ML20198Q171

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Rev 1 to 1-OM-2.10, Response to Events, Memo Re Issuance of MP1 Operations Manual sections,MP1-OPS-97-081 & Index
ML20198Q171
Person / Time
Site: Millstone Dominion icon.png
Issue date: 11/03/1997
From:
NORTHEAST NUCLEAR ENERGY CO.
To:
Shared Package
ML20198Q164 List:
References
1-OM-2.10, NUDOCS 9711120129
Download: ML20198Q171 (9)
v • d • e


Text

. s 1-OM 210, Rev.1 Page 1 of 3 O Mi a"e unit one OPERATIONS MANUAL SECTION 2.10

" RESPONSE TO EVENTS"

) Sponsor: D.J. Mookhoff // // f 7 Effective Date IABLE _OF CONTENTS #

PAGE NUMB.EB 1.0 PURPOSE 2

2.0 DEFINITIONS 2

3.0 INITIAL RESPONSE 2 4.0 PERSONNEL EVENT 2 5.0 SIGNIFICANT PERSONNEL EVENT 3 Approved by:

O Shh!.W MP1 Operations Manager Dft !D K 050

. t 1 oM 2.10. R:y.1 Page 2 of 3 RESPQMS.! TO EVENTS 1.0 PURPOSE 1.1 To provide directions for responding to events involving Operations Department Personnel to ensure appropriate actions are taken and to ensure lessons learned from each event are communicated throughout the Operations Department in a timely manner.

2.0 DEFINITIONS Personnel Event - An event in which an individual's action or inaction is the primary cause of an adverse or undesirable result.

Significant Personnel Event - An event in which an individual's action or inaction is the primary cause of an adverse or undesirable result and one of the following actually occurs:

. A reduction in the margin of safety for personnel e damage to equipment

. adverse impact to the environment

. reduction in the margin of safety of the core O 3.0 INITIAL RESPONSE 3.1 When notified that an event has occurred involving Operations Department Personnel, the on-watch Shift Manager shall conduct a fact finding session to determine if Operations Department personnel performance caused or contributed to the event.

3.2 If the fact finding session determines that Operations Department Personnel performance did not cause or contribute to the event, exit this Section.

If the fact-finding session determines that Operations Department Personnel performance did cause or contribute to the event, the Shift Manager shall determine if the event is a significant personnel event.

3.3 If the event is not a significant personnel event, go to 4.0, Personnel Events.

3.4 If the event is a significant personnel event, go to 5.0, Significant Personnel Events.

4.0 PERSONNEL EVENT

/ 4.1 Operations Department personnel involved in the event shall complete an " Event Summary" form, Attachment 1.

o

i 1 oM 210. Rw.1

i. Page 3 of 3 l

,q 4.2 Shift Manager review cc upleted " Event Surnmary" forms, Attachment 1 with the Q Operations Manager.

4.3 Operations Manager and Shift Manager determine appropriate method for communicating event, lessons learned and consequences to all Operations Department Personnel.

4.4 Operations Manager and Shift Manager determine the need for and apply counseling or discipline as appropriate.

5.0 SIGNIFICANT PERSONNEL EVENT 5.1 Shift Manager remove personnel involved from Licensed duties.

5.2 Consider testing for drug and alcoholin accordance with the Fitness For Duty Manuar, FFDM 3.3, For Cause Testing, for Operations Department Personnel involved in the event.

5.3 Shift Manager ensure Condition Report written concerning the event.

5.4 Operations Department personnel involved in the event shall complete an " Event Summary" form, Attachment 1.

O 5.5 Operations Manager and Shift Manager determine appropriate method for communicating event, lessons learned and consequences to all Operations Department Personnel.

5.6 Operations Manager and Shift Manager determine the need for a.1d apply counseling or discipline as appropriate.

5.7 Operations Manager and Shift Manager determine the need for remediation for Operations Department Personnel.

5.8 If remediation is not required, individuals involved may be restored to Licensed duties with concurrence of the Operations Manager and Shift Manager.

5.9 If remediation is required, contact the Supervisor, Operator Training, for development of

. a remediation program.

5.10 if remediation is required, individuals involved may be restored to Licensed duties with concurrence of the Operations Manager and Shift Manager upon satisfactory completion of the assigned remediation program.

O U

. i EVENT

SUMMARY

l I Briefly describe event : ,_

How did event occur? (NOTE 1) l How, specifically, did you apply the STAR self-checking routine while performing this task?

What plant or environmental factors contributed to this event? (please circle the applicable STAR cues on the attached sheet) l I How could STAR have been used differently to prevent this?

What else could be done to prevent this type of event from occurring again?

NOTE 1 Use additional sheets as needed to develop a chronology of events.

1-OM 2.101 Rev.1 Page 1 of 2

{ }

l

. . r WHEN DO WE NEED TO SELF CHECK 7 i

l l l l'

This self checking technique is applicable to all Millstone Station activities. However, industry experience has shown that cDrtain CUES (conditiorn) usually exir' before a human performance events occurs.

Tho following is a list of the most frequently occurring CUES that should initiate the self-checking process:

1. Performing steps of a procedure without understanding the intent of the steps " cook booking"
2. Task interruption - continuity of mental thought is interrupted.
3. Routino but critical tasks - worker is so familiar with task that it becomes routine having to remember more than three to five pieces of information.
4. Departure from a well established routine - performing task differently.
5. Time - pressure - hurriod.
6. Unable to remember- relying on one's memory for successful task performance; having to remember more than three to favo pieces of information.
7. No labeling or poor labeling
8. Performing two or more tasks simultaneously - mentally overloaded - ability to perceive reduced
9. Unexpected encounter with system or component interlock
10. Misreading a labol- especially for components, cabinets, and doors
11. Recent work experience on another unit / system / train / component - habits formed for a particular task
13. First day of work after several days off
13. 2nd or 3rd shift and/or extended hours 14 Repetitive 4;oring task - complacency, reduction in vigilance
15. Prooccupation with specific task - loss of the big pictureiperspective, too involved; may miss important information
16. Insufficient indication (s) of system / component status - potentially forces unconscious assumptions, true status I k. unknown l

'Semething doesnt fool tight"- doubt that exists about a task or situation; tendency is to rationalize the doubt away

18. Tired 4atigued- reduced ability to think due to lack of rest; reduced attention to detail
19. Conflict between indications
80. Confusion - mind may wander to personal thoughts
21. Unfamiliar with task / performance standards or first time to perform task
32. Insufficient lighting, hlgh noise
23. Missing stop(s) of a procedure near the end of a sequence of actions - preview of procedure could identify steps that are candidates for omission
24. Verdalinstructions - remembering more than three to five simple instructions increases the likelihood of omitting the middle steps 25 Tasks with a large number of discreto steps - greater possibility that one or more steps could be omitted
26. 7cedure step large amount of imbedded information Indivl .s) exhibited Self Checking (STAR) principles:

e Excellent e Good . Fair . Poor Comments:

( ) 1 OM 2.10-1 Rev.1 Page 2 of 2 j

Northexsr '

Utilities System Memo October 39.1997 MP1 OPS97-081 TO: OM Copy Holders

/

l ROMI - R. M. Schraldtkne Unit i Operations Mariager (Millstone Ext. 4280)

SUBJECT:

Issuance c; MP1 Operations Manual Sections i

Attached for issuance are the following OM Sections:

OM Index dated 10/31//97 Effective Date Section 1-OM-2.10, Rev.1, " Response to Events 11/14/97 l Section 1-OM-3.1, Rev.1, " Operations Manager" 11/14/97

' Section 1 OM-3.11, Rev. O," Cold Weather Preparation and Operation 11/14/97 Section 1-OM-4.4, Rev.1, " Notifications" 11/14/97 Section 1-OM 5.3, Rev. O, " Simulator Training 11/14/97 Section 1-OM-6.1, Rev.0, " Shift Tumover 11/14/97 Section 1-OM-9.2, Rev. O, " Procedure Administration" 11/14/97 (Replaces 1-OPS 3.09, " Procedure Administration and Review" Cancel the following Operation Department Instructions effective 11/14/97 1-OPS-3.09, Rev. 2," Procedure Administration and Review" and associated Forms RMS:Jmn ec: Correspondence file (Memo only)

P. Hinnenkamp R. Schmidtknecht E. Berry B. Merryman Control Room g T raining (

(

m

e 1 OM indix

. Pege1of3 Unit 1 Operations Department OM Index 10/31/97 l Number Subsection Iille licL Status SECTION 0 OPERATIONS MANUAL 0.1 Control Of The Operations Manual 0 issued SECTION 1 OPERATIONS DEPARTMENT l.1 Operations Organization 0 Issued SECTION 2 OPERATIONS POLICIES 2.1 Appearance / Clothing Policy 0 Issued 2.2 Operations Personnel Career Plan 0 1ssued 2.3 Crew Member Rotation / Reassignment 0 Issued 2.4 Shift Manning Requirements 0 1ssued 2.5 Not Used 2.6 Vacation Policy 0 Issued 2.7 Control Room Protocol 0 Issued 2.8 Cortrol Room Access Policy 0 Issued 2.9 Shift Turnover Policy 0 Issued 2.10 Response to Events 1 Issued SECTION 3 OPS PERSONNEL RESPONSIBILITIES 3.1 Operations Manager 1 Issued 3 la Assistant Operations Manager 0 1ssued 3.2 Senior Licensed Operators 0 Issued 3.3 Licensed Operator 0 Issued 3.4 Non-Licensed Operators 0 Issued 3.5 Shift Technical Advisors 0 Issued 3,6 Operations Work Control Supervisor 0 Issued 3.7 Control Room Clerk 0 Issued 3.8 Maintenance of Operators License's 3.9 License School Selection Process 0 Issued 3.10 Reactivity Management 0 Issued 3.11 Cold Weather Preparation & Operation 0 Issued SECTION 4 COMMUNICATIONS 4.1 Verbal Communications 0 Issued 4.2 Briefings 0 Issued 4.3 Standing Night Orders 0 1ssued 4.4 Notifications 1 Issued SECTION 5 TRAINING 5.1 Training Overview 5.2 OJT/TPE 5.3 Simulator Training 0 Issued 5.4 Document Acknowledgment Sheets 0 Issued O 5.5 Not Used 5

V i

, i 1 OM-ind3x

, Pagi2 of 3 Unit ) Operations Department OM Index s 10/31/97 Number Subsection Iltic Rem Status SECTION 6 SillF1/ PERSONNEL RELIEF 6.1 Shift Turnover 0 Issued 6.2 Temporary Relief 0 Issued SECTION 7 OPERATIONS 7.1 Alarms and Indications 0 Issued 7.2 Not Used 7.3 Not Used 7.4 Operations Key Control 7.5 Operation of Motor Operated Valves 0 issued 7.6 Not Used 7.7 Not Used SECTION 8 ROUNDS AND LOGS 8.1 Requirements for Rounds 0 1ssued 8.2 Requirements for Logs 1 Issued 8.3 Recorder Charts and Annunciators p SECTION 9 PROCEDURES ij 9.1 Procedure Use 0 Issued 9.2 Procedure Administration 0 Issued 9.3 Operator Aids 0 Issued SECTION 10 PLANT / EQUIPMENT STATUS 10.1 Plant Status Documentation 0 Issued 10.2 Equipment Deficiencies 10.3 Control Room Panel, Anunciator, & CRD Deficiencies 0 issued 10.4 Not Used 10.5 Equipment Returned to Service 10.6 Not Used 10.7 Not Used 10.8 Not Used 10.9 Operability Determination Processing 0 Issued 10.10 System Readiness Review 10.11 Surveillance Test Data for Pumps & Valves SECTION 11 STAR AND VERIFICATIONS 11.1 Operations Self-Checking Program (STAR) 0 Issued SECTION 12 LCOs AND PERFORMANCE MONITORING 12.1 Safety System Performance Indicezr Monitoring 12.2 Operation Action Logs 12.3 Technical Specifications and TRM 0 Issued

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  • 1 OM.index

, P:g)3 of 3 Unit 1 Operations Department OM Index 10/31/97 Number Subsection lille Ren Status SECTION 13 OVERSIGilT 13.1 Operations Oversight Program 0 Issued SECTION 14 PLANT SYSTEMS / MISCELLANEOUS 14.1 Divers Working Intake 14.2 Equipment Rotation Schedule 14.4 Waste Oil Separator Pits inspection SECTION 15 OPERABILITY 15.1 Operability (Later)

SECTION 16 OPERATIONS PERFORMANCE 16.1 Operations Performance Standards SECTION 17 ELECTRICAL 17.1 Sub Station (Convex) Interface 17.2 Resetting Protective Devices / Restoring Power 0 issued 17.3 Not Used 17.4 Unit 1 Transformer Yard Control 0 issued SECTION 18 RADWASTE 18.1 Radwaste Operations O

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