ML20195J145
| ML20195J145 | |
| Person / Time | |
|---|---|
| Site: | Seabrook  |
| Issue date: | 07/23/1997 |
| From: | Diprofio W, Sovetsky E NORTH ATLANTIC ENERGY SERVICE CORP. (NAESCO) |
| To: | |
| Shared Package | |
| ML20137T709 | List: |
| References | |
| PROC-970723, NUDOCS 9906180104 | |
| Download: ML20195J145 (70) | |
Text
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RMD CONTROL COPY j
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i OPERATDIC EXPERIENCE MANUAL (SSOE) 1 h.
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J DETERMINATION OF SAFETY EVALUATION APPLICABILITY:
1.
The individual answering the questions below shall have completed 10 CFR 50.59 training.
2.
Does this manual / manual revision:
a.
Make changes in the facility as described in the O Yes do UFSAR?
b.
Make changes in procedures as described in the UFSAR? O Yes No c.
Involve tests or experiments not described in the O Yes No UFSAR?
/
'd.
Require a change to.the existing Operating License O Yes M (including the Technical Specifications) or are additional Operating License requirements needed?
3.
If any of the above questions are answered y n, a safety evaluation per the Regulatory Compliance Manual (NARC) is required.
PREPARED. BY:
E. J. SOVETSKY, TECHNICAL PROJECTS SUPERVISOR q
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SUBMITTED BY:
a E. J. SOVETS
,T HNIDAf PROJE PERVISOR DATE 1
k7' / / 2.
7/A}N7 SORC REVIEW COMPLETED DURING MEETING NUMBER:
DATE:
APPROVED BY:
e GO 9@n W D
vh3/97 W. A. DipkOFIO,. STATION DIRECTOR DATs REVISION 15 -- EFFECTIVE:
07/28/97
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e orpo 9906190104"990615 PDR ADOCK 05000.443 s
OPERATING EXPERIENCE MANDAL (SSOE)
TABLE OF CONTENTS CONTENT ZAgI CHAPTER 1: INTRODUCTION 1.0 GENERAL 1-1.1 1.1 POLICY 1-1.1 1.2 SCOPE 1-1.1
1.3 BACKGROUND
1-1.1 1.4 PROGRAM RESPONSIBILITIES 1-1. 2 1.5 PROGRAM IMPLEMENTATION 1-1.4 1.5.1 General 1-1.4 l
'1.5.2 Reporting of Adverse Conditions 1-1.4 1.5.3 Operating Experience Reference (OERE) Manual 1-1.4 1.5.4 Event Reduction Methods 1-1.5 2.0 HUMAN ERROR PREVENTION 1 2.1 CHAPTER 2: ADVERSE CONDITION RESPONSE 1.0 OVERVIEW OF THE OPERATING EXPERIENCE PROGRAM 2-1.1 1.1 ADVERSE CONDITIONS 2-1.1 1.2 SCOPE 2-1.1 1.3 ' MANAGEMENT EXPECTATIONS 2-1.1 1.3.1 Levels of Defense of Quality 2-1.1 1.3.2 Employees 2-1.2 1.3.3 Supervisors 2-1.2 1.3.4 Management Review Team 2-1.2 1.3.5 Management Guidelines 2-1,3 1.4 OPERATING EXPERIENCE PROGRAM OWNERSHIP 2-1.4 2.0 DEFINING OPERATING EXPERIENCE THRESHOLD REPORTING CRITERIA 2-2,1 2.1 REPORTING 2-2.1 2.2 SIGNIFICANCE LEVELS 2-2.1 2.3 ROOT CAUSE ANALYSIS THRESHOLD 2 2.1 3.0 PRIORITIES 2-3.1 Page 1 SSOE Rev. 15 I
CONTENT EaqE CHAPTER 2: ADVERSE CONDITION RESPONSE 4.0 DEFINING CAUSES 2-4.1 5.0 RESPONDING TO ADVERSE CONDITIONS 2-5.1 5.1 IMMEDIATE MANAGEMENT OVERVIEW (Protected: Ref. NA #930786) 2-5.1 j
5.2 ADVERSE CONDITION REPORT (ACR) 2-5.1 6.0 SIX CRITICAL ATTRIBUTES OF THE ACR 2-6.1 7.0 MANAGEMENT REVIEW TEAM (MRT) INITIAL REVIEW 2-7.1 8.0 OTHER ACR REVIEWS AND EVALUATIONS 2-8.1 l
8.1 REGULATORY REVIEW 2-8.1 8.2 INDUSTRY OPERATING EXPERIENCE REVIEW PROGRAM 2-8.1 l
8.3 OTHER REVIEWS 2-8.1
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9.0 DESCRIPTION
S OF EVALUATIONS 2-9.1 9.1 EVENT EVA1DATION 2-9.1 9.2 ROOT CAUSE ANALYSIS (See OERE Manual) 2-9.1 9.3 OPERABILITY DETERMINATION 2-9.2 9.4 APPARENT CAUSE EVALUATION (OE 4.8) 2-9.2 9.5 TREND ONLY 2 9.2 9.6 CORRECTIVE ACTION ONLY 2-9.2 9.7 STAR SHEETS (Protected: Ref. NA #930786) 2-9.3 9.8 SELF-CHECKING REVIEW - ACR ORIGINATOR AND ACR EVALUATOR (Protected: Ref. NA #930786) 2-9.3 9.9 CAUSE AND FAILURE ANALYSIS 2-9,4 10.0 CORRECTIVE ACTIONS 2 10.1 i
10.1 DEFINITIONS 2-10.1
]
i 10.1.1 Remedial Corrective Action (s) 2-10.1 10.1.2 Interim Corrective Action (s) 2-10.1 I
10.1.3 Corrective Action (s) Io Prevent Recurrence (CATPRs)
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10.1.4 Enhancements 2-10.1
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CONTENT 26EA CHAPTER 2: ADVERSE CONDITION RESPONSE 10.0 CORRECTIVE ACTIONS
'10.2' DOCUMENTATION FOR COMPLETING CORRECTIVE ACTIONS 2-10.1 3
10.2.1 Corrective Action 2-10.1 10.2.2 Enhancements 2-10.1 10.3 REVISION REQUIREMENTS FOR CORRECTIVE ACTIONS 2-10.1 10.4 IMMEDIATE CORRECTIVE ACTIONS 2-10.2 10.5 CORRECTIVE ACTION ATTRIBUTES 2-10.2 11.0 MANAGEMENT REVIEW TEAM - FINAL REVIEW 2-11.1 12.0 OTHER ACR REQUIREMENTS 2 12.1 12.1 SORC REVIEW - WHEN REQUIRED BY THE MRT 2 12.1
-12.2 ACR - FINAL DOCUMENT CLOSURE 2-12.1 12.3 ACR - REVISION PROCESS 2-12.1 l
12.4 FINAL RECOMMENDATIONS 2-12.1 12.5 ACR CANCEL 1ATION 2-12.2 13.0 TREND ANALYSIS 2-13.1 13.1 DATA COLLECTION 2-13.1 13.2 DATA ANALYSIS 2-13.1
'14 0 CORRECTIVE ACTION DOCUMENT EVALUATIONS 2-14.1 14.1 EVALUATION FOR SIMI1AR 0CCURRENCES 2-14.1 1
14.2 EVALUATIONS FOR PERSONNEL ERROR 2-14.1 15.0 OPERATING EXPERIENCE FRESENTATION (Protected: Ref. NA #930786) 2-15.1 15.1 DEPARTMENT PRESENTATION 2-15.1 15.2 MANAGEMENT PRESENTATION 2-15.1 16.0 MANAGEMENT EFFECTIVENESS REVIEWS (Protected: Ref. NA #930786) 2-16.1 17.0 TRANSITIONAL PERIOD 2-17.1 17.1 EXPECTATIONS FOR LOWER-TIER DOCUMENTS 2-17.1 4
Page 3 SSOE Rev. 15
CONTENT ZAGI CHAPTER 2: ADVERSE CONDITION RESPONSE 18.0 FIGURES 2-18.1 FIGURE 2-2-1 EXAMPLES OF ADVERSE CONDITION THRESHOLD RRPORTING CRITERIA 2-18.2 FIGURE 2-2-2 EXAMPLES OF SIGNIFICANCE LEVELS 2-18.6 FIGURE 2-2-3 ROOT CAUSE ANALYSIS THRESHOLD 2-18.8 Figure 2-3-1 SAMPLE WEEKLY STATUS REPORT OF OPEN SIGNIFICANCE LEVEL A/B PRIORITY 1/2 ACRS 2-18.9 FIGURE 2-7-1 SAMPLE MANAGEMENT REVIEW TEAM MEETING ATTENDANCE SHEET 2-18.10 FIGURE 2-7-2 SAMPLE MRT CHECKLIST FOR INITIAL ACR REVIEW 2-18.11 FIGURE 2-10 1 ADVERSE CONDITION CORRECTIVE ACTION CLOSURE MEMO 2-18.12 FIGURE 2-11-1 SAMPLE MRT CHECKLIST FOR COMPLETED ACR EVALUATIONS 2-18.14 FIGURE 2-15-1 TYPICAL OPERATING EXPERIENCE PRESENTATION WORKSHEET 2-18.15 CHAPTER 3: ADVERSE CONDITION REPORTS i
OE 3.1 Adverse Condition Report OE 3.2 CANCn.T rn OE 3.3 CANCELLED i
OE 3.4 STAR Program CHAPTER 4: ADVERSE CONDITION ANALYSIS METHODS l
OE 4.1 Event Evaluation I
OE 4.2 Cause and Failure Analysis OE 4.3 CANCELLED OE 4.4 CANCELLED OE 4.5 Operability Determination OE 4.6 CANCELLED OE 4.7 CANCELLED OE 4.8 Apparent Cause Evaluation
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1 CORIENT Zag 3 CHAPTER 5: PORCED OUTAGES
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. OE 5.1 Forced Outage Respriase CHAPTER 6: ADVERSE CONDITION TRENDING OE 6.1 CANCELLED:
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~ OE 6.2 Nuclear Plant Reliability Data System
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i OE'6.3 CANCELLED
'I CHAPTER 7: OPERATING EXPERIENCE REVIEW
' OE.' 7.1 Operating Experience Review Program OE 7.2 Use of Nuclear NETWORK j
APPENDICES APPENDIX A MANACEMENT REVIEW TEAM CHARTER A-1
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Page 5 SSOE Rev. 15 i
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LIST OF EFFECTIVE PAGES m
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Cover 15 2-16.1 12 TOC 1 -~5 15 2-17.1 12 IDEP 15 2-18.1 12 l
I 2-18.2 12
~1-1.1 12 2-18.3-13
.1 1.2-12 2-18.4 13
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1-1.3 12 2-18.5 13
'1-1.4 12 2-18.6 13 1-1.5 12 2-18.7 13 2-18.8 13 1-2.1-12 2-18.9, 13 2-18.10 13 2-1.1 12 2 18.11 13 2-1.2 12 2-18.12 13 2-1.3 12 2-18.13 13 2-1.4 12 2 *_8.14 13 2 '.8.15 13 J
2-2.1 12 1
OE 3.1 08 2-3.1 12 OE 3.4 00 2-4.1 12 OE 4.1 03 OE 4.2 03 2-5.1 12 OE 4.5 04 J
OE 4.8 00 2-6.1 12 OE 5.1 02 2-7.1
'12 OE 6.2 00 2-8.1 12 OE 7.1 01 2-9.1' 12 l OE 7.2 02 2-9.2 12 2-9.3 12 A-1 09 2-9.4-12 2-10.1 14 2-10.2' 14' 2-10.3 14 2-11.1 12 2 11.2 12 2-12.1-12 2-12.2-12 2-12.3 12 4-2-13.1 12
.2-14.1 12
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2-15.1' 12 Page 1 SSOE Rev. 15
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1.0 figNER&L 1.1 POLICY i
It is North Atlantic's policy to respond to and document adverse conditions at Seabrook Station'in a timely manner using a standard, well defined, and disciplined
. methodology. This approach will ensure that the responso 1.
is reasonabin and rational, i
2.
'is based on documented facts, 3.
corrects the real problem,
.4 prevents recurrence of the problem, S.
satisfies rugulatory requirements, i
6.
addresses human performance issues, 7.
satisfies personnel and equipment safety concerns, and i
i 8.
protects the health and safety of employees and the general public, i
j 1.2-SCOPE l
This manual describes the Corrective Action Program and contains the requirements,
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the processes, and the procedures used by North Atlantic personnel to properly j
respond to adverse conditions at Seabrook Station.
Adverse conditions affect the operation of Seabrook Station either directly or indirectly. They may range from minor occurrences that require a STAR sheet, a
. procedure change, a work request, or a repetitive task sheet for correction to major events that cause the reactor to trip, or failures, conditions, malfunctions, deviations, and nonconformances that are adverse to quality.
1.3 BACKGROUND
l'
-1.
The following' documents provide regulatory requirements and industry guidelines for implementin5 the Corrective Action Program, and usin5 and reviewing Operating Experience for lessons learned:
a.
INPO 89 005, Guidelines for the Use of Operating Experience, describes key elements for effective use of operating experience at nuclear power stations, b.
INFO 85-020, In-House Operating Experience Review, describes a methodology for reviewing in-house operating experience.
.c.
INFO 85-019. Industry Operating b.perience Review, describes a i
methodology for reviewing industry operating experience.
i d.
USNRC Ceneric Letter 91 18, Information to Licensees Regarding Two NRC Inspection hanual Sections on Resolution of Degraded and Nonconforming Obnditions and on Operability.
10 CFR 50 Appendix B Criterion XM, Corrective Action.
e.
1-1.1 SSOE Rev. 12 1
1.3 BACKCROUND 2.
This msnual provides the focel poine for interface between the different or5anizations, programs and procedures within North Atlantic that e
l fulfill operating experience and corrective action requirements.
3.
This manual was developed to a.
ensure that root cause analyses address the root cause and provide corrective actions to prevent recurrence, b.
ensure a consistent and conclusive approach is used during the preparation, assignment, evaluation, and completion of the Adverse Condition Report (ACR),
c, ensure that North Atlantic organizations agree on evaluation conclusions and corrective actions, d.
ensure that Corrective Action Program and industry operating experience documents are consistent with regulatory reports provided to North Atlantic management and outside agencies, einsure reportability determinations are performed and reported in a e.
timely manner per the requirements of the Regulatory Compliance
- Manual, f.
ensure that operability determinations are performed in a timely
~l manner, and l
g.
provide information necessary for performance improvement.
4.
This manual also provides for responses to forced outages and " lessons learned" from Station operating experience, Management Review Team responsibilities and corrective action trending requirements.
1.4 PROGRAM RESPONSIBILITIES j
1 Station Director - Responsible for the Operating Experience Program and the Corrective Action Program. Approves final operability determinations.
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Assistant Station Director - Responsible for implementing the Operating Experience Program and the Corrective Action Program.
Site Emerrency Director - Determines if an Event Evaluation Team is necessary immediately following a highly si nificant adverse condition, e.g.,
reactor 5
l trip.
l gagreenev onerations Manarer - Using the post trip review operating procedure, i
provides a critique of those events that cause a reactor trip or safety j
inj ection.
Control Room Communicator - Notifies responders of a forced outage as directed by the Shift Manager or the Outage Coordinator.
ggrrective Action Program Manager - Implements the Corrective Action Program including responsibility for root cause analyses, human performance enhancement, STAR program, and trending for Station performance improvement, 1-1.2 SSOE Rev. 12~
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1 1.4 PROGRAM RESPONSIBILITIES (C:ntinusd) pgpartment Managers and Supervisors - Ensure that evaluations and recommendations are reviewed and implemented in an effective and timely manner.
Event Evaluation Team Manarer - Oversees the progress of an Event Evaluation i
Team leader or team leaders and reports directly to the Station Director.
Event Evaluation Team Leader - Coordinates the activity of an Event Evaluation
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Teaan and reports directly to the Event Evaluation Team Manager.
Egreed Oqtage Notification Coordinator - Assembles the forced outage notification lists.
I Licensine Manager - Determines if an adverse condition is reportable and provides the necessary reporting functions.
Management Raview T?uB - Performs duties as prescribed in the MRT Charter of this manual.
Management Review Team ChaL; person - Provides direction for the Management Review Team (MRT) assigned to support the Corrective Action Program.
North Atlantic Personnel - Responsible for reporting adverse conditions per l
the requirements and direction in this manual. Complete STAR sheets per this manual.
Nuclear Plant Reliability Data System (NPRDS) Personnel - Perform a review of NPRDS equipnient failures to determine if similar occurcences have been reported by the nuclear industry.
Nuclear Safety Audit Review Committee (NSARC) - P-rforms independent reviews of the Corrective Action Program per Technical Specifications.
l Nuclear Safety Enrineerine Supervisor - Coordinates the review of industry operating experience information and selected NRC correspondence and disse:ainates information for additional review.
Initiates and/or performs the annual effectiveness review.
Querations Manager - Approves preliminary and final operability determinations.
Outare Coordinator - Provides the initial response during a forced outage, determines the nature of the immediate problem, and assumes responsibility for conducting the outage.
Plannine. Scheduline and Outare Manager - Ensures the unscheduled outage report is implemented during a forced outage and determines the work that will be accomplished during the outage.
Oual i ty Services Croun - Provides independent oversight of the Corrective Action Program.
Responsible Mananer - Performs a review and approves the final evaluation of the Adverse Condition Report.
1-1.3 SSOE Rev. 12
- 1. 4 - PROGRAM RESPONSIBILITIES (C:ntinuid)
Root Cause Evaluator - Performs a formalized root cause analysis for a Significant Condition Adverse to Quality or when directed by the MRT Chairperson.
Shift Manager - Performs imeediate operability and reportability l
determinations.
.l Station Oneration Review ca==fttaa (SORC)
Makes recommendations to the Station Director for approval of selected final ACR packages.
Technical Proiacts Suoarvisor - Coordinates the implementation of the l
Operating Experience Program and the Corrective Action Program.
1.5 PROGRAM IMPLEMENTATION 1.5.1 General
'l The Operating Experience Program provides the administrative controls for reporting, documenting, evaluating, recommending, and trending adverse conditions lat Seabrook Station. The requirements established by this program should enhance personnel awareness of the potential for adverse conditions at Seabrook Station and the need to document them. Reporting is required in order to 1.
comply with regulatory requirements, 2.
comply with North Atlantic pro 6 rams and procedures, 3.
report abnormal occurrences, 4
report conditions adverse to quality or significant conditions adverse to quality, 5.
provide operating experience trend analysis, 6.
provide " lessons learned.* and 7.
reduce or eliminate repeat occurrences.
1.5.2 Ernortine of Adverse Conditions 1.
Adverse conditions are documented using the Adverse Condition Report (ACR).
2.
The ACR requires specific avaluations and reporting methods based on the significance level of the adverse condition. The methods I
in this manual will provide consistency in reporting, evaluating, and trending these adverse conditions.
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1.5.3 Oneratine Exnerience Reference (OERE) Manual 1.
The Operating Experience Reference manual is used to supplement this manual for providing a root cause analysis, common cause analysis, KPIs (key performance indicators), trending, and other related activities.
I 1 1.4 SSOE Rev. 12
f 1.5 PROGRAM IMPLEMENTATION l
1.5.3 Oneratina Runerience Reference (OERE) Kanuel 1
2.
The OERE and any revisions are approved by the Station Director or Assistant Station Director.
3.
The Records Management Department issues controlled copies of the OERE as directed by the Assistant Station Director.
4.
The purpose of the OERE is to provide root cause evaluators with supplemental guidance to support high significance, high priority ACRs, trending initiatives, common cause analysis and other i
associated activities, j
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- 1. 5.4 - KY.tDr Reduction Metho'ds 1.
There are three methods to reduce operating experience occurrences or events. These are e
Prevention l
Detection l
Correction 2.
Prevention is the most cost-effective method in reducing operating experience occurrences or events.
Detection of operating experience occurrences or events uses leading, real-time, and lagging performance indicators.
Gprrection of significant operating experience occurrences or events and significant adverse trends requires a root cause analysis and corrective action to prevent recurrence.
i 1-1.5 SSOE Rev. 12 6
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l 2.0 HUMAN ERROR PREVENTION l There are three key elements for prevention of human error:
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l Expectations - Missions, goals, priorities e
l Training - Prevention Techniques e
.l Accountability - Error rate reduction These three key elements must be expressed and reinforced by Management and accepted by employees when dealing with work practices and expectations for performance.
Appropriate training must be completed to acquire the techniques, skills, methods, and strategies for.the prevention of human errors.
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1-2.1 SSOE Rev. 12
l 1.0 OVERVIEW OF THE OPERATING EXPERIENCE PROGRAM 1.1 ADVERSE CONDITIONS 1.
An adverse condition is defined as a condition adverse to quality, or an unexpected or undesirable occurrence. It is a detrimental difference l
between what is and what should be.
Concerns about issues or conditions that are questionable, may not be obvious or are indeterminate as an adverse condition shall be documented l
on an Adverse Condition Report (ACR).
2.
A repeat occurrence is defined as an adverse condition that is assigned the same event code and failure mode code as a previously identified adverse condition.
3.
Adverse conditions shall be reported, documented, analyzed, evaluated, l
and/or trended to ensure compliance with regulatory requirements, programs, and e
procedures, to document completed recommendations for corrective actions in e
order to prevent recurrence (i.e., a repeat occurrence), and l
to improve human performance.
1.2 SCOPE 1.
Adverse conditions may or may not directly affect plant or Station personnel (e.g., local and state Emergency Planning issues) but may require formal evaluations or may include significant, reportable events such as a reactor trip or Engineered Safety Feature (ESF) actuation or repetitive occurrences such as personnel errors.
2.
Analyses of adverse conditions or precursors to adverse conditions (reactor trip, safety injection, ESF actuation, personnel errors, loss of configuration control, loss of FME, etc.) provide an awareness of the potential for such events, making it possible to minimize unplanned outages which reduce power generation, e
j prevent or minimize challenges to plant safety systems, and j
e analyze occurrences to provide " lessons learned" and to ultimately e
reduce adverse conditions and reduce similar or repetitive adverse conditions.
.1.3 MANAGEMENT EXPECTATIONS l
1.3.1 Levels of Defense of Ouality 1.
There are four levels of defense of quality, which are used to prevent problems from becoming events:
e First level of defense: the individual or work group 2-1.1 SSOE Rev. 12
1.3 MANAGEMENT EXPECTATIONS l
1.3.1 Levels of Defense of Ouality (Continued) e Second level of defense: supervisory personnel or management e
Third level of defense: internal oversight l
Fourth level of defense: external oversight 2.
Each employee contributes to one of the first three levels of defense of quality in the performance of his or her tasks. The goal is to find problems early before the problems become significant occurrences.
3.
The first level of defense (individual or work group) constitutes
" prevention" techniques used to reduce human error and ic most cost effective.
1.3.2 Emnlovees It is the responsibility of each employee to report any adverse condition by documenting that occurrence on the Adverse Condition Report (ACR), using the guidelines provided in this manual.
1.3.3 Suoervisors 1.
It is the responsibility of supervisors to review adverse conditions reported by their direct reports to ensure the information provided in the ACR is adequate to permit an effective evaluation of the condition, that required immediate actions were identified and taken, and that proper notifications were made (i.e., to the control room and senior management).
2.
Supervisors are expected to provide a recommended disposition based on minor fact finding and to list the cause of the problem, if known.
3.
Supervisors are expected to take the ACR to the control room within 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> of receiving it.
1.3.4 Management Review Team 1.
It is the responsibility of the Management Review Team (MRT) to provide guidance for implementing the Corrective Action Program i
using this manual.
l 2.
This chapter provides the MRT with instructions to prioritize, determine evaluation requirements, and assign responsible managers to complete ACR evaluations, in an effective and timely manner.
This must be accomplished in order to prevent recurrence of the documented adverse condition. In addition, these efforts will support responsible managers in prioritizing their daily work activities, i
2-1.2 SSOE Rev, 12
1.3 MANAGEMENT EXPECTATIONS 1.3.4 Management Review Team 3.
The MRT will provide initial reviews of the ACR and review final evaluations and provide a recommendation on approval of ACRs that are classified as Significance Level A and B, and selected ACRs classified as Significance Level C.
4 The MRT's initial assignments (e.g., evaluation required, responsible manager, significance level, priority, etc.) may be changed.
The responsible manager may request that the MRT change, add, or delete the assigned attributes with concurrence of the MRT.
It is expected that the responsible manager obtain the concurrence of a peer manager if the change affects that peer manager. The requesting manager must present these changes to the MRT for final acceptance and approval.
5.
It is expected that the manager who is assigned responsibility for the ACR will request assistance from a peer manager when necessary, to complete an ACR evaluation, and it is expected that peer manager support will be provided.
6.
The Technical Projects Supervisor will support the MRT, as appropriate, provide a final review of Level C (Low Significance)
ACRs, track, review and approve closure of ACR recommended corrective actions, and document SORC subcommittee reviews, SORC reviews, and final completion of the ACR.
The Technical Projects Supervisor may request MRT review of selected Significance Level C ACRs when the evaluation does not address the noted condition.
l 7.
Trending personnel will provide corrective action trending
-reports as required by the Station Director and per the instructions of this manual.
1.3.5 Management Guidelines 1.
This chapter provides the overall guidelines, from documenting an adverse condition to final review and approval of the Adverse Condition Report. This includes documenting any recommended corrective actions as a result of the ACR evaluation, assigning responsible managers and due dates as recommended for approval by the MRT and approved by the Station Director.
2.
Procedure OE 3.1, Adverse Condition Report (ACR), provides the basic steps required for completing the ACR.
3.
The ACR must be completed by using the guidelines and understanding the requirements (for resolving adverse conditions) that are outlined in this chapter.
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INFORMATION 2-1,3 SSOE Rev. 12
1.3 MANAGEMENT EXPECTAT10NS 1.3.5 Manarement Guidelines l
4 The administrative process for performing a review or evaluation r
of an adverse condition can be complex, and it is expected that members of the MRT bridge the gap between " Management Expectations" and assignment and acceptance of all adverse condition attributes to provide a successful Corrective Action Program.
l 1.4 OPERATING EXPERIENCE PROGRAM OWNERSHIP 1.
In order to ensure the success of this program, it must be understood that all employees are " owners" of the Operating Experience Program.
2.
The Management Review Team carries out its responsibilities per the MRT Charter contained in Appendix A.
INFORMATION ONLY 2-1.4 SSOE Rev. 12
l 2.0 DEFINING OPERATING DtPERIENCE THRESHOLD REPORTING.CRITERTA l 2.1 REPORTING
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1.
Figure 2-2-1 provides threshold reporting criteria requiring the initiation of an ACR.
2.
These criteria are not necessarily fully encompassing but should be used as a guideline to ensure operating experience occurrences are documented.
l 2.2 SIGNIFICANCE LEVELS 1.
Figure 2-2-2 provides examples of significance levels for ACRs (e.g.,
High - A, Moderate - B, and Low - C).
l 7.
The following provides definition of significance levels:
a.
Level A - Hieh Sirnificance. These reprasent adverse conditions which have or potentially have serious consequences such as death, damage, financial impact, radiation exposure and secious discredit to the organization. These issues include reactor trips, serious regulatory violations, damage to major equipment, and failure or degradation to safety-related systems, b.
Level B - Moderate Sirnificance. These include recurring programmatic deficiencies, generic problems, s.dverse trends, and other problear which, if not corrected, can be expected to result in a Level A adverse condition in the future. Examples include recurring issues in areas such as procedure noncompliance, i
configuration control, tagging, FME, and reactivity control. NRC severity level 4 or 5 Notice of Violations are Significance Level B issues.
c, Level C - Low Sirnificance. These are conditions adverse to quality which re. quire the lowest level of response. These adverse conditions require corrective actions, when appropriate, and trending to support performance assessment. Analysis of Level C adverse condition trend data and appropriate corrective actions are expected to prevent Level B and Level A adverse conditions from occurring. Examples include document deficiencies, labeling errors, drawing errors, unexpected plant alarms, and equipment failures. If they are not corrected in a timely manner, and become repetitive, a higher significance factor may be warranted.
l 2.3 ROOT CAUSE ANALYSIS THRESHOLD 1.
Figure 2-2-3 provides examples of evaluations necessary to complete the ACR evaluation, based on significance level.
l 2.
Examples in Figure 2-2-3 are not intended to be fully encompassing.
2-2.1 SSOE Rev. 12
3.0 PRIORITIES 1.
Guidelines for priorities are as follows:
I Priority 1-Requires immediate attention with whatever resources are required to mitigate, evaluate, and implement at least interim corrective actions appropriate for the given adverse conditions. Priority 1 adverse conditions are expected to be worked 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> a day, seven days a week until resolved.
Once the Priority 1 issue is resolved, the MRT (or by responsible manager request) may elect to lower the priority; Priority 2-Requires elevated attention to ensure prompt resolution.
These adverse conditions should be worked steadily as required by management expectation for completing these evaluations.
Priority 3-Routine work. These adverse conditions should be worked on in a manner consistent with other ongoing work and reflect whatever constraints apply.
2.
Priorities are assigned to the ACR to provide management with the necessary information for assigning. resources to the investigation or resolution of the adverse condition.
a.
Use of priorities replaces due dates for any required evaluations associated with responding to the ACR.
This approach allows
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management the flexibility to resolve adverse conditions within the constraints of ongoing work, b.
Some ACRs may require due. dates to support program requirements such as LER submittal, QA audit responses, NOV responses, INPO responses, EPA responses, ANI responses, management issues, etc.
ACRs written to support regulatory submittals shall be completed in an expeditious manner in order to support reports such as the LER, etc.
(Protected: ACR 96-685, Recommendation A) c.
Management attention to the backlog of open issues, based on priority and date the ACR was initiated, is required to ensure that l
the program is well managed. Figure 2-3-1 provides a sample weekly status report of open ACRs, which is distributed periodically at q
the Station Director's daily meeting.
d.
Any recommended corrective actions that must be completed as a result of the ACR evaluation will be assigned to a responsible manager with due dates and will be tracked on the commitment tracking system.
2-3.1 SSOE Rev. 12
l 4.0 ' DEFINING CAUSES 1.
The objective of the Corrective Action Program is to determine the root
)
cause of a significant adverse condition and take corrective action to prevent recurrence of the condition or similar condition.
2.
The "cause of an adverse condition" is a generic term associated with the evaluation process using the corrective action document (i.e., ACR).
3.
The Corrtctive Action Program provides the following definitions for types of "cause";
fundamental reasons for an adverse condition which, if a,
goot cause corrected, will prevent recurrence of the adverse condition.
b.
Aggarant Cause - the most probable cause of an adverse condition based on readily available information.
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2-4.1 SSOE Rev. 12
l 5.0 KESPONDING TO ADVERSE CONDITIONS When appropriate, the following sections may be performed concurrently. Management
)
will select the appropriate evaluations to be completed depending on the significance of the adverse condition.
5.1 IMMEDIATE MANAGEMENT OVERVIEW (Protected: Ref. NA #930786) 1.
The manager or department supervisor whose area of responsibility (people, tools, equipment, work practice) resulted in the adverse condition (e.g), nuclear safety concern, industrial safety considerations, personnel error, etc.) should determine its l
significance. (Significance levels are discussed in Chapter 2, 52.0.)
2.
Based on the significance of the adverse condition, the following immediate actions should be taken:
i s.
Debrief the individuals involved in the adverse condition.
b.
Review all applicable operating procedures following an unusual occurrence (such as an accident, an unexpected transient, significant operation error, or an equipment malfunction).
(Protected: Ref. NYN-94127) c.
Initiate immediate corrective actions (e.g., temporary signs, roped off areas, notifications).
l d.
In Part 1, Section 1 of the Adverse Condition Report (ACR),
document immediate corrective actions taken or proposed.
,5.2 ADVERSE CONDITION REPORT (ACR)
I 1.
An ACR shall be prepared if the adverse condition threshold reporting criteria of Figure 2-2-1 of this chapter are met.
2.
The ACR is completed using the instructions of procedure OE 3.1.
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2-5.1 SSOE Rev. 12
l 6.0 SIX CRITICAL ATTRIBUTES OF THE ACR 1.
The six critical attributes of the ACR for trending occurrences are as
)
follows:
l a.
Ornanizations involved with the inappropriate action I
b.
Prorr=== associated with the activities when the inappropriate l
action occurred l
c.
Kev Activity being performed when the inappropriate action occurred d.
Ha==n Error /Inanoropriate Action Failure Mode associated with the inappropriate action e.
Orranizational/Prorr----tic Failure Mode associated with the inappropriate action l
f.
Hn=an Error Tvoe associated with the inappropriate action (1) Skill-Based Error - unintentional slips or lapses, e.g., not thinking.
(2) Rule-Based Error - conscious decision made using experience, but rules were incorrectly or inappropriately applied.
i (3) Knowledge-Based Error - an analytical decision; no rule to apply.
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2.
This information is located in the operating Experience Reference : ZRE) manual.
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2-6.1 SSCE Rev. 12
7.0 MANAGEMENT REVIEW TEAM (MRT) INITIAL REVIEW 1,
MRT members should complete an initial review of the ACR by using a facsimile of Figure 2-7-2, Sample MRT Checklist for Initial ACR Review.
)
2.
The MRT will review the ACR to determine and assign the following:
a.
Significance: Level A or Lavel B, and may review selected Level C ACRs b.
Priority:
1, 2, or 3 c.
ACR responsible manager d.
Evaluation type e.
The need for a completion date f.
The need for any additional information/ instructions 3.
The Additional Information block is used by MRT to request that specific questions be answered or other affected issues be addressed and be included in the assigned evaluation.
4 Management may assign any necessary self-assessment initiatives to determine the cause or causes of the condition in order to prevent recurrence.
5.
The Technical Projects Supervisor will provide appropriate references to repetitive /similar/ reference occurrences to support the responsible I
manager in completing the ACR.
6.
The 10 CFR 21 block, when applicable, is checked and appropriate assignments made by the MRT.
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2-7.1 SSOE Rev. 16
l 8.0 OTHER ACR REVIEWS AND EVALUATIONS 8.1 REGUIATORY REVIEW
)
l 1.
Licensing Services reviews the ACR to determine if any regulatory report (LER, EPA, State, OSHA, etc.) is required per the Regulatory Compliance Manual (NARC).
2.
Regulatory reports are submitted to the MRT for review and recommended approval and should be consistent with the ACR evaluation.
3.
Regulatory reports are normally submitted to the Station Operation Review Committee (SORC) for review and Station Director approval.
4.
The Licensing Manager will notify MRT when an ACR has been determined to be reportable or it requires a response to a regulatory agency. If the ACR has already been reviewed by MRT, it will be returned for assignment or required due dates or change in significance level and priority to support the regulatory submittal.
(Protected: Ref. ACR 96-685, Recommendation B) 8.2 INDUSTRY OPERATING EXPERIENCE REVIEW PROGRAM l The Nuclear Safety Engineering Supervisor will provide a review to determine if similar industry events occurred and will provide documentation to the manager responsible for the ACR.
l 8.3 OTHER REVIEWS 1.
When requested, NPRDS personnel will review the ACR and determine if similar events have occurred in order to provide applicable information to the responsible manager.
2.
When requested, other departments may be required to review the ACR in support of the assigned manager.
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2-8.1 SSOE Rev. 12
9.0 DESCRIPTION
S OF EVALUATIONS 9.1 EVENT EVALUATION 1.
For a reactor trip or Engineered Safety Feature (ESF) actuation an event evaluation shall be performed. Other major occurrences may require an event evaluation if deemed necessary by the MRT or assigned responsible manager.
2.
The Station Director (or Site Emergency Director [ SED]) will select an Event Evaluation Team manager, Event Evaluation Team leader, and a team to investigate and compile an event summary report per procedure OE 4.1.
3.
The Event Evaluation Team manager may use any source of information to complete the event summary report. Additional discussions with personnel involved in the event may be held at a later time, if required.
4.
The Event Evaluation Team manager shall provide a preliminary determination of the cause of the reactor trip, ESF actuation, or other significant occurrences and shall provide a justification and any recommendations to the Station Director regarding restart of the reactor or continued plant operation.
5.
Immediate corrective actions may be required to be completed prior to restart of the reactor.
6.
The Station Director's permission is required prior to reactor startup.
7.
The final event summary report is provided to the Station Director during the SORC review process.
8.
Procedure OE 4.1 provides guidance for using the event evaluation process.
9.2 ROOT CAUSE ANALYSIS (See OERE Manual) 1.
A root cause analysis shall be performed for a reactor trip, ESF actuation, and all Si nificance Level A ACRS (unless the MRT justifies 5
in writing why a root cause analysis is not required).
(See Figure 2-2-3.)
l 2.
The MRT may require that a root cause analysis be performed for (See Fi ;ure 2-2-3. )
j Significance level B ACRs.
t 3.
A root cause analysis is performed per the Operating Experience Reference (OERE) manual.
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4.
A root cause analysis is included in the ACR and is provided to the MRT,
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and/or SORC, as part of the final review process.
5.
Include in the ACR the appropriate recommended corrective actions from the root cause analysis that were approved by the MRT or SORC.
2-9.1 SSOE Rev. 12
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9.3 OPERABILITY DETERMINATION 1.
Procedure OE 4.5 provides requirements for performing an Operability Determination.
2.
Completing the requirements of OE 4.5 is necessary when there is a reasonable question as to whether or not the structure, system or component (SSC) will be capable of performing its required safety (Technical Specification related SSC) functions or its support (non-Technical Specification related SSC) functions.
l 3.-
Necessary reviews, approvals (e.g., Operations Manager, SORC) and time constraints (e.g., Preliminary or Final Operability Determination) are provided in procedure OE 4.5.
l 9.4 APPARENT CAUSE EVA13ATION (CE 4.8) 1.
An' apparent cause evaluation is assigned when an issue has been identified, but the solution is not apparent (normally for a low significance and low priority occurrence).
l 2.
An apparent cause evaluation may include the following:
a.
evaluation of the problem to ensure the issue is understood and corrected, b,
evaluation of the problem to ensure that a significant condition is not present, c.
evaluation of the problem to determine failure mode for trending purposes.
l d.
evaluation of the problem to allow consideration of taking corrective action to prevent recurrence.
9.5 TREND ONLY 1.
Some low significance, one time, or minimal impact adverse conditions may initially require trending only, i
2.
Any necessary immediate corrective actions to mitigate the adverse l
condition shall have been documented in Part 1, Section 1, of the ACR.
1 3.
If the adverse condition is repetitive as indicated during the trending process, an evaluation may be necessary.
Is.
The Trend Only block in Part 3 of the ACR'is checked.
9.6 CORRECTIVE ACTION ONLY 1.
Some low significance, one time, or minimal impact adverse conditions may require the completion of " corrective actions only."
2.
Some adverse conditions that are reported via an outside agency or internal reports (e.g., INPO, NRC, ANI, PUC, IRT, Self-assessment l
Findings, NSEG Findings) may require corrsctive actions using the ACR as the appropriate tracking vehicle.
2-9.2 SSOE Rev. 12 i
9.6 CORRECTIVE ACTION ONLY l
3.
If the concern has already been documented on an ACR, it is not
)
necessary to issue another ACR. However, the previously issued ACR should reflect the stand alone report, as a reference.
4.
The Corrective Action Only block is checked and a responsible manager is assigned to document and complete corrective actions.
5.
The appropriate significance level and priority are also assigned.
9,7 STAR SHEETS (Protected: Ref. NA #930786) 1.
When management requires a STAR sheet, it shall be prepared per procedure OE 3.4 and may be included in the ACR.
2.
STAR sheets may be used to support the evaluation to ensure that all pertinent information is factual and correct. Disclosure of individuals' names is not required if the STAR sheet is included in the ACR.
3.
When a STAR sheet is used to support the ACR evaluation, it may not be necessary or required t; complete an Adverse Condition Report Information Sheet, form OE 3.1B.
9.8 SELF-CHECKING REVIEW - ACR ORICINATOR AND ACR EVALUATOR (Protected:
Ref. NA #930786)
E91E The following actions shall be completed for Level A (High Significance) and Level B (Moderate Significance) ACRs and :nay be applied to Level C (Low Significance) j ACRs.
1.
If the originator of an ACR is directly involved with the adverse condition identified in the ACR, the evaluator of the ACR should consult the originator to determine the following:
)
I a.
The evaluator should understand the Problem Statement in the ACR.
(1) The originator should also provide what is believed to be the j
appropriate corre,etive actions to resolve the ACR issue.
(2) The evaluator should discuss the final corrective actions with the originator to identify how the ACR concern is being resolved.
b.
Even if the originator of an ACR is not directly involved with the adverse condition identified in the ACR, the ACR evaluator should still discuss the proposed corrective actions with the originator.
2.
The originator should review the final ACR to ensure that the report is f-etual and correct and that the corrective actions could reasonably be expected to preclude future problems.
2-9.3 SSOE Rev. 12
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9.8 SF.LF-CHECRING ILEVIEW - ACR ORIGINATOR AND ACR EUALUATOR (Protected: Ref. NA (930786)
?
3.
'Any necessary changes must be addressed to the responsible manager
)
I before submitting the final ACR package to the MRT and/or SORC.
-l 9,9 CAUSE AND FAII1*RE ANALYSIS.
~1;
' A cause and failure analysis is performed when the MRT determines that
- this type of evaluation is required to obtain the apparent cause of an adversa condition dealing with equipment problems.
l 2.
A cause and failure analysis _is perfomed per procedure OE 4.2.
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2-9.4 SSOE Rev. 12 1
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10.0 CORRECTIVE ACTIONS 10.1 DEFINITIONS EQIf.
The followins are tracked as Category C, X, M or P on the commitment tracking j
system.
10.1.1 Bemedici corrective Action (s) l Designed to fix the broken component or correct the adverse condition; usually taken immediately after problem discovery; designed to minimize / mitigate the immediate risk.
j 10.1.2 Interim Corrective Action (s)
Short-term corrective actions designed to reduce the risk of recurrence (ehile awaiting implementation of long-term corrective actions to prevent recurrence.)
10.1.3 {iorrective Action (s) to Prevent Recurrence (CATPRs)
Long-term actions designed to preclude recurrence of the adverse condition.
These address the identified root cause(s), will prevent recurrence, and will not create another undesirable condition.
10.1.4 Enhancements Actions that result in enhancements (upgrades / improvements) whose level of importance is minimal and therefore are ng_t expected to be tracked.
10.2 DOCUMENTATION FOR COMPLETING CORRECTIVE ACTIONS 10.2.1 Corrective Action Records Management-archived documentation describing the issue and the actions completed to close out the issue are required (see Figure 2-10-1).
10.h.2 Enhancement 3 For enhancements there is no detrimental impact if not completed; therefore, actions are not tracked.
10.3 REVISION REQUIREMENTS FOR CORRECTIVE ACTIONS Once the corrective actions have been identified and the Adverse Condition Peport l has been given fir.a1 approval, changes to corrective actions must be reviewed and approved as follows:
l 1.
Category C Commitmencs (Protected:
Ref. ACR 97-1440) l Due date changes require Station Director approval.
e l
Changes to corrective actions require MRT and SORC review.
2-10.1 SSOE Rev. 14 m
<110,3. REVISION REQUIREMENTS FOR CORRECTIVE ACTIONS l
2.
Category X Commitments l
Changes to corrective actions or due dates I
' require approval of the manager / representative responsible for e
overall completion of the activity.
l require MRT and/or SORC review, as appropriate.
e 3.
Category P Commitments Due date changes may be approved by Technical Projects and/or MRT, as appropriate.
'l e'
Changea to corrective' actions require MRT and/or SORC review.
10.4 IMMEDIATT. CORRECTIVE ACTIONS 1.
Immediate corrective actions are taken.to minimize any risk to plant personnel or equipment (e.g., temporary signs, barrier tape, fire
.vatches, temporary covers).
.2.
These actions shall be documented in the ACR in Part 1, Section 1, item B. immediate corrective actions taken.
10.5 ' CORRECTIVE ACTION ATTRIBUTES
- 1. -
The responsible manager shall ensure the following are included on the Litt of Recommended Corrective Actions (OE 3.1B), which shall be i
attached to the ACR:
a.
a recommended corrective action that is appropriste, measurable, achievable, clear, and concisa b.
the name of the manager responsible for completing the corrective action-c.
the due data d.
the commitment category e
C. ' Commitments to the NRC X - Other external commitments (State, PUC, OSHA, etc.)
e M
Management required commitments e
P - Programmatic e
e.
the schedule reference code (e.g., OROS, OR06) (when applicable)
(Protected: Ref. ACR 95-0484)
I 2-10.2 SSOE Rev. 14
10.5 CORRECTIVE ACTION ATTRIBUTES f.
the commitment MODE code.
)
Items a. through f. are also included on the commitment tracking system with " Unit * ' and " System" codes.
(Protected: Ref. ACR 96-757, Recommendation D) 2.
The individual assiping. corrective actions shall ensure the individual responsible for Saggletine the corrective action agrees with the information provided for item 1 above.
3.-
Document actions taken within the'ACR evaluation (or within the corrective action)~ and the results of those actions (if applicable) if the recommended corrective action was "C0K?LETE" at the time the ACR was presented for final Station Director approval.
4.
List any corrective actions'that support fixing the apparent cause or root cause,.that are not to be isolemented (e.g., excessive costs, budget constraints, management discretion, etc.) and provide the justification in the ACR evaluation (or within the corrective action).
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11.0 MANACEMRMT REVIEW TEAM - FINAL REVIEW l'.
The MRT will review the ACR evaluation and corrective actions prior to submittal to SORC and/or Station Director for all ACRs classified as level A (High Significance).
2.
MRT will review completsd ACR root cause analyses (Significance Level A
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or B) and recommended corrective actions for adequacy and completeness 1
in responding to and addressing the adverse condition. MRT review of apparent cause evaluations is optional.
3.
Level C (Low Significance) ACRs are approved by the department manager, and independently reviewed by the Technical Projects Supervisor.
~
Leve1 C ACRs are submitted to the MRT if the final evaluation does not appear to resolve the issue or if the Technical Projects Supervisor identifies a generic issue for overall review, f
4.
The responsible manager shall determine if the worker / participant and/or j
immediate supervisor should be included in the final MRT discussion and
" review of the ACR evaluation based on significance level,, industrial safety, plant operational impact, regulatory issues, etc. The responsible manager shall note such involvement in the report evaluation.
5.
Figure 2-11-1, Sample MRT Checklist for' Completed ACR Evaluations, or facsimile should be completed at this time.
6.
If the MRT has determined that the ACR evaluation and/or recommended corrective actions are not adequate, the MRT chairperson shall return the ACR to the responsible manager for re-review and appropriate changes. The Technical Projects Supervisor will track the rejected evaluation.
7.
.The MRT will submit g H Level A (High Significance) ACRs to the SORC for review.
kLO1E The MRT review is considered a SORC subcommittee review as defined in the Station Management. Manual (SSMM). A review by the SORC committee must still be completed as prescribed in the SSMM.
8.
The MRT will determine which Level B (Moderate Significance) ACRs should be submitted to SORC based on the following:
a.
Areas to be reviewed by the SORC as delineated in the Station Management Manual (SSMM), Appendix B, Station Operation Review Committee Charter,Section VIII, SORC.
b.
Areas to be reviewed by the SORC as delineated in Chapter 6 of the Technical Specifications.
c.
Adverse conditions resulting in a regulatory report (e.g., EPA, OSHA, NRC).
'l d.
Root cause analysis performed.
2-11.1 SSOE Rev. 12
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11.0 MANAGEMENT REVIEW TEAM - FfMAL Rrdj[gg e,.
Adverse conditions that have a significant plant operational impact.
f.
Industrial safety issues.
5 Repetitive or similar adverse conditions that have a significant impact on Station operations, equipment performance, or personal safeqr.
h.
The responsible manager requires SORC review of the document.
i.
The Station Director requires SORC review of the document.
l 9.
Using the above criteria, the MRT will determine if the responsible manager should present the final ACR evaluation at the Station Director's daily meeting.
l 10.
Using the above criteria, the MRT will determine if the other NU units should te informed of the adverse condition to provide " lessons l
1 earned."
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I l 12.0 OTHER ACR REOUIREMENTS 12.1 SORC REVIEW - WHEN REQUIRED BY THE MRT 1.
The responsible manager presents the ACR,to the SORC in accordance with the Station Management Manual.
2.
Assistance may be provided by associate managers when other supporting documentation should be submitted to SORC, at the same time (e.g., LER, l
root cause analysis, event evaluation, or operability determination).
12.2 ACR - FINAL DOCUMENT CIDSURE 1.
The Technical Projects Supervisor is responsible for ensuring the ACR package is complete, including all signatures / dates, evaluations, STAR Sheets (if applicable), supporting documentation, engineering evaluations, operability determinations, etc.
l 2.
The ACR package is submitted to the Records Management Department (PJ{D) for archival per the requirements of the Records Management Manual j
(NARM).
3.
RMD discributes the completed ACR package. The Technical Projects Supervisor determines and updates the distribution list.
4.
The Technical Projects Supervisor shall ensure the recommended corrective actions are entered on AIITS and tracked to completion.
12.3 ACR - REVISION PROCESS I
1.
A completed ACR may be revised at any time when new or unanticipated information has been obtained, management determines corrective actions must be changed, or management deternines other changes are necessary, etc.
2.
The appropriate sections of the ACR are resubmitted (e.g., signature blocks, additional information) co the MRT/ Technical Projects Supervisor (as applicable) for review and approval, 3.
It is not necessary to resubmit the complete report, only those ACR sections requiring revision.
4.
The revised sections of the ACR will be reviewed and approved per this chapter and submitted to the Technical Projects Supervisor for final document closure.
l 5.
The revised sections of the ACR are submitted to the RMD for archival and distribution.
12.4 FINAL RECOMMENDATIONS 1.
The individual responsible for completing a recommended corrective action should ensure that the responsible evaluator for the ACR is satisfied and agrees with the closure of the recommended corrective action.
(Protected: Ref. ACR 95-143, Recommendation B) 2-12.1 SSOE Rev. 12
F' 12.4 FINAL RECOMMENDATIONS i
2.
Upon completion of each (Category C, X, M, or P) recommended corrective action, the responsible manager should
]
l a.
obt N Licensing Services concurrence for closure of Category C and l
l Category X (applicable to ACRs) actions, respectively, b.
complete corrective action closure actions outlined in Figure
-l 2-10-1, um All actions must be completed / documented by a document that is archived in accordance with the Records Management Manual (NUtM).
l c.
forward a copy of any associated memoranda to the Technical Projects Supervisor for closure of the item, and d.
forward a copy of any memoranda (for all completed corrective actions that are also NRC commitments per a licensee event report) to the Station Director and the Licensing Manager.
3.
The recommendations shall be reviewed, evaluated, and closed by the Technical Projects Supervisor. Recommendations that are Category C or X per the Commitment Management Program also require concurrence by l
Licensing Services for closure.
12.5 ACR CANCELLATION l.
Management Review Team (MRT) Recommendation a.
The MRT or the responsible manager may recommend cancelling an ACR and provide a reason for cancellation (e.g., reporting threshold criteria are not met) on the ACR, b.
When appropriate, the MRT will provide a reference document (e.g.,
l Work Request, Repetitive Task Sheet, Engineering Work Request) that completes the action, The MRT chairperson shall sign and date in the appropriate block, c.
d.
The original ACR is marked " CANCELLED."
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e.
The Technical Projects Super *?isor will submit the ACR to RMD with any supporting information for cancelling the ACR.
2.
Station Director Cancellation ACRs are normally recommended for cancellation by the MRT; however, a.
an ACR may be cancelled by the Station Director, even though the MRT has reccamended that the ACR be issued.
b.
The Station Director may write the reason for cancelling the ACR in the Additional Information Block on the form OE 3.lA and sign and date in the approval block.
2-12.2 SSOE Rev. 12
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12.5 ACR CANCEL 1ATION c.
The original ACR is marked aCANCELLED.*
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d.
The Technical Projects Supervisor will submit the ACR to RMD with any supporting information for cancelling the ACR.
3.
The manager of the individual who submitted the ACR should discuss with this individual the reason the ACR was cancelled.
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l l 13.0' TREND ANALYSIS l 13.1 DATA COLLECTION Trend data is ' collected to support periodic reports, perform custom data retrievals, and determine adverse trends per the Operating Experience Reference (OERE) manual.
} 13.2 DATA ANALYSIS 1.
Trending data is analyzed periodically for reports and determination of advarse trends.
2.
When analyzing data for determination of adverse trends, several attribute categories may be considered. Attribute categories include, i
but.are not limited to, the following:
a.-
Significance of problems b.'
. Frequency of problems c.
Lepartment involved d.
. Activity involved e.
System involved j
f.
Cause of problem i
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3.
If an adverse trend is noted, an ACR will be generated.
4.
This trend generated ACR is provided to the MRT for both initial and final review.
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2-13.1 SSOE Rev. 12
r 14.0 COR2FCTIVE ACTION DOCUMENT EVALUATIONS 14.1 EVALUATION FOR SIMILAR OCCURRENCES
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1.
Some occurrences that are reported may be similar.
2.
The Station Director, MET, or re:ponsible manager may require that ONE evaluation be performed for 3 Brouping of similar occurrences. This is done by attaching the evaluation to one Adverse Condition Report (ACR) and making reference to the evaluation in the other ACRs.
3.
It is preferable to evaluate similar adverse conditions as "one" to ensure peripheral and underlying generic causes are identified and corrected for the composite similar adverso conditions. This will ensure global concerns have been addressed and corrected.
4.
Each adverse condition should be reported separately to support trending requirements.
5.
The ACRs may be processed as a group.
14.2 EVALUATIONS FOR PERSONNEL ERROR 1.
ACRs identified as personnel error shall be reviewed by individuals involved in the event as well as their immediate supervisors.
2.
A statement that this review was performed shall be included in the ACR (e.g., "The individual involved in the adverse condition has been coached and/or counseled").
3.
The purpose for this is to ensure that the facts are accurate, the corrective action is appropriate to eliminate or reduce similar events, and to make personnel aware of the evaluation.
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2-14.1 SSOE Rev. 12
l 15.0. OPERATING EXPERIENCE PRESENTATION (Protectad: Raf. NA #930786) 15.1 DEPARTMENT PRESENTATION
')
1.
The line supervisor or supervisor of the individual or individuals involved in the adverse condition reviews the ACR and provides " lessons to be learned" curing department meetings, when required by the group manager.
2.
The format of the presentation should be as outlined in Figure 2-15-1, Typical Operating Experience Presentation Worksheet.
15.2 MANAGEMENT PRESENTATION 1.
The Station Director's expectation is that the responsible manager will present an overview of an identified adverse condition during the Station Director's next daily meeting.
2.
The responsible manager does not have to wait for the ACR to be initiated before verbally presenting the adverse condition at the Station Director's daily meeting.
3.
However, the ACR shall be initiated as soon as possible and submitted to the MRT for review.
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2-15.1 SSOE Rev. 12
16.0 MANAGEMENT EFFECTIVENESS REVIEWS (Pratsetsd: Raf. NA #930786) 1.
Managers who are assigned responsibility for completing ACRs shall
.)
periodically perform an effectiveness review of selected Level A (High Significance) and Level B (Moderate Significance) ACRs to determine if completed corrective actions were successful in mitigating similar occurrences.
2.
- This review may be required by the Station Director, MRT Chairperson, or group managers and the action assigned to a responsible individual with due dates on AITTS. The effectiveness review requirements shall be noted on the ACR as a corrective action.
3.
The Nuclear Safety Engineering Supervisor may be called upon to perform this review.
4.
Managers shall take appropriate action when corrective actions are not effective and notify the Station Director of any necessary changes and follow-up.
5.
Ineffective corrective actions will be reported and identified as new ACRa, and may require escalated analysis for identifying further corrective actions and lessons learned.
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i 2 16.1 SSOE Rev. 12
I 17.0 TRANSITIONAL PERIOD 17.1 EXPECTATIONS FOR IDWER-TIER DOCUMENTS 1
1.
The Corrective Action Program is undergoing a major change which will include incorporating activities documented by present lower-tier pro 5 ram documents into the Corrective Action Program, using the ACR.
2.
There lower-tier program documents include but are not limited to a.
Quality Audit, Surveillance or Inspection Findings (Open Issues),
b.
Industry Operating Experience Occurrences that potentially could affect station operations, and c.
Engineering Self Assessment Report (ESAR).
3.
Reporting occurrences per the lower-tier document programs will remain in effect until the associated programs and procedures have been cancelled.
4.
After the lower-tier document programs procedures have been cancelled, it is expected that newly identified adverse conditions be reported via an ACR.
It is F.QI expected that an adverse condition that has been documented using a lower-tier program be transferred to an ACR, unless deemed necessary by the responsible manager.
Outstanding lower tier documents that were generated in accordance with their associated program / procedures remain valid even if the associated program / procedures have since been cancelled. These lower-tier documents will be closed out through normal administrative processes as approved deviations per the Station Management Manual (SSMM).
i i
2-17.1 SSOE Rev. 12
h 18.0 FIGURES Figures referenced in Chapter 2 of this manual are found in this section.
l Figure 2-2-1, Examples of Adverse Condition Threshold Reporting Criteria l Figure 2 2-2, Examples of Significance Invels l Figure 2-2-3, Root Cause Analysis Threshold Figure 2-3-1, Sample Weekly Status Report of Open Significance Level A/B Priority 1/2 ACRs l Figure 2-7-1, Sample Management Review Team Meeting Attendance Sheet Figure 2-7-2, Sample MRT Checklist for Initial ACR Review Figure 2-10 1, Adverse Condition Corrective Action Closure Memo l Figure 2-11-1, Sample MRT Checklist for Completed ACR Evaluations l Figure 2-15-1, Typical Operating Experience Presentation Worksheet l
i i
t 2-18,1 SSOE Rev 12
l FIGURE 202-1 EXAMPTRC OF ADVRDCE CONDITION THRREHOLD REPORTING CRITERIA (Not intended to be fully encompassin5)
EQTL This. figure was formerly titled " Operating Experience Threshold Reporting Criteria." Other documents may contain references to this figure using the former title. Either title is valid.
1.
Any departure from the conditions of the operating license, Technical Specifications.
2.
Any unplanned Engineered Safety Features (ESF) actuation described in the Regulatory Compliance Manual (NARC).
3.
Any occurrence or plant condition that requires notification (excluding security events) to the NRC or other regulatory agency in accordance with the NARC.
4.
Failure to meet the provisions of the Technical Requirements Manual (SSTR).
5.
Any cited Nuclear Regulatory Commission (NRC) Notice of Violation (NOV) or NRC concern.
6.
Failures or degradations involving safety-related components that are determined to have generic implications.
7.
Repetitive occurrences following the completion of corrective actions or reports that have a significant operational impact.
8.
A degraded and/or' nonconforming condition which calls into question the OPERABILITY of Technical Specification Structures, Systems, and Components (SSCs) or the functionality of support SSCs. The OPERABILITY of an SSC is called into question when there is a reasonable question as to whether or not the SSC will be capable of performin5 its required safety function (Technical Specification SSCs) or if a support SSC will be capable of performing its required support (non-Technical Specification SSCs) function.
An Adverse Condition Report (ACR) shall be initiated when the Station Director or Operations Manager determines that an Operability determination is required. The operability determination shall be completed if the Station Director or the Operations Manager agrees that there is a reasonable concern regarding OPERABILITY of a Technical Specification SSC or the functionality of a support SSC.
For purposes of initiating an ACR and performing an operability determination the following definitions will be used:
a.
Derraded Condition - A condition in which there is evidence of a loss of quality or the loss of functional capability of an SSC to perform its specified safety (Technical Specification SSC) functions or its support (non Technical Specification SSC) functions.
2-18.2 SSOE Rev. 12
c
. FIGURE 2-2-1 EIAMPLES OF ADVERSE CONDITION THRESHOLD REPORTING CRITERI4 (Not intended to be fully encompassing)
(Continued)
)..
b.
Nonconforming condition - A condition of an SSC in which there is a failure to meet licensing requirements or current licensing basis commitments such that the capability of the SSC to perform its specified safety (Technical Specification SSC) function or its support (non Technical Specification SSC) function is called into question. Nonconforming conditions do not include errors in which the UFSAR is incorrect and the plant is correct. Examples of nonconforming conditions include the following:
(1)
A failure of an SSC to conform to one or more applicable codes, standards, or commitments as specified in the UFSAR.
(2)
As-built or as-modified SSCs that do not meet UFSAR design requirements.
(3)
-Operating experience or engineering reviews that demonstrate a design inadequacy in an SSC.
(4)
Documentation required to verify that SSCs conform to NRC requirements is deficient or not available.
(5)
A suspected error in any analyses, calculation, or testing that could affect the ability of an SSC to perform its safety or support function.
9.
The identification of a nonconservative value or surveillance requirement in the Technical Specifications.
10.
Any_ failure to meet the requirements of Technical Specifications Appendix B, the NPDES permit, the Environmental Studies Program, the Clean Air Act, the Clean Water Act, the Environmental Protection Agency, or the New Hampshire Department of Environmental Services.
(Protected:
ACR 95-208, Recommendations K and L)
- 11. Unplanned occurrences of lost generation equal to or greater than 1000 MWH. This would include forced outages, reductions in power, or unexpected efficiency losses.
12.
Occurrences or conditions involving a human performance error beyond those requiring reporting per lower tier programs (e.g., work control, l
design coordination reports, quality assurance findings, etc).
13.
Occurrences or conditions involving a human performance error (e.g.,
configuration control, improper operation of equipment, tagging errors).
14.
Conditions that may have a significant plant operational impact.
i i
15.
Industrial safety issues of a repetitive nature or that require management attention.
)
- 16. Repetitive and significant equipment failures that occur prior to the and of expected service life.
2-18.3 SSOE Rev. 13 e
FIGURE 2-2-1 RYAMPT Fe OF ADVEDRE CONDITION THRRMHOLD 'RFPORTING CRTTERIA (Not intended to be fully encompassing)
(Continued)
L l
17.
Conditions resulting in a Maintenance Rule Functional Failure (MRFF).
l 18.- Any occurrence that appears to jeopardize radiological protection, or 1
may be _ a violation of a program, procedure, or regulation with l
radiological implications.
(Protected: Ref. NRC Inspection Report No. 50-443/93-11)
- 19. A closed commitment to a regulatory agency that has not been implemented as required.
20.
A major breakdown in the Quality Assurance Program.
21.
Any motor-operated valve that has less than 101 thrust or torque margin or the thrust margin is less than or equal to 1000 pounds as described in Generic Letter 89-10.
(Protected: Ref. Memorandum CEM #96-299) j 22.
Repetitive occurrences of lower tier problems determined by management
{
or the MRT to require further evaluation or analysis.
{
23.
Concerns about issues or conditions that are questionable, may not be obvious or are indeterminate as an adverse condition.
24.
Any condition considered by management to require documentation using the adverse condition report.
l APPLICABILITY / EXCEPTIONS
)
1.
Measuring and Test Equipment (M&TE) failures / issues are documented per SSMA requirements, except when METE problems affect systems, structures, or components and cause an adverse condition.
2.
Security events are documented per the Security Manual (SSSP).
3.
Fitness for Duty events are documented per the Security Manual (SSSP).
4.
Employee concerns are documented per the Employee Concern Resolution Program.
5.
Employee issues are documented per the Employee Issue Resolution Program.
6.
Procedure revisions and changes made in accordance witL ihe Station Management Manual (SSMM), Procedure Administration Manual (NAPA) and the North Atlantic Management Manual (NAMM) do not require an ACR unless the use of the procedure causes an adverse condition.
7.
Supervisory Walkdown Program issues are documented in accordance with the SSMM, except when the issue affects systems, structures, or components and causes an adverse condition.
2-18.4 SSOE Rev. 13
FIGURE 2-2-1 EXAMPLES OF ADVERSE CONDITION THRESHOLD REPORTING CRITERIA (Not intended to be fully encompassing)
(Continued) 8.
Procurement issues are documented on a Condition Report per the Procurement Manual-(NAPM), except when the issue affects systems, structures, or components and causes an adverse condition.
l 9.
The Work Control Program and performance monitorin5 activities address equipment failure detection and corrective actions and are used to document overall plant performance and system / component performance.
l However, an ACR is required for the following:
cases involving reporrability e
repetitive failures of significant equipment needed for plant e
operation following corrective actions failure of significant equipment when the failure cause should have e
been anticipated i
potential common mode failure of safety related SSCs e
l design errors e
i 2-18.5 SSOE Rev. 13 t
i
FIGURE 2-2-2 EXAMPLES OF FIGNIFICANCE LEVELS (Not meant to be fully encompassing)
Sirnificanea Laval Rwa = ales of Conditions Level A 1.
Severe or unusual plant transients, including High Significance -
unplerned reactor trip ct ESF actuation,
.Immediate, Adverse extt^..dinary actions required to respond to an Impact event (such as actions not specified in abnormal 3
or emergency procedures), multiple equipment malfunctions or inappropriate human performance that increased the severity of the event, or a plant condition that severely inhibited the operator's ability to control or reduce the severity of the event.
2.
Safety system malfunction or improper operation. This includes the loss of the ability of a safety system to perform its function during a test, transient, or plant operation due to a common mode failure or a functional failure in a single train system.
3.
Actual, or potential for, serious personnel injury.
4.
Major equipment damage.
5.
Challenge to conditions of the license (Excludes TS Section 6, Admin portions).
6.
Safety system status unknown / indeterminate.
7.
Repetitive moderate significance level occurrences.
8.
Damage or degradation to safety equipment / system.
9.
.LER - Conditions reportable to the NRC per 10 CFR 50.73.
- 10. Condition indicative of a significant breakdown in Management control.
- 11. Fuel handling or storage event.
- 12. NRC Violation (NOV) Category 1,2,3.
- 13. Repetitive risk significant functional failures.
- 14. Exceeding a federal or administrative exposure limit.
- 15. A significant loss of control of radioactive i
I material outside the protected area.
Level B-1.
"Near Miss" to a high significance level Moderate Significance -
condition.
Increased Probability 2.
Damage or degradation to significant of Adverse Impact
. equipment / system (non safety).
3.
Diminished electrical capacity (1000 mwhrs) 4.
Significant system status unknown / indeterminate.
S.
Noncompliance to regulatory requirements (NRC Violation [NOV) Category 4, 5, Non-Cited
{
(Excluding LERs)). Technical Specification non-J compliance Section 6.0 Admin Section.
j 6.
Impact on corporate reputation.
7.
Inadequate compensatory measures / actions.
8.
-Repetitive low significance level occurrences.
2-18.6 SSOE Rev. 13 i
FIGURE 2-2-2 EXAMPLES OF SIGNIFICANCE LEVELS (Continued)
Level B (Continued) 9.
Noncompliance with procedures with potential safety impacts.
- 10. Challenges to the Environmental Compliance Program.
- 11. Challenges to the Radiation Protection Program.
- 12. Challenge to industrial safety (potential for minor injury).
- 13. Violation of state or federal requirements (non-NRC).
- 14. Maintenance Rule Functional Failures.
- 15. Leakage of sealed source (requiring leak testing) greater than 0.005 aci of removable contamination.
- 16. Willful violation of_ health physics policies or procedures with actual or potential radiological significance.
- 17. Receipt of a significant unexpected dose.
Level C 1.
Damage or degradation to equipment / system that has Low Significance --
no/ low effect on safety or reliability.
Low Probability of 2.
"Near Miss" to a moderate significance level Adverse Impact-condition.
3.
System status unknown / indeterminate that has no effect on safety or reliability.
4.
Noncompliance with procedure, with no safety impact.
5.
An RWP violation not meeting the above criteria and beyond the scope of the STAR program only.
6.
A missed radiological survey.
]
2-18.7 SSOE Rev. 13 4
I.-
FIGURE 2-2-3 ROOT CAUSE ANALYSIS THRESHOLD (Protected: Ref. ACR 96-588, Recommendation E & F)
(Not meant to be fully encompassing) l Significance Root Cause Analysis Root Cause Analysis Required Optional
{
14 vel A Reactor Trip None o ESF Actuation (Note 1) i (Note 2) 1Avel B Not required e Economic
- Trend Management Discretion e
e NOVs Level C None None None Occurrences not reported into the Corrective Action Program ERTI 1.
An event evaluation per OE 4.1 is required for a reactor trip or ESF actuation.
2.
Significance Level A occurrences listed in Figure 2-2-2 require a root cause analysis. The MRT may recommend that a root cause analysis not be performed or-change the significance level only if a jus::ification is provided in the ACR.
l I
1 1
2-18.8 SSOE Rev. 13
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l l
. FIGURE 2-7-1 SAMPLE MANAGEMENT REnIEW TEAM MEETING ATTENDANCE SHEET MILT MEETINGf l
VEEK OF:
i NAME DEPT DATES (Chairperson)
SD/ASD j
Ops Manager Licensing Manager Maint Manager Oversight Manager CM & MP Manager Site Serv (Other)
)
l
)
2-18.10 SSOE Rev. 13
l$s 5
FIGURE 2-7-2 SAMPLE MRT CHECKLIST FOR INITIAL ACR REVIEW a.
Is the problem statement brief, concise and no more than 2 sentences?
b.
Does the problem statement contain any opinions, assumptions or describe evaluations?
c.
Is the background sufficient to support a & b above?
d.
Are the immediate corrective actions completed and inclusive?
e.
Are the proposed corrective actions reasonable?
(If not, delete and ensure responsible manager notifies the originator.)
f.
Is there an individual (e.g., N7r member) who was able to support answering MRT questions?
g.
Initial ACR rejected?
h.
Should other NU units be notified?
1 l
l l
J l
2-18.11 SSOE Rev. 13
FIGURE 2-10-1 ADVERSE CONDITION CORRECTIVE ACTION CLOSURE MEMO j
i North i
filantic IMS# D05.99.99 Subject ADVERSE CONDITION REcomiENDED CORRECTIVE ACTION CLOSURE From Manager Assigned Responsibility Date To Technical Projects Supervisor Reference ACR Tracking #
Assignment #
LER#
ca.pptlenbte)
Attachment A provides documentation for completing Recommended Corrective Action, Tracking #
for ACR Manager Assigned Responsibility (Signature) 09Il
)
1.
The information contained in the attached form (Attachment A - closure form) may be included in the body of this memo, rather than on the closure form.
For actions classified as Category C or X per procedure NM 12900, forward copies of this memo to the individuals lir'ed below.
2.
Alternately, if the required action has been completed by an archived document (procedure change, Engineering Evaluation per Procedure XXX, number memoranda,.etc.), the corrective action can be completed electronically using AITTS. The archived document must be referenced in the assignment completion notes (panel TIMA023) of the corrective action assignment.
cc:
See NOTE #1 Station Director Assistant Station Director Licensing Manager
)
a snaber of the Northeast Utilities System 2 18.12 SSOE Rev. 13
FIGURE 2-10-1 ADVERSE CONDITION CORRECTIVE ACTION CLOSURE MEMO (Continued)
Attachmerit A CLOSURE FORM for ADVERSE CONDITION RECOMMENDED CORRECTIVE ACTION (Optional - If this form is not used, this information must be included in the cover meno.)
Descriotion of Action:
Tracking #
Completion
References:
)
Brief Summary of Comoleted Acti3D:
2-18.13 SSOE Rev. 13
FIGURE 2-11-1 SAMPLE MRT CHECKLIST FOR COMPLETED ACR EVALUATIONS c.
Has the originator reviewed the evaluation?
b.
Does the originator need to be present at the MRT meeting?
c.
Is the evaluation adequate?
d.'
Are the corrective actions appropriate?
o'.
Is this a repetitive issue? If yes, are there any corrective actions that remain open that should be completed expeditiously?
f.
Are the corrective actions clear, concise and measurable?
g.
Does a corrective action address the apparent cause (root cause)?
h.
Are there any event driven' corrective actions that require a schedule reference code or Mode code?
i Should the effectiveness of proposed corrective actions be monitored?
If yes, the method, responsible manager and due date shall be added to the ACR Corrective Actions.
J.
Is SORC review required?
k.
Is discussion required at the Station Director's meeting?
1.
Should the ACR evaluation results be shared with other NU Units?
)
n.
ACR rejected?
.)
2-18.14 SSOE Rev. 13
FIGURE 2-15-1 TYPICAL OPERATING EXPERIENCE PRESENTATION WORKSHEEI 1.~
WHAT Describe what happened during the operating experience occurrence.
2.
WHERE Describe the system, location, and environmental conditions that may help understand this occurrence.
t 3.
WHO Describe positions, departments, or others that may have been involved either directly or indirectly with I
this operating experience (o Training, e Procedure j
t writers, o Department Support personnel).
)
4.
WHEN Describe the shift, time of day, or other occurrence i
related times that may add to understanding the chronology (i.e., e before coffee break, e after lunch, i
sixth day, e after dark).
e prior to end of shift, e
5.
SIMILAR Describe if the condition or similar conditions have OCCURRENCES occurred previously.
6.
RECOMMENDATIONS Describe the recommendation to prevent recurrence.
)
2-18.15 SSOE Rev. 13
m
' ADMINISTRATIVE PROCEDURE APPROVED CHANGE LIST Pegs a A.
IDENTIFICATION i-
)
NUMBER OE 3.1 REVISION 08 TITLE ADVERSE CONDITION REPORT ORIGINATOR E. J. Sovetsky
)
' B.
CHANGE CHRONOLOGY (Place this form in front of the Administrative Procedure Cover Form.)
R
. CHANGE NO.
CHANGE PAGE NUMBERS AND FORMS R
E I
Remove 5, 6, Form OE 3.1A 97-113 01
! /
Insert a, 5, 6, Form OE 3.1A
}
P r
l'-
bM 6.1D Rev. 13 Chg. 02
.1
OE 3.1 Pcgs 1 Rsv. 08 ADMINISTRATIVE PROCEDURE COVER
\\
A.
IDENTIFICATION NUMBER OE 3.1 REVISION 08 TITLE ADVERSE CONDITION REPORT ORIGINATOR E. J. Sovetsky DETERMINATION OF SAFETY EVALUATION APPLICABILITY:
1.
The individual answering the questions below shall have completed 10 CFR 50.59 training.
2.
Does this procedure / procedure revision:
a.
Make changes in the facility as described in the O Yes eso UFSAR?
b.
Make changes in procedures as described in the UFSAR? O Yes G4o c.
Involve tests 't experiments not described in the O Yes ho UFSAR?
d.
Require a change to the existing Operating License O Yes ho (including the Technical Specifications) or are additional Operating License requirements needed?
3.
If any of the above questions are answered y.g.1, a safety evaluation per the Regulatory Compliance Manual (NARC) is required.
B.
MANAGER / DEPARTMENT SUPERVISOR APPROVAL TITLE SIGNATURE DAH
$/. red $>a4 Sweavua
$/5/97 v
p C.
NUCLEAR OUALITY SERVICES REVIEW j
TITLE SIGNATURE pag
/% Tramesavaw wrroPv.
l$
'///3'/9 ~)
D.
EQRC REVIEW SORC MEETING NO.
97-OY#'[
E.
APPROVAL FOR IMPLEMENTATION
[Djj, h30[97 05/12/97 I
STATIOR"DpCTOR APPROVAL DATE EFFECTIVE DATE SM 6.lA Rev. 13 Chg. 03
i OE 3.1 Pega 2 Rev. 08 CONTENTS AND REVISION STATUji CONTENTS PAGE NO.
PAGE REV.
COVER 1
08 CONTENTS AND REVISION STATUS 2
08
.1.0 OBJECTIVE 3
08 2.0 ' PROCEDURAL REFERENCES 3
3.0 SCOPE 3
4.0' INSTRUCTIONS.
3 4.1 MANAGEMENT EXPECTATIONS 3
4.2 IDENTIFICATION AND PREPARATION 3
4.3 IMMEDIATE REPORTING CONSIDERATION 3
4.4 COMPLETING THE ADVERSE CONDITION REPORT (ACR) 4-8 08 5.0 FICURES None 6.0 FORMS OE 3.1A, Adverse Condition Report 08 l
OE 3.1B List of Reconnended Corrective Actions 08 I
1 l
OE 3.1 Pegn 3 Rsv. 08
~1.0 OBJECTIVE This procedure provides the reporting mechanism used to document adverse conditions that meet the threshold reporting criteria in Chapter 2 of this manual.
J 2.0 PROCEDURAL REFERENCES j
1.
NAMK, Chapter 2, Corrective Action Program 2.
NAMM, Chapter 2, Management Review Team 3.
'NM 12900, Commitment Management Program 4.
Regulatory Compliance Manual (NARC) 5.
Station Management Manual (SSMH) 3.0 SCOPE This procedure provides the vehicle for documenting adverse conditions.
4.0 INSTRUCTIONS 4.1 MANACEMENT EXPECTATIONS Understanding the expectations and requirements of Chapter 2, which describes the overall response to an adverse condition, is necessary for completing the Adverse Condition Report.
4.2 IDENTIFICATION AND PREPARA'IION I
1.
Chapter 2 provides the adverse condition threshold reporting criteria requiring the preparation of an ACR.
2.
Immediate supervisors should provide guidance for initiating ACRs.
3.
The Shift Manager, Technical Projects Supervisor, or the Management Review Team (MRT) may provide additional guidance regarding when an ACR is raquired.
I 4.3 IMMEDIATE REPORTINC CONSIDERATION a
The Shift Manager shall be informed immediately, by phone or in person, when it is known that the adverse condition requires a regulatory report, operability determination and/or requires immediate corrective actions to protect the plant, the i
general public and/or employees (e.g., industrial safety issue).
l
l OE 3.1 Page 4 Rav. 08 4.4 COMPLETING THE ADVERSE CONDITION REPORT (ACR)
HDIE When more space is required for a SECTION of the ACR, additional (plain or lined) sheets may be used.
^
SECTIONS of the ACR do not need to be performed in sequence, as long as the responsible individual has been provided with appropriate information to complete his/her actions.
Refer to Chapter 2 of the SSOE for threshold recortine criteria and attributes and criteria for renconding to adverse conditions.
PART 1, SECTION 1:
IDENTIFICATION OF CONCERN RESPONSIBILITY IASE EQII The originator of an ACR needs to complete only Part 1, Section 1, of the ACR and submit only Part 1 of the ACR to the Control Room.
ORIGINATOR 1.
Completes Part 1, Section 1, of the Adverse Condition Report (OE 3.lA) as follows:
A.
DESCRIPTION OF CONDITION (1) Problem Statement (a)
Provide a clear and concise statement to define "what is the problem?" (normally one or two sentences)
(b)
Include whether the occurrence involves a procedure problem, equipment problem, technical specification violation, or personnel error, etc.
(2) Background Information (a)
Which program / procedure applies to the problem?
(self-explanatory)
(b)
Which activity within the program / procedure applies to the problem?
(self-explanatory)
(c)
Which organizations were involved in the problem?
(self-explanatory)
(d)
Why did the problem occur?
(self-explanatory)
OE 3.1 Psga 5 Rsv. 08 Chg. 01 4.4 COMPLETING THE ADVERSE CONDITION REPORT (ACR)
RESPONSIBILITY I.6SE il ORIGINATOR B.
IMMEDIATE ACTIONS TAKEN (1) Corrective Actions List any immediate corrective actions taken to mitigate the occurrence, e.g.,
roped off area.
(2) Notifications List any notifications made (e.g., control room notified, department supervisor notified).
jj C.
RECOMMENDED ACTIONS (Self, explanatory) 1l D.
Provide the following:
Event (Date/ Time) - when it occurred Discovery (Date/ Time) - when it was recognized to e
be an cdverse condition E.IZ The date and time of the event and discovery may be the same.
E.
SYSTEM
, TAG ID fj F.
REFERENCES - Self explanatory 1l C.
Ori inator - Prints name, signs, dates, and lists 5
telephone extension.
1l ORIGINATOR
- S H.
SUPERVISOR'S RECOMMENDED DISPOSITION SUPERVISOR' s-1.
Reviews the ACR for completeness. Conducts minor fa:t-finding as necessary to ensure understanding of condition.
2.
Ensures that immediate actions were taken to restore the adverse condition to an acceptable state.
3.
Ensures appropriate notifications were made (e.g., control room or supervisor).
4.
Provides recommendation for ACR disposition as follows:
E OE 3.1 Pegs 6 Rsv. 08 Chg. 01 4.4; COMPLETING THE ADVERSE CONDITION REFORT (ACR) (Continued) 1 RESPONSIBILITY IASK ORIGINATOR *S.
a.
checks Further Evaluation Box (cause unknown or SUPERVISOR unsure of cause), or i
b.
checks Corrective Action only bot (knows what needs to be done/not yet done), or
.c.
checks Trend Only box (nothing needs to be done/ action
]
already taken).
d.
Provides a brief justification for disposition.
1l.
I.
Originator's Supervisor - Prints name, signs, dates, and lists extension.
]
PART 1, SECTION 2: OPERABILITY /REPORTABILITY REVIEW - SHIFT MANAGER l
I g
The Shift Manager needs to complete only Part 1. Section 2',
of the ACR and submit only Part 1 to management for action.
SHIFT MANAGER 1.
Using the flowchart in Part I, Section 2, of the ACR, completes Section 2, Operability /Reportability Review.
2.
Signs and dates in Section 2 of the ACR, and forwards the original to the Technical Project Supervisor and a copy to the NRC Coordinator, via the Operations Manager.
PART 2: ' APPROVAL / ACTION ASSIGNMENT - MANAGEMENT REVIEW TEAM (MRT) INITIAL REVIEW l
-TECHNICAL P'ROJECTS 1.
Assigns a number to.the ACR (e.g.,97-021 [ year sequential no.)) and records the required data.
SUPERVISOR 2.
Reviews the ACR for repetitive /similar/ reference occurrences. Lists these occurrences in the
" repetitive /similar/ reference occurrences" block and attaches copies of referenced ACRs, as appropriate.
MRT 3.
Assigns.the applicable significance level and priority, assigns the." Type of Evaluation," and assigns responsible managers. : Documents additional actions, as necessary, in the " Additional Information" block.
1
l OE 3.1 Pags 7 Rsv. 08
{
4.4 COMPLETING THE ADVERSE CONDITION REPORT (ACR)
RESPONSIBILITY IAEK t
MRT CHAIRPERSON 4.
Signs and dates the appropriate block.
TECHNICAL PROJECTS 5.
Ensures copies are distributed to appropriate personnel, SUPERVISOR-and the ACR is logged and entered on the commitment trackiQ, system.
PART 3, SECTION 1:
EVALUATION - RESPONSIBLE MANAGER RESPONSIBLE MANAGER 1.
Assigns a responsible individual or individuals to evaluate the ACR.
j l
RESPONSIBLE 2.
Perform an evaluation of the adverse condition to EVALUATORS determine the cause using the method assigned in Part 2 of 1
the ACR.
3.
Signs and dates the Evaluator block, kEiiDNSIBLE MANAGER
- 4. ' Reviews and concurs with the evaluation, recommended corrective actions, assigned group / department, and due j
dates. Signs and dates the Evaluator's Manager block.
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PART 3, SECTION.2:
FINAL REPORTABILITY REVIEW - LICENSING SERVICES LIC3NSING 1.
Reviews the ACR using the guidance in the Regulatory SUPERVISOR Compliance Manual (NARC) to determine if a written report
]
to a regulatory agency is required (e.g., 10 CFR 20, 10 CPR 50.73, 10 CFR 73.71, 10 CFR 50.9, EPA, OSHA, etc.).
2.
Enters the appropriate reportability information. Signs and dates the appropriate olock.
PART 3 SECTION): MANAGEMENT REVIEW TEAM - FINAL REVIEW (Required for Significance Levels A and B)
MRT 1.
Reviews final ACR evaluations for acceptance.
MRT CHAIRPERSON 2.
If unacceptable, returns the ACR to the responsible
- anager, with comments, for action.
MRT 3.
If acceptable, determines if a.
SORC review is required, b.
Presentation at the Station Director's daily meeting is required,~and I
c.
Other NU Units should be informed.
t
1 OE 3.1 Pags 8 R:v. 08 4.4 COMPLETING THE ADVERSE CONDITION REPORT (ACR)
RESPONSIBILITY M
MRT CHAIRPERSON 4 '. Signs and dates to approve the ACR.
i 1
PART 3, SECTION 4:
SORC REVIEW (Required for Significance Level A)
STATION DIRECTOR 1.
Signs and dates to approve the ACR.
. TECHNICAL PROJECTS 2.
Completes all actions necessary to track any corrective SUPERVISOR actions.
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1
.p, 9
i
r PART1 ADVERSE CONDITION REPORT ACR No.
Significance Level A B
C Tracking No.
Priority 1 2
3 SECTION I IDENTIFICATION OF CONCERN (use additional sheets if more space is required)
A.
DESCRIPTION OF CONDITION Problem Statement:
2.
Background information:
- a. Which program / procedure applies to this problem?
- b. Which activity within the program / procedure applies to this problem?
- c. Which organizations were involved in this problem?
- d. Why did the problem occur?
B.
IMMEDIATE ACTIONS TAKEN 1.
Corrective Actions:
2.
Notincations:
C.
RECOMMENDED ACTIONS l
D.
Event (Date/T,ime)
Discovery (Date/ rime)
E.
System Tag ID F.
REFERENCES (WR, RTS, L'FSAR ETC.)
O.
Originator (Pr:nt Name)
(Sign)
(Date)
(Ext)
H.
Supervisor's recomnwnded disposition:
Further Evaluation C Corrective Action Only 0 Trend onir Justancation for disposition:
1.
Originator's Supervisor (Print Name)
(Sign)
(Date)
(Ext)
OE3.lA Rev. 08 Chg. 01 Page1of4
PART 1 ADVERSE CONDITION REPORT l
(Continued)
ACR No.
SECTION 2 OPERABILITY /REPORTABILITY REVIEW - SHIFT MANAGER
.]
(
ADVERSE CONDITION IDENTIFIED
)
I The i
oonomen sneese Comment:
yg, the swue of a ssC
'Yes tne amas owe mese reewee m ssc No
- OPTIONAL: 9nformation only" AST entered T.SJT.R Yes I
seaceroman oNRAst.a No 6 en isnm AST entered for SSC O T.S/T.R Yes Desenbe why the safety function or support function of the SSC is satisfied.
OFTIONAL: EWR O gr Engineenng Evaluation O corsees The SSC is NOT in service or the CONDITION does not currently apply or affect OPERABILITY O or norm e Non o s ContinuedQ Desenbe why the safety or support function of the SSC is expected to be supported by the OE 4 5.
Irutial OE 4.5 is due in the greater of 24 Hrs or T.S. ACT:
u Date/ time y,,
Continued 0 1
Can you confirm that the condit6on resulted from unintentional personnel error? YesO, No C.
)
y mm Can you confirm that the condition has been adequately explained?
Yes O No D.
cause et m conomon cor*med as e empo No' Can you confltm that no similar sonous conditions have been reported recently? Yes 0, No O.
Does the event lack complexity and indicate that a simple error is likely?
Yes O.No O.
[E any question above is answered *NO,' then immediately inform the Station Director. Operations Manager and NRC Resident. Contact the Secunty Manager and review the Secunty Manual Yes (S$3p),
r
._ N_
capon reewed aer en a p 3 No inehamct ir Reportable per Due Contacted NRC / Other Date Time Shsft Manager:
Date Time
(.
p:\\ap,wwisio\\rcrpage2 ved
)
OE 3.1A Rev, 08 Chg.01 Page 2 of 4
PART2 ADVERSE CONDITION REPORT (Continued)
ACR No.
APPROVAL / ACTION ASSIGNMENT MANAGEMENT REVIEW TEAM (MRT) INITIAL REVIEW TYPE OF EVALUATION RESPONSIBLE MANAGER OTHER ACTIONS RESPONSIBLE MANAGER O Event Evaluation O Root Cause (OE 4.i)
Analysis (see OERE)
O Cause & Failure Analysis O ' Corrective Action (OE 4.2)
Only 0 Operability 0 io CrR 2i Report Determination (OE 4 $)
(NARC)
O ^pparent cause 0 Trena Oniy
<xone, Ev'aluation (OE 4.8)
- (Sections 1,3, and/or 4 of Part 3 may not be required to be completed)
O ^dditioaai rnrormation:
1 i
r Repetitive /Similar/ Reference Occurrences:
MRT Chairperson Approval Date OE3.1A Rev. 08 Chg. 01 Page 3 of 4 0
c.
PART 3 ADVERSE CONDITION REPORT (Continued)
I ACR No.
SECTION I EVALUATION - RESPONSIBLE MANAGER (Enter "N/A" if Evaluation is net required)
(ATTACH EVALUATION /OTHER DOCUMENTATION)
A Responsible Group; Evaluator Date Evaluator's Manager Date SECTION 2 FINAL REPORTAE!LITY REVIEW LICENSING SERVICES C Not Reportable Reportable per iTS. OSHA. EPA ANI. etc i Report Due Date Licensing Services Date OECTION 3 MANAGEMENT REVIEW TEAM FINAL REVIEW (Enter"N/A" if MRT Review Not Required)
- 1. Evaluation adequate? Yes O (1f not complete returned to responsib1e manaser ror action.)
- 2. SORC review required?
Yes O No O
- 3. Discuss final evaluation at Station Director's daily meeting? Yes O No O
- 4. Inform other NU Units of this adverse condition? Yes O No O MRT Meeting Review Date r
MRT Chairperson Date SECTION 4 SORC REVIEW (Enter "N/A" if SORC Review Not Required)
.SORC Meeting No.
Date LER No.
(Other Reports)
Station Director Date --
OE3.lA Rev. 08 Chg. 01 Page 4 of 4
LIST OF RECOMMENDED CORRECTIVE ACTIONS ACR No.
i Provide the name of the responsible Broup manager, the due date, category of corrective actions Scheduled Refe.rence Code from AITTS (when applicable) and Mode' Code from AITTS (when applicable).
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W i
f OE 3.1B Rev. 08 C-