Skills, Work Practices, or Decision-Making deficiency. The following graph shows the I-

breakdown between job skills, work practices and decision making.

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IAs versus O&P Failure Mode (Expected Error of 5%) 30.00 % 25.00 % -$7 k[ en 20.00% - 3; 4 S o p 15.00% -- o F ? 10.00 % -- g fl n r n 5.00% -- if ~ ek

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l 8 j. y ~ ~ M n 0.00% - 05 04 001 P2 P1 P4 03 OP1 PP1 PP3 P3 O2 O&P Failure Mode Category Description 05 Inadequate Job Skills, Work Practices, or Decision Makino 04 Inadequate Communication within the Organization 001 Inadequate Interface Amono Organizations P2 Inadequate Scope P1 Insufficient Detail P4 Inadequate Self Verification Process The PII CCA identified a large number of Organization and Programmatic DefKiencies in the category of " Inadequate Job Skills, Work Practice, or Decision Making." Kevin Rackley stated he defaulted to this category when he did not have enough information to allow further categorization. Based on my understanding of the events and the PII categorization I have re-categorized a number of these items into other categones. The following graph shows the result of this rect &wiGcolivn. P) v

(% inappropriate Actions for O&P Deficiency O-5 (inadequate Job Skills, Work Practice or Decison Making) 7% 0Misjudgement (Decision " "9) 7% 41 4 NCommitted Actions Not Carried Out 11 % E '[ Olnadequate Job Skills or c, Knowledge O nattention to Detail t l 54 % LL g ja Dinadequate Mental State >p t6.d

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21 % ~. p The graph shows that only 11% of the inappropriate actions are due to inadequate job skills or Q knowledge while 54% are due to inadequate decision making. This is consistent with the CCA conclusion that the dominant failure mode is misjudgment. The inadequate work practice deficiency is captured by the inappropriate actions of " committed actions not carried out" and " inattention to detail." Inadequate work practices account for 28% of the inappropriate actions. De remaining 7% of the inappropriate actions are categorized as " inadequate mental state" and are assigned to the " fear of failure"," fatigue" or " overconfidence" subcategories. These inappropriate actions are due to internal states the worker brings to the task and reveal themselves through work practices. O

l-l l l O Phase 1 Conclusions l l l E Inappropriate actions causing FCS events are organizationalin nature vice being associated with particularprocesses or activities I No difference in characteristics of inappropriate actions between 1997, 1998, and the '98' refueling outage O Phase 1 Conclusions I 83% Decision-making (Rule and Knowledge-based) Errors I Predominant Internal Failure Mode Category Was " Misjudgment" i errors were application ofincorrectrulesor the misapplication ofrules. I 80% " Administrative", Vice " Technical", Tasks or Expectations l I performance of simple activities L li V, 1 l

l O) L Focus of further l investigation I Communication within departments I Lateral integration between departments I Supervisory effectiveness and culture. O Phase 2 Determination of Underlying Causes O 4

O Phase 2 Methodology I Site Wide Surveys (322 Responses) I Administrative Procedural Compliance I Accountability and Self-Motivation I Supervisor / Effectiveness I Formal interviews and informal discussions L Administrative Procedure Compliance Survey Results i High perceived mental burden associated with administrative procedure compliance I Low probability of receiving consequences when not complying with an administrative requirement i Low probability of receiving positive feedback when observed complying with management expectations / administrative requirements (3

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O Accountability System Survey Results i The current accountability system does nothave a positive impact on human performance, especiallyin the area of administrative procedure compliance. i 4 O Survey Results for Supervisory 4 Error Reduction Effectiveness I Not helping to reduce, or induce, human errors I Supervisory Skill Weaknesses I communication & coordination I field sunteillance I standards reinforcement i 4 O

O v Conclusions of Lateral Integration and Coramunication Analysis I Breakdowns are occurring in the lateral integration and vertical communication at FCS I The lateral communication mechanisms are in place I The breakdowns are occurring due to a lack of teamwork O Underlying Causes I Most fundamental are cultural issues I Poor and Inconsistent Teamwork I Ineffective vertical communication I The existing accountability system does not have a significant, positive effect on human performance l l l I

c i,] Underlying Causes L I A higher than desired potential error rate l for noncompliance with administrative requirements exists. l O Contributing Cause I Supervisors not effective in applying human error reduction skills t

4 Q Oorrective Actions I Based on review of CCA completed by - NRC and Performance Improvement International I Review of initiatives in progress I v Corrective Actions l B Initiatives in progress I " CHOICE" Program I Organization Changes -1 Alignment Initiative I Leadership Development Training I Resolution of INPO Findings l l Development of Business Plans l () l

O v Corrective Actions I Additional / continued emphasis is needed in the following areas: 1 Improving Lateral and Vertical Integration / Communications I Implementation of an Effective Accountability System and Follow-up 'Ov Corrective Actions I Areas for Additional / Continued Emphasis (Cont.): 1 Administrative Burden Reduction I Procedure / Program Quality Improvement 1 Human Error Reduction Tools and Training i Supervisory Effectiveness in Human Error Reduction Skills -( ?

oV Corrective Actions l l Improve Lateral Integration i I Integrated Business Planning Process i 1999 Resource Loaded Business Plan i Departmental Business Plans Completed I Division Manager review to assure integration and consistency with " CHOICE" Program Initiatives (in progress) i Review by Division Managers on at least a quarterly basis in 1999 nU Corrective Actions improve Lateral Integration l I Site-wide work prioritization system (in progress) B Behavior-Based Performance Expectations i FCS Values identified by Management (complete) i Safety Conscious, Individual Respect i Integrity, Accountability, Teamwork i Simplicity O l 1

4 O Corrective Actions improve Lateral Integration I Behavior-Based Performance Expectations i Behaviors to support values developed by management team (complete) I sought additionalinput during Nuclear Performance Meeting i Behaviors being communicated (in progress) I Using Multi-discipline teams to resolve problems and improve buy-in (e.g. CHOICE teams) I Next Step Is Adoption of These Behaviors at the Work Group Level

O Corrective Actions Vertical Communication Loop I Started with " Team Building" Meetings at the top I Several Process Team Building Sessions scheduled over next three months I Additional New Leadership Training for Managers will focus on

1 Alignment - Creating a Common Reality l 1 Integration - Helping people connect I Commitment - Franchising high performance I Culture - Passenger, Navigator, or Architect t V

O Corrective Actions Vertical Communication Loop I FCS Leadership Meetings to Go Over Training & Leadership Issues - scheduled for Mondays I Expectations for Face-to-Face Communication Up & Down the Chain I More Frequent use of FCS On-Line I Better Use of 3N I Nuclear Performance Meetings O Corrective Actions Accountability System I Management Changes / Reorganization I Four Division Managers I Plant Manager from INPO I New Training Manager I Two Assistant Plant Managers I Two Operations Supervisors O

J O l Corrective Actions l Accountability System I Holding People Accountable for Management's Expectations I Motivating Work Force to Maintain Desired Behavior I Coaching & Counseling Process I Developed a New Disciplinary Policy I Requires peer review O u Corrective Action Implement a Burden Reduction Strategy i I Focus on Most Burdensome Procedures / Processes

O Corrective Action Improve Procedure Quality I S0-G-30 revised to implement procedure " owner" concept and facilitate procedure revision process (complete) I Evaluate further improvement to procedure revision process I Eliminate, downgrade and simplify current administrative procedures and policies ) 1 Operations Standards Handbook O Corrective Actions Improve Procedure Quality I Address Procedure / Program Quality Issue I Line Management Oversight i Functional Group Ownership I Production Quality (I.E. Writer Training) I Process Simplification l .O

l' O Corrective Actions improve Procedure Quality I Operations Procedures l Emphasize Operating crew procedure ownership I Operator training on the Writer's Guide I All operating procedures will be reviewed to meet the Writer's Guide O Corrective Actions Provide Personnel at All Levels With Human Error Reduction Tools I Exemplary Human Performance (CHOICE) I C - Critical Self Assessments I H - Human Performance is Exemplary I O - Operations are Event Free I I - Initiatives in High Visibility Areas Have Strong Performance I C - Corrective Actions are Broad & Lasting I E - Excellence in Materiel Condition l O

n Corrective Actions Provide Personnel at All Levels With Human Error Reduction Tools I INPO Human Performance Assist Visit I Developed Human Performance Plan zI Training is Being Provided to Improve Human Error Reduction i Human Performance Fundamentals Course I " Titanic" Training O v Corrective Actions Supervisory Effectiveness in Reducing Human Error I Improving Supervisory Effectiveness in Reducing Human Errors I Organizational Changes in the Operations Area 1 Additional supervisor in Operations Group I Additional Assistant Plant Manager l Plant Manager focused on day-to-day operation, leadership skills improvement and communication of manacement expectations b O

O Corrective Actions Supervisory Effectiveness in Reducing Human Error I Improving Supervisory Effectiveness in Reducing. Human Errors I Supervisors will receive human performance -training i Pre-job briefings have improved i Scorecard concept introduced i Improvements discussed previously will have major impact I Additional training needs are being evaluated O Summary I The Majority of the Issues Identified Through the CCA Are Being Addressed Through Initiatives Started Prior to the Last Refueling Outage I Additional Corrective Actions Are Being Identified to Address Some of the Newer Insights O )

O Summary Next Steps I Build on Successes to Date in Operations Area I Factor Corrective Actions Into Business Plan I Repeat CCA l \\ j 4 i!Q ) 5 i a}}