ML20202F145

Independent Investigation Team Rept on Safety Conscious Work Environment at Zion Station

ML20202F145
Person / Time
Site:	Zion  File:ZionSolutions icon.png
Issue date:	12/03/1997
From:	Spiers L, Waldinger L COMMONWEALTH EDISON CO.
To:
Shared Package
ML20202F144	List: A97068, Forwards Independent Investigation Rept Assessing Safety Conscious Work Environ at Zion Station.Rept Details Team Investigation,Conclusions & Basis for Conclusions,As Requested in ML20202F145
References
NUDOCS 9712090024
Download: ML20202F145 (35)

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INDEPENDENT INVESTIGATION TEAM'S REPORT ON Tile SAFETY CONSCIOUS WORK ENVIRONMENT AT ZION STATION

! December 3,1997 ex ae- .

Larry spiersl eam T Leader Corporate Audit Director s ] NNd Approved:' Lon Wfidinger Nuclear Oversight Manager 9712090024 971205 PDR ADOCK 05000295 P PDR ,,,

.m TABLE OF CONTENTS I . E X E C U T I V E S U M M A R Y . . . . . .. . . .. . . .. . . .. . . . .. . ... .. . . . . . . .. .. . . ... . .. . ... . . . . . . . . ... . . . ..... . . . . ... .

I 1. I N T R O D U CT I O N . . . .. . . .. . .. . . . ..... . . . . . .. .. . .. . . . . . . . . .. . . ... . .. . . . . .. . . . . . . ... . . . . . . .. . . . . . . . . . . . .

A. BACKGROUND. .

.5 B. TIIE INDEPENDENT TEAM'S FOCUS.. .

. .7 III. ACTIVITIES AND RESULTS OF TIIE INDEPENDENT INVESTIG A r")N TEAM........ 9 A. BACKGROUND. .

. .9 B. INTERVIEW RESULTS.. .9

1. Summer 1997 Surver Results..... . . . , , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. ....................9

2. InitialInterview Results..... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .....................10

3. Independent Interviews....... ... . ... . . . . . . .. . . . . . . . . . . . . . . . . . . .. .. . . . . . . . 10

a. General Site Environment . .I1

b. Atmosphere for Raising Safety Concerns . . 13

c. Effectiveness of Reporting Processes . .16 d Effectiveness of the Employee Concerns Program.. . .17 C. CORRECTIVE ACTION PROGRAM. .

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1. General Review af PIF Process..... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. ... I 7

2. Operations PIFSample Review... . . . . . . . . . . . . . . . . . . ...... .. . .......... . .. I8

3. Additional Deficiency Document Revias... . ,. . . . . . . . . . . . . . . . . . . . . . . . .........I9

a. Procedure Change Process. . . 19

b. Operator Work Arounds.. .

. .20

4. Employee Feedback on IdentifiedIssues...... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. .. 20 Problem identification Form (PIF) Feedback. .21

b. Procedure Action Requests.. .21 D. OPERATIONS ASSESSMENT.. .21 E. CAUSAL FACTORS.. .

.23 1V. EM PLOYEE CONCERNS PROG RAM EFFECTIVENESS............................................... 25 A. BACKGROUND. .

.25 B. CURRENT EFFECTIVENESS. .26 V. CONCLUSIONS......................................................................................................................28 VI . RE C O M M E N D A TI O NS ....... ............ .. ........... ......................... . ............... ............ ................... 3 0 ENCLOSURE SIGNS OF BARRIERS TO A SAFETY CONSCIOUS WORK ENVIRONM ENT.................. 31 ii

O TABLE OF CONTENTS

1. E X E C U T I V E S U M M A R Y .. . ..... . . . .. .. .. .. .. . . ..... . .. . .. . . . . .. . . ... . . . . .. . . .. . . . . . .. .. .. . . . . . . .. . . .. .. ..... . . . . . .. . .

. II. B A C KG RO UN D A N D INTRO D U CTI O N ...................................................................................... 3 Ii1. INVESTIG ATION AN D ANA LYSIS O F A LLEGATlONS ......................................................... 4 A. ZION SAFETY ENVIRONMENT . . . .. , . ,, . . , , . . . . . , , , , . , , , .4 B. CORRFCTIVE ACTION PROCESSES: FORMER OPERATORS' PIFS AND NTS ITEMS . . . . .6 C. OPERATIONS ASSESSMENT , ., , .. . .. . . ... , , .... ,, ,,7 D. OPERATIONS OVERTIME . , . . , , , . . . , , , , , ., ,

. . .I1 I V. R E VI EW O F TECll N I CA L I SS U ES ........... ............................................................................... I 5 V. CONCLUSIONS.............................................................................................................................16 ENCLOSURES

1. M A Y 2 9 T I I 1. E T T E R ... . .. . .. . . . .. .. . . . . . . .. . . .. . ... ... . .... . .. . . ...... . . .. . . . . .... . . .. ..... . .. .. . .. . . . . . . .. .. . .... ... . . ... ... .. . . . . .... ..

2. O P E R A TO R P I FS A N D NTS ITE M S ..................................................................... ............... ........ 2 0

3. SUMM ARY OF TECHNICAL REVIEW OF COMPLAINT STATEMENTS IN TIIE CAP.... ,25

4. DEFINITIONS OF CORE COM PETE NCY DESCRIPTORS...................................................... 36 11

o I. EXECUTIVE

SUMMARY

In the Fall of 1996, Comed management became aware of issues that were indicative of a-declining Safety Com.cious Work Environment at Zion Nuclear Station. Then, during the winter, several key events took place at Zion Station that also indicated a declining performance and contributed to Zion workforce apprehension. These events were: Zion Station was placed on the NRC Watch list, the February Reactivity Event, and the Comed Board of Directors decision not to fund Steam Generator Replacement. In response to the issues surrounding the Reactivity Event,' the general capabilities of the Operations Department were called into question and an assessment process was -developed and implemented. As a result, some tough decisions were made regarding the future acceptability of some of the plant's Operations staff.-

In parallel, Nuclear Division management took a number of actions to better define and characterize the work environment at the Station, and to identify those corrective actions necessary to ensure an appropriate work environment is maintained. Several corrective actions were implemented in response to these weaknesses and to improve the Safety Conscious Work Environment at the station. These included several site communications regarding management's expectations to raise safety concerns, a complete restructuring and staadardization of the Corrective Action Program, assignment of a full tim; Employee Concerns Program Administrator, and others.

In July,19'/7, the NRC S*.aff requested a public meeting to discuss: (1) the steps being taken to ensure that a Safety Conscious' Work Environment exists at Zion Station; (2) the potential for a " chilling effect" at Zion Station; (3) the methods used to ensure that employees rece;ve feedback about issues they have raised; and (4) the effectiveness of the Employee Concerns Program. In response, the Nuclear Oversight Manager commissioned an independent team-

_ (the team) to assess thes ' tate of the Safety Conscious Work Environment at Zion and to provide recommendations for correcting any identified weaknesses. The team's investigation included reviewing existing surveys of the site workforce, facilitating interviews with site personnel, evaluating the effectiveness of the Corrective Action Program, reviewing the.

Operations Assessment, and evaluating the effectiveness of the Employee Concerns Program.

The preliminery results of this team's investigation were the basis for Comed's presentation during its meeting with the NRC Staff on October 2,1997, at the NRC Regional Offices in Lisle, Illinois. During this presentation Comed discussed the issues as requested by the NRC

- Staff and concluded that, presently, the working environment at Zion generally encourages workers to raise safety concerns without fear of retribution and that there had been no actual cases of retaliation against individuals for raising safety concerns at Zion Station.

Subsequently, on October 20,1997, the NRC Staff sent Comed a letter requesting Comed's further evaluation and characterization of the Safety Conscious Work Environment at Zion Station. Therefore, the team was directed to ensure that its final report documents and, if needed, supplements the information provided to the NRC in the course of the October 2nd meeting, and addresses the requests made in the NRC Staff's October 20th letter.

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Relying on information from a site-conducted survey, the team conducted preliminary inteniews in August,1997, which provided some insights about the then-current state of the Safety Conscious Work Environment. In the interest of removing bias and ensuring that i workers being interviewed could be open with inteniewers, the team retained a group of consultants with proven interviewing skills who were not part of tFe Comed organization. In early September, those consultants formed an independent inteniew group that conducted over one hundred inteniews of randomly selected Comed and contractor personnel. These inteniews focused on: (1) the general station environment for raising safety concerns; (2) mechanisms to raise concerns and their relative efTectiveness; (3) the ability of workers to raise issues in specific work environments; and (4) general work environment attributes. The independent inteniewers later conducted a follow-up set ofinteniews, in November,1997, focusing on the same issues as the first inteniews but with additional emphasis on measuring the relative changes in the work environment during the past six months. This second set of inteniews was therefore designed to permit a Nuantitative" comparison with the initial set of inteniews and aid in determining the efTectiveness of station safety culture improvement initiatives.

Starting in August,1997, the team began a general review of the Corrective Action Program in light ofits major contribution to a healthy work environment. As part ithat review, the team examined corrective action documents initiated by Operations Department personnel to determine the effectiveness of corrective actions in response to specific issues raised in those documents. This corrective action review was also used to substantiate conclusions from the baseline inteniews.

The team reviewed events leading up to the Operator Assessment, the need for that assessment, and the overall assessment process as this Assessment appeared to be central to the friction observed between some bargaining unit employees and some members of site l management.

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l Finally, the team reviewed the effectiveness of the Employee Concerns Program (ECP) since an effective ECP represents an important alternative to raising concerns directly through line managemeat and therefore is an important attribute of a healthy Safety Conscious Work Environment.

Based on these reviews, as discussed in the October 2nd meeting with the NRC StatT, the team concluded that the fundamental attributes of a Safety Conscious Work Environment exist at Zion Station although there are weaknesscs and some individual perception issues that must be addressed. The team concluded that individuals are not r.-taliated against for raising safety concerns at Zion Station. Specifically, the team found that when safety concerns are raised they are generally addressed in proportion to their safety significance. However, the team found that a few individuals nevertheless perceive that there was a relationship between the raising ofissues and the actions taken during the Operator Assessment process. The team reviewed the basis for which assessment ratings were assigned and found no evidence supporting their perception that individuals were retaliated against during the Operator Assessment process.

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J At the same time, the team found that almost all individuals inteniewed during the first set of worker inteniews in September feel there is a high priority on safety at the Station and that the Zion management team generally is fostering an atmosphere in which reporting of safety 4

concerns is encouraged. However, the team concluded that issues and concerns could be addressed in a more timely manner and feedback to employees for issues entered in the corrective action processes could be enhanced.

A second set ofinteniews conducted in November complimented the results from the first set ofinteniews, though this second set ofinteniews also identified a potential morale problem in the contract security organization (based on a sample of four guards). The second set of inteniews specifically demonstrated that workers continue to feel that there is a high priority on safety and that the Zion management team continues to foster an atmosphere in which reporting of safety concerns is encouraged. In addition, the second interviews demonstrated improvement in employees' attitudes about raising concerns of all types. Moreover, just as the inteniews conducted in September indicated that employees would not hesitate to raise a significant safety concern; this continues to be the case with some incremental improvement when employees were asked in November to reflect back six months. For lesser concerns, particularly for Operations, the results are significantly more positive today than in the summer.

In summary, the November inteniews demonstrated that the steps being taken by site management have resulted in improvement in the work enviromnent at Zion Station.

Finally, the team concluded that the Zion Employee Concerns Program (ECP) had not been fully effective largely due to a lack of awareness of the program and its objectives. However, the results of the November inteniews showed a higher recognition of the existence of the Employee Concerns Program. Several inteniewees indicated that they had recently been briefed on the ECP in workgroup meetings by the site ECP Administrator. Additionally, most interviewees during this latest set ofinteniews, demonstrated knowledge about the program and how to access it.

Based on its conclusions, the team attributed the barriers to a robust safety culture existing at Zion in late summer of 1997, to the following causes:

uncertainty and apprehension within the Zion workforce attributaole to upcoming industry deregulation and the recent decision not to replace Z:on's steam generators; fundamental changes imposed on the Zion organization by the former management team, especially in the area of personal accountability; individuals nc; recognizing the relationship of their activities to unit restart or their role in the overall success of the station; weak feedback to individuals who raise issues in the Corrective Action Program; some lack of awareness of the Employee Concerns Program; and a lack of trust and teamwork at the site due to long-standing strained relationships between bargaining unit and management personnel.

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Based on these causal factors, the team identified several corrective action recommendations to improve the werking conditions at Zion Station. The recommendations for site management focus specifically on Corrective Action Program improvements including more timely resolution of issues raised and more routine feedback to initiatora of issue resolution.

Additionally, the team recommends that site management demonstrate visible support for all aspects of the issue resolution process and take steps to make employees more aware that they welcome employee participation in the issue identification and resolution processes. Finally, the team recommends that site management continue initiatives to mitigate and eventually eliminate tension butween management and the bargaining unit. Better teamwork needs to be promoted and trust needs to be restored.

The team also recommends that actions be developed and implemented to address Employee Concerns Program awareness by better publicizing this program so that it is as well known as the other mechanisms for raising safety concerns. The team also recommends that Zion Station continue to conduct training workshops to ensure that First Line Supervisors and above are sensitive to the imponance c,f creating an open and receptive environment to employees issues and concerns.

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11. INTRODUCTION A. Background l Comed has been aware of indieztions of a declining safety culture at Zion Station and, therefore, has attempted to better understand the work environment at Zion and the causes for l

the declining performance. To this end, in the Fall of 1996, an initial independent nuclear I safety culture assessment was commissioned to determine the overall status and health of the safety culture at all Comed nuclear stations including Zion Station. This assessment indicated that the employees' ratings of the safety .alture at Zion Station were more than 10% below industry average.

The cause of this relatively low rating for the safety culture at Zion Station was largely attributed to the lack of a questioning attitude and little focus on conservative decision making by Zion personnel. In addition, key programmatic elements typical cf a strong nuclear safety culture had not received sufficient emphasis and commitment such as effective implementation of a Corrective Action Program and learning from operating experience. Furthermore, unlike other methods for raising safety concerns, the Employee Concerns Program was not seen by employees as a visible or viable alternative for raising concew The assessment also provided some recommendations to strengthen that program (See Section VI, Recommendations).

Several additional independent assessments were later commissioned which validated the Zion j site environmental conditions, identified additional issues, and defined further corrective l actions. These activities included the Safety Culture Index Survey, an Independent Self-Assessment performed by an experienced peer team, and an operations focused peer group evaluation labeled the 'Palo Verde" Assessment because it was performed primarily by personnel from that station.

The Safety Culture Index Survey, conducted in September,1996, provided additional detail supporting the earlier assessment. For example, that survey noted that:

Several Zion processes associated with corrective maintenance, problem reporting, root cause analysis, etc., were not fully effective in investigating and identifying causal factors. Also, appropriate corrective actions had not been taken to solve organizational and programmatic issues and prevent their recurrence.

Zion was not fully effective at monitoring and improving the work procenes such as work screening and prioritization, work planning, and work control.

Needed changes to procedures were not made in timely and eflicient fashion Of the above work processes, the Corrective Action Program was identified as the weakest and in general the survey noted that many station personnel viewed this program as ineffective.

The findings of the Independent Self-Assessment and the 'Palo Verde" Assessment were generally consistent with the Safety Culture Index Survey results.

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From these assessments, Zion Station developed an action plan to correct the identified deficiencies. This action plan included: additional site communications regarding management expectations with resp (;t to raising safety concerns; a complete restructuring and standardization of the Corrective Action Program; development of a standardized Operating Experience program; assignment of a full time Employee Concerns Program (ECP)

Administrator at each site; and implementation of a standardized ECP procedure. Although improvement has been noted in these areas, continued improverrent, as described below, is warranted in some steas to meet management expeciations.

In a letter dated July 22,1997, the NRC notified Comed that there had been a significant increase in the number of r3egations regarding employment practices at Zion, including claims that:

An employee claimed job termination after fmding too many problems and writing Problem Identification Fomis (PlFs);

• l Supenisors yell and barass employees when [they try) to give input; and l Workers are afraid to report incidents involving .iupervisors because the supenisors I have friends or relatives in the Comed organization, and those friends or relatives will I see that no disciplinary action is taken egainst an offending supervisor.

As a result, the NRC staff reguested to meet with Comed to discuss steps taken or being taken to ensure that a Safety Conscious Work Environment exists at Zion. The staff also requested that, during this meeting, Comtid discuss its assessment of the potential for a chilling effect at Zion, the methods used to ensure that employees receive feedback abour issues they have raised, and the etTestiveness of the Employee Concerns Program. To respond to the NRC Stafl's request, the Comed Chief Nuclear Oflicer directed the Comed Nuclear Oversight Manager to establish an it' dependent investigation team. That team was directed to tal.e steps to understand and characterize the current state of the Zion Station safety culture, and to recommend additional corrective actions where warranted.

in a subsequent letter dated September 15, 1997, the NRC Staff expanded the scope of the planned discussion by specifically requesting that Comed alco addrest programs in place to ensure concerns raised by employees are appropriately addressed. On October 2,1997, Comed held the requested meeting with NRC Staffin the Regional Ollices in Lisle, Illinois.

During this meeting, Comed discussed the issues as requested by the NRC Staff and piovided conclusions based on the preliminary investigation that had been completed by the team.

Subsequently, on October 20,1997, the NRC Staff sent Comed a letter requesting Comed's further characterization of the Safety Conscious Work Environment at Zion Station. As a result, the team was directed to ensure that its final report document and, if needed, supplement the information prosided to the NRC in the course of the October 2nd meeting, and fully respond to the requests contained in the NRC Staf1's October 20th letter.

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11. The Independent Team's Focus l l

One of the first actions the team took was to identify the attributes of a Safety Conscious l Work Ensironment and potential barriers to establishing such an ensironment or 'bulture"at Zion Station. Based upon the guidance published by the NRC in February 1997 (62 FR 8785),

and by INPO in November,1996 (INPO 96-006), the team determined that such attributes include, in part Management responds to problems, issues, and concerns without defensiveness;

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An effective corrective action process results in concerns being resolved and closed in a timely manner; Effective communication of the resolution of concerns is consistently provided to concerned parties; A safety ethic exists at all levels which is characterized by an inherent questioning attitude, commitment to excellence, and personal accountability in safety matters; and The Employee Concerns Prograrn has suflicient resources, independence, and authority to resolve issues.

These attributes, which are more fully set forth in Enclosure I to this report, were used to help guide the team's inquiry into whether there are barriers to establishing and maintaining a Safety Conscious Work Enviionment at Zion.

G ice the Safety Conscious Work Environment attributes (and potential barriers) were idtntified, the team established a timeline of events (Table 1) that could be potentially significant in understanding the environment at Zion Staticn. The timeline also facilitated tae identification of causal factors.

This report documents the team's investigation and supplements the information provided to the NRC in the course of Comed's October 2,1997, meeting with the NRC Staff. This report also provides the team's assessment of Zion Station's work environment, the method used to ensure that employees' concerns are appropriately addressed and employees are provided feedback, and the effectiveness of the Employee Concerns Program. In addition, the team's report documents recommended corrective actions to improve identified weaknesses (See Section VI, Recommendations).

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• Table 1:

Timeline of Selected Events (Aug. 96 to Sept. 97)

Date Event / Action August 1996 Appointed New Zion Site Vice President.

September Synergy Consulting, Inc. Safety Culture Assessment identified several cultural 1996 deficiencies. Also, FPI international performed a Culture Index Determination for Zion Station that indicated stagnant or declining performance. In addition, peers from other nuclear stations performed an independent assessment of Op; rations. This assessment also indicated cultural weaknesses. Comed assigned d full time Employee Concerns Program Administrator to Zion Station.

November independent Self Assessment of Zon Station was conducted which again 1996 identified culturalissues, Also, Station Quality Verifict. tion (SQV) issues Corrective Action Record (CAR) on Overtime Control.

January l'997 Zion Station was placed on NRC Watch List.

February Zion Reactivity Event further demonstrated unacceptable level of performance 1997 within operations depanment. NRC issued a Confirmatory Action Letter directing Zion to remain shutdown until performance issues within Operations are corrected, hiarch 1997 Board of Directors decided not to fund Steam Generator Replacement.

Announcement impacted site morale in that it signaled to che workforce that Zion may not operate for its full operatirig license term.

April 1997 Operations Department Assessment resulted in 26 bargaining unit members of the Operations Department evaluated as unacceptable. Of those rated as unacceptable,15 were placed in remediation and 7 were removed from Zion Station. Twenty Operations management personnel were also affected.

hiay 1997 Overtime in Operations increased due to fewer qualified operators to vand watch. hianagement SRO's assigned to stand watch end further tensions grew between bargaining unit and management.

hiay 1997 New Nuclear Division Corrective Action Program implemented at Zion Station.

July 1997 Comed completed a self assessment of the Employee Concerns Program (Quality First) and identified several weaknesses in program implementation.

August 1997 Station management sent several communications emphasizing expectations to raise safety concerns. The "% ion Opera'ing Department Agreement" was signed, settling the Union and hianagement issues regarding Statling and Operator Shift issues (overtirne, Crew Selection, License Re-qualification Bonus, Training, Professionalism, and Compensation). NRC issue: a Level IV Violation on Overtime Control (50-295/o7013-02;50-304/97013 02).

September Nuclear Operations Division Realignment which included the announcement 1997 of a new Zion Acting Site Vice President.

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I G 111. ACTIVITIES AND RESULTS OF THE INDEPENDENT INVESTIGATION TEAM A. Hackground The team considered the results from a random employee survey entitled ' Voice of the People," to aid in their preliminary understanding of the then current state of the Safety Conscious Work Environment. Using these survey results, team members who were part the Employee Concerns Program Staff conducted preliminary inteniews of Operations Supenisors to get a basic urderstanding of conditions in the Operations Department. Based on the preliminary results, the team decided that the best way to quickly get a broad, unbiased, and complete understanding of the state of the Safety Conscious Work Environment was to have inteniewers from outside of Comed conduct additional one-on one inteniews. The team directed these independent interviewers to inteniew a large sample of the Operations Department bargaining unit and management personnel and also to inteniew a representative sample of site personnel from other functional areas. The first set ofinteniews conducted in September provided baseline information for the October 2nd meeting with the NRC.

Subsequently, in November, the inteniew team conducted a second set of inte, views to determine the relative effectiveness of certain Station improvement initiatives and to provide a comparison with data collected during previous interviews.

The team also evaluated the station's Safety Conscious Work Environment by examining the Zion Corrective Action Program. This included a general review of the Problem identification Form (PIF) process, a more detailed review of PIFs generated within the Operations Department, and a review c' two additional deficiency processes - the Procedure Change Process and the Operator Work Around Process. Additionally, employee feedback mechanisms in selected corrective action processes were evaluated with specific focus on PIFs and procedare changes.

H. Interview Results The team's charter required that they gain sn understanding of workers' perceptions about the general work environment. Therefore, prior to conducting these inteniews, team membeis reviewed recent random surveys (called ' Voice of the People') of some site workers on their perception of the work environment. Those survey results prosided the team with some preliminary insights about worker perceptions.

1. Eummer u 1997 Survey Resuks In early August,1997, Zion Station conducted a 'Yoice of the People" Survey. This servey was not comprehensive, or statistically based, but it we anonymous and provided the team with insights about worker perceptions. The majority of the site population surveyed indicated that Zion management encourages the raising of safety concerns. A few station personnel, however, responded negatively to some survey questions regarding the raising of safety concerns. Although not intended to be statistically rigorous, the ' Voice of the People" survey results suggested that a minority of people at 7. ion believed management did not foster an environment for raising safety 9

o concerns.' in contrast, all those suney:d agreed that employees must be able to raise safety concerns if Zion Station is to irrprove and stated that they would inform their

. supenisor of a safety concern if they had one.

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2. Initial.Intcryiew Resuhs Armed with the ' Voice of the People" survey results, the team generated some preliminary questions to gain a better understanding of the site environment, specifically in the Operations Department. The Employee Concerns Program Manager and an Employee Concerns Program Administrator inteniewed a sample of Operations Department Supervisors to get an initial understanding of the way concerns were managed within that department. The Operations Supenisors stated that they had

, communicated their expectations to their subordinates regarding the need to bring concerns forward when they were identified. All of the supervisors stated that concerns were documented on the appropriate document, such as a PlF or a Procedure Change Request, when concerns were brought to them. These supervisors also indicated that feedback to the person who raised a concern was provided and they were not aware of any concerns that were not being currently addressed.

These initial inteniews gave the team the information it needed to seek a better understanding of a broader sample of the workforce. These inteniews also demonstrated the need to create an inteniew team comprised of individuals from outside of Comed to ensure a willingness on the part ofinteniewees to openly share their opinions and draw conclusions from these inteniews w:th a minimum of bias or predisposition. Accordingly, the team commissioned an indepudent group of consultants with proven inteniewing skills to inteniew Zion management and

, bargaining unit personnel to gain a more comprehensive understanding of generally held perceptions about the Safety Conscious Work Ensironment and communication barriers at Zion.

3. Independent inteniews A group of independent outside interviewers with extensive experience in organizational dynamics and cultural assessments inteiviewed a broad based sample of Zion workers in early September. That sample ine' ded: 21 Comed Ope.ations personnel, 79 other Comed Zion employees (who included personnel from virtually all other Station departments), and 13 contract workers at Zion Station. Of the Comed personnel interviewed, 53% were bargaining unit employees and 47% were management employees. This independent efTort was intended to be a diagnostic tool from which appropriate recommendations could be made to addiess any deficiencies which may exist in the Zion Safety Conscious Work Environment.

Four of the twcaly-six people wbo responded to this survey question indicated agreement with a newspaper article that qwted allegations of former Operators about managemen: not wanting personnel to voice safet) comerns.

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The independent inteniews focused heavily in the Operations area because of the recent allegations reponed to have originated in that group. Even so, these interviews were conducted across all departments and most large contractor organizations to ensure that any formulated recommendations considered groups needing specific or customized solutions to work environment barriers or other challenges.

In November, the independent inten'iewers returned to Zion Station to determine the efTectiveness of the station safety culture improvement initiatives and to permit comparison with the. safety culture baseline established by the first set ofinteniews. A representative sample of over 140 employees and contractors from the major work populations at Zion Station was selected for these follow-up interviews. This sample included 50 bargaining unit operators, or about 63 percent of the Operations department bargaining unit population. The survey instrument used by the interviewers included a number of 't luantitative" questions. The introduction of these questions facilitated the measurement of trends and provided a general indication of site progress on the safety culture issues since the summer time frame.

The quantitative sun'ey results and inteniews indicate positive progress in terms of employees' attitudes about raising concerns of all types. The suney and inten'iews confirmed the September finding that employees would not hesitate to raise safety concerns. At the same time, the quantitative results demonstrate that Operations personnel are more willing to raise concerns of lesser significance today tnan in the summer. The independent consultants also documented improvement with the awareness and the probability of use of the Employee Concerns Program.

The results of these two sets ofinteniews were placed into the following categories and are described in detail below: General Site Er.vironment, Atmosphere for Raising Safety Concerns, EfTectiveness of Reporting Processes, and Effectiveness of Employee Concerns Program.

a. GeneralSite Environment During the first set ofintenlews, the inteniew team noted the following attributes of the current general site environment:

liigh Priority on Safety - A large majority of the employees inten>iewed felt there was a high priority at the site on safety and that management's expectations in this area were recognized. Many employees felt this priority had been increased d. iring recent months. Ilowever, some employees noted that the site has a history of allowing production concerns to dominate, and they are not convinced that safety will remain a priority as the date for Unit 2 restart approaches.

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l Atmosphere of Uncertainty - Employees expressed frustration with the amount of management turnover and associated changes in site focus and priorities.

i Some of the employees interviewed felt that site Senior Management ('The 6*

Floor") was largely irrelevant to their work environment.

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] Management Style - While a few of the employees interviewed state! that the depaning senior management team's focus on upgrading standards and holding i

people accountable was needed, the leadership style of the departing I management team was perceived in an extremely negative manner by the l majority of the employees inteniewed, Interviewees characterized this

l. management style variously as hostile, unprofessional, and overly f

! confrontational; however, the ' hostility"was unrelated to the raising of safety

concerns. Some employees, especially members of the management team, w-reportedly subjected to public berating that adversely affected morale damaged trust between various employee groups. The tone that was set by this management style also appears to be associated with a degraded level of

communication and teamwork across department lines. Some interviewees j commented that this style continues to be reflected in inter-departmental 4 meetings such as Plan of the Day meetings waere these individuals say raised l voices and fmger pointing are common.

Frustration with Lack of Progress - Most of the employees inteniewed were ,

frustrated that they were not making sufficient progress toward returning the station to operation. In addition to the changing focuses and priorities, work planning and scheduling were repeatedly mentioned as major barriers to progress. Some employees felt that they were either sitting idle for major portions of the workday, waiting for planning and scheduling support, or were  ;

busy with low priority work that was not relevant to station restart.

Operations Assessment and Operations Protest Effects in Operations - The assessment of the operations staff earlier this year continues to be a divisive -

issue within that department. Many of the interviewees from the Operations Department bargaining unit remain convinced that this process was flawed and vindictive.

Low Morale, with a Recent Upturn in Optimism - Several of the factors mentioned above have affected site morale. In addition, the general uncertainty about the future of the site and attendantjob security are also having an adverse impact on morale across all employee groups. The recent management changes have been cause for an increase in optimism and have been seen as a positive by most of the interviewed employees.

In the November follow up inteniews, the inteniewers concluded there had been significant improvement in the Zion employees perception of the quality of their overall work environment. This improvement was especially pronounced for the operations 12

bargaining unit population, though the team did fmd isolated examples where operators are still uncomfortable in interfacing with specific supervisory personnel because of the supenisor's perceived role in the assessment process. The interviewers also found that with the exception of an apparent morale problem in the contract security force (which had not been sampled in September), the improvement was broad based, and evident acioss al! major work populations. According to the employees and contractors inteniewed, the most significant factor influencing this improvement is the senior management team's willingness to genuinely solicit and act upon input from employees.

Many employees also noted an improvement in teamwork across the station. Recent progress in moving toward Unit 2 restart has also apparently lowered the frustration level that was noted in the Septen.ber inteniews.

b. Atmospher wfai Raising Safety Concerns During the first set orinterviews, the following observations were made relative to the effectiveness of the atmosphere for raising safety concerns:

Perception that Reporting of Safety Concerns is Generally Encouraged -

Almost all of the inteniewed employees felt that the management team generally is setting an atmosphere in which reporting of safety concerns is encouraged.

Perception that Some issues Exist that May inhibit Raising Concerns -

Although none of the employees inteniewed indicated that they would hesitate to report a nuclear safety concern, several did believe that either they or others 2

might be hesitant to raise concerns of a less significant nature. In addition, it is the opinion of some inteniewees that they have observed behaviors that tend to discourage a questioning attitude. The following issues were reported to th-Team as having substantively contributed to this perception:

The April 1997 Operations Assessment: Many bargaining unit Operations Department emoloyees expressed the opinion that the Operators who were removed from their duties as a result of this Assessment were among those operators who would most readily raise questions and concerns about operations evolutions. The team found no correlation between this perception and objective criteria used during the Operations Assessment, Although most employees are sufliciently confident of theirjob status to not be inhibited by the residual effect of this Assessment, the ir'eniewers felt that some employees may be hesitant to raise certain types ofissues with management (for example, concerns that are not safety-significant or concerns that might implicate another worker).

2 The less significant issues wetc only dcscribed anecdotally and accordingly no precise threshold was established. Examp'es eglained to the inteniewers are described b; low.

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Residual Confrontational Management Style: Many employees shared anecdotes regarding management behaviors that were perceived to be hostile and overly confrontational and sometimes directed at those who voiced concerns or expressed alternative opinions. Several employees, predominately in Operations, indicated that there are individuals within their reporting chain who are perceived to continue to possess abrasive management styles and to whom they would not feel comfortable raising l some concerns! Interviewers referred the specific issues raised during these interviews to the Employee Concerns Program and they were i subsequently resolved. Concerns raised during the second set of l inteniews were similarly referred to the Employee Concerns Program i

for resolution.

Specific Cases of Perceived Retribution for Raising Concerns: There were a few instances anecdotally related by inteniewees in which interviewees thought others were harassed by management or by others as a result of raising questions or as a result of entering items in the PIF system. Those instances reported .ncluded perceptions of serbal grilling by supenision as well as perceptions that performance evaluations referred to poor judgment because employees raised issues or initiated PIFs! These instances weie not current and the individuals who related them did not feel that further resolution was required. Even so, management has been made aware of these issues so that they can take action, as appropriate.

Although it appears that very few employecs were impacted by the actions and behaviors described above, many employees are aware of the Operations Assessment and the residual confrontational style of former site management and this may represent an additional barrier to a healthy Safety Conscious Work Environment. In addition to the above management related issues, the Team noted an additional barrier to raising concerns that is slightly different in nature:

Bargaining l' nit Aversion to implicating Fellow Bargaining Unit Personnel: As a condition to be allowed to conduct inteniews with IBEW Local 15 members, the Union mar.ement stipulated that no bargaining unit member should ofter any comments aoout other bargaining unit employees at the Zion station. Some of the bargaining unit inteniewees also indicated during the inte" iews that they would be hesitant to write problem identification forms (PIFs) if another bargaining unit employee would be twplicated. It is the opinion of the The types of concerns were only anecdotally characterized by indhiduals during anonymous inteniews, for example, as issues that might result in the implication of another empio3 cc but not uhere nuclear or personnel safety was an issue, This perception is contradicted by the esidence collected about the Operations Assessment, described below.

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independent inteniewers that this action could limit the raising of concerns and corrective action reporting to some extent. Ilowever, bargain:ng unit leadership has subsequently stated that it will work closely with management to resolve this issue.

Finally, some of the inteniewees hold an opposing siew to that expressed by Operations Depanment employees in the bargaining unit. These people believe that:

The Allegations are Pretextual, and are Not being Raised for Safety Purposes -

A number of bargaining unit employees and low level managers hold the opinion that the Operators who have claimed an atmosphere exists in which some employees might be hesitant to raise safety concerns have raised this allegation as a pretext for their own purposes. The bases for this opinion were variously expressed as follows: (a) their lack of knowledge of anyone being hesitant to report safety concerns; (b) their perception that the Operations department employees' concern for safety is very high and co-equal with their own; and (c) their belief that job insecurity due to the uncertainty about the plant's future and the union's separate agenda (to protect operator's jobs) influenced a few vocal operators. Most of the employees in other departments did not mention the Operations Assessment in theli inteniews, but many were cr9ical of the control room protests and 'bperator" actions -- actions that were directly tied to the Operations Assessment.

In the November follow-up inteniews, the inteniewers found significant improvement in the atmosphere for raising safety concerns at Zion, particularly in the Operations area. Specifically, Zion Operations personnel rated this area significantly below other site groups based on the perceptions of the conditions existing three to six months ago.

The team found no significant difference across site workgroups in this rating as perceived today. This same positive trend was also seen in the rating of comfort level of employees in raising plant operating and nuclear safety concerns, as well as in raising concerns oflesser significance. Inteniewees credited this improvement to the attitude of openness and responsiveness demonstrated by the senior management team, as weit as the concerted efTerts to emphasize safety in shill meetings, pre-job briefings, work group meetings, all-hands meetings, and formal communications. Inteniewees also cited many examples of supenisors and managers acknowledging employees who have raised concerns in the last three to six months. The one area where results were not consistent with the team's findings is the Contract Security Organization where the team found individuals who indicated a hesitancy to raise concerns below the significant station security or personnel safety threshold. Based on this finding, the team recommends that the scope of the actions particularly focused on improving the environment within the Operations Department be expanded to include the Contract '

Security Organization.

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c. l.;[fectiveness ofReporting Processes  ;

During the first set ofinterviews, the following observations were made regarding the I effectiveness of the site corrective action program reporting processes:

Preference to use the Chain of Command - The vast majority of the employees inteniewed stated that they normally take any significant problem or concern to their immediate supervisor and feel very comfortable doing so. This wa:

viewei. as a very healthy indicator of the Zion safety culture by the Team.

{

Problem Identification Form (PlF) Effectiveness - The PlF process was generally viewed by the inteniewees as the primary method to report issues.

However, the system was widely perceived in a negative way for the following reasons:

Inappropriate Use: There is a widespread perception that the PIF process is used fairly frequently by employees to punish another employee or organization. This was not punishment for raising safety concerns but rather a form of'If you tell on me, I'll tell on you." 'PlF Wars"is a commonly used site buzzword for this type of activity. Also, many individuals felt that the PIF process was clogged with frivolous items such as overflowing garbage cans, parking lot issues, etc.

Insuflicient Feedback: Most of the employees inteniewed were concerned that the PIF system does not generally provide feedback to the initiator related to the disposition of the problem. This lack of feedback appears to have increased the perception that the PIF process is not effective. Some employees expressed hesitancy to use the process for this reason.

Contract Organization Hesitancy: Inteniews with contractors and Employee Concerns Program Administrator inteniews with contract supenision indicate that use of the PIF process is discontaged by a significant number of contractors including contract supenision. The perception is that use of PIFs reflects negatively upon the competence of the contract organization with respect to its relationship with Comed.

The inteniewers also noted that the threshold or criteria for use of the PIF system is not clearly understood by many inteniewees.

During the November follow-up inteniews, the team found that the interviewees still consider the level of performance of the PIF system to be relatively low, for reasons similar to those expressed during the earlier inteniews. In addition, the team found that many employees apparently do not understand the purpose of the PIF system, e g.,

there is confusion iegarding the difference between the purposes of the PIF and Action Request (AR) systems.

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d. Nfectivenen of the Employee Conc erns Program Durinr the first set ofinteniews, the great majority of the interviewees recognized the availability of the Emplo>ce Concerns Program (ECP). Ilowever, in many cases there was only a vague understanding of the purpose of the program or its processes. In this regard. a number of those interviewed confused this program with the Employee Assistance Program. The Team noted that the current site General Employee Training module still refers to the program by its old name, ' Quality First." A few of the intenic ' employees indicated that they would be nervous about using the ECP because of fear of breach of confidentiality.

The team inteniewed the site ECP Administrator who indicated that he has met with all the site work groups within the past year, many on multiple occasions, to talk with employees about the program's provisions. In addition, he also has met informally with individuals and small groups of employees for the same purpose. Nevertheless, the team concluded that additional communications concerning the purpose and workings of the program should be undertaken.

During the November interviews, the inteniews found a higher recognition of the existence of the Employee Concerns Program than in September. Severalinteniewees indicated that they had recently been briefed on the ECP in workgroup meetings by the site program administrator. Most inteniewees demonstrated knowledge about the program and how to access it.

C. Corrective Attion Program Because of the significant role that effe.tise corrective action has in the maintenance of a healthy Safety Conscious Work Environment, the team evaluated the Zion Station Corrective Action Program (CAP) to assess its contribution to the Zion environment. liowever, the team found that the Zion Station CAP had been recently modified as part of a Disision-wide CAP improvement effort, thus the team recognized that many of the improvement actions taken as part of that effort might not yet be fully effective. The team's review included: (1) a general programmatic effectiveness review of the Problem Identification Form (PIF) process; (2) a resiew of PIFs written by operations personnel, (3) a resiew of other deficiency processes such as procedure changes and operator work arounds; and (4) an assessment of the quality of feedback provided to employees who raised concerna.

1. General Rmiew of PIF Procen During the past 12 months, several improvement initiatives had been implemented to address identified deficiencies with the PlF process. These improvement initiatives included:

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Implementation of a new Corrective Action Program (CAP) (this new CAP is designed to be consistent across all Comed nuclear sites, and was benchmarked against several other utilities prior to implementation);

Creation of a dedicated Corrective Action Group, Establithment of a Corrective Actions Review Board (CARB) to review root cause investigation reports; Extensive revision to the Nuclear Tracking System (NTS) process to more effectively control creation closure and due date extensions for all site commitments; and Re-assignment of dedicated root cau' investigators back to the individual line organizations to enhance ownership.

However, the team found that, as of late summer 1997, the Zion Corrective Actica Program improvements had not been implemented for suflicient duration to demonstrate that identified deficiencies had been correctr.: ~ amples include weak and inconsistent management involvement in the daily review of PIFs, a large backlog of overdue NTS (Nuclear Tracking System) items (~ 480), root cause reports commonly exceeding the 30 day due dates, and LERs frequently requiring supplemental reports continued to create the perception that there were programmatic weakness.

The team also found there was a lack of direct feedback to those individuals who raised issues. Collectively, these factors led the team to conclude, as of summer 1997, that workers at the site perceive that the existing PIF process continued to be weak.

However, program improvement may result from full implementation of the existing program, with the passage of time, and accomplishment of additional corrective actions to improve program implementation that are being tracked in the Zion Nuclear Station Recovery Plan and various Quality and Safety Assessment Corrective Action Reports (CARS).

2. Operations PIF Sample Review The team reviewed PIFs initiated by the Operations Department from June 1996 to August 1997. This resiew was perfortned to identify the types oiissues being reported by Operations personnel, to identify any potential safety concems, to evaluate timeliness ofissue resolution, and to assess the adequacy of employee feedback.

Operations personnel have generated 239 PIFs since the new CAP was implemented in May 1997. The team resiewed these PIFs to identify recurring problems and themes within the recently produced PIFs. The team noted that several of the PIFs contain information reflecting Operator's fmstration with: uncertainty about expectations, standards, and direction; timeliness of correction of previously identified concerns; and a lack of awareness about the status cfissues they previously identified.

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I I

The team also noted that Operator concerns are not always resolved in a timely manner and in several instances the same concern was documented on PIFs by more than one  !

operator. Overall, the team concluded there is a need for improving timeliness and  ;

feedback ofissue resolution.

In addition to the general review of Operations generated PIFs, eleven issues were selected for a more detailed review based on their potential safety significance.

Through this review, the team determined that several PIFs in the sample are greater than one year old, have past due commitments, and document recurring concerns. l liowever, the team did not identify any long standing, safety-significant issues that I have not been addressed. The foibwing exemplifies the type of recurring problem the team did find. Deficiencies with the Battery and Inverter Room Ventilation System has l been an open issue with some potential safety significance, but adequate interim i compensatory measures have been implemented. These measures monitor hydrogen concentration in the rooms at an appropriate frequency until permanent corrective action is implemented. The team felt this example was not safety significant, however, they also felt the permanent corrective measures were taking e long time to complete.

Although this review occurred too soon afler program upgrades- to document significant change, it largely confirmed the need for the changes in May,1997.

3 Additional Deficiency Document Review The team also reviewed additional categories of problem identification documents (e.g.,

Operations Procedure Changes and Operator Work Arounds) to determine whether potential safety concerns are being identified within those processes, whether problems are being resolved in a timely manner, and whether feedback of the concern disposition is being provided to the originating individual. Results of these reviews are discussed below.

a. Procedure Change Process A log of open Operations Procedure Changes and a sample of open procedure change requests were reviewed to determine if identified pro;edural errors having potential safety significance are incorporated into procedures in a timely manner and if feedback to the originator is provided. Thirty (30) open Operations procedure change requests were selected for review including Abnormal Operating Procedures (AOPs).

Annunciator Response Manuals (ARMS), Emergency Operating Procedures (EOPs),

Fire Operating Procedures (FOPS), Periodic Test Procedures (pts), and System Operating Instmetions (SOls). Additionally, the team interviewed members of the Operations Procedure Group and the Procedure Administrative Group to understand the procedure change process and the current effectiveness of this process.

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Although there are more than 1600 open Operations Procedure Action Requests (PAR), some dating back to 1992, the team found that procedures that are not technically correct, contain an unresolved Nuclear or Industrial Safety problem, or express ALARA concerns, are prioritized and revised in an exoeditious manner However, change requests not hav'ng safety significance take too long to resolve thus contributing to the perception held by some operations personnel that some issues raised in the corrective actions process are not resolved in a timely manner.

Additionally, although numerous procedure changes are being identified by Operations personnel to improve the procedures and reduce the potential for challenges to Operations, the resources ded' a to revising the operating procedures are not able to keep up with the incoming procedure changes and there.4re, have not been able to reduce the backlog. This further contributes to Operators' frustration with the

( timeliness of resolving identified deficiencies.

h. Operator Il'ork Arotmds Operator Work Arounds (OWA) were evaluated from several perspectives. First, the trend of open OWAs was reviewed by comparing the number of currently active OWAs to the number active OWAs at the end of 1996. Second Operator Work Arounds were reviewed for timely resolution and potential negative effect on Operations that may contnbute to the burden on the Operators while performing their normal activities.

Although, Operator Work Arounds (OWA) have increased from December 1996 to August 1997 by five (from 28 to 33),25 OWAs have been closed in 1997. Of the 33 OWAs that remain active, two appear to hinder Operations in performing their normal duties and contribute to the perception that management does not act on issues in a timely manner. The OWAs identified as supporting this perception are: Component Cooling Water Pumps auto-start when secured, and fire alarms are caused when Service Water Pumps start. The team observed that a plan to workdown significant OWAs is included in the Zion Recovery Plan.

4. E_mplosederdhnk_on identified Issun Because of the perception that concerns raised are not addressed, a review was conducted of eighteen processes that are used at Zion Station to raise concerns to assess the quality of feedback given to employees regarding the issues they raised.

These processes include: the PIF process, Procedure Change process, Employee Concerns Program, Action Requests, Engineering Requests, and Field Change Requests. Thirteen out of the eighteen processes reviewed contained a step requiring some form of feedback to the originator. Because the PlF and Procedure Action Request processes are the primary mechanisms for Operatiens personnel to identify issues, these processes were seiected for further review.

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a. Problem Identification Form (PlF) Feedback The governing procedure at Zion, NSWP A-15, provides guidance for PIF processing.

Once the originator initiates the PIF in accordance with this guidance, a supenisor reviews it and enters an electronic signature and then transmits it to the operating shifi for review and signature. Each day a committee meets to review the P!Fs generated since the previc,us business day for significance and the resulting screening information I is entered into the CAPSYS database. A 'thank-you" letter is then generated and sent back to the originator. This letter includes such information as significance level, report type, and who is assigned to perform the cause evaluation. These 'thank-you" letters are sent every 2 weeks via station mail to the respective originators! The team determined that although the feedback provided tells the originator what happened to the PIF, it does not tell the originator what actions are planned or have been taken to resolve the issue. To find this information, the originator must take the initiative to access CAPSYS and NTS to identify the corrective actions that have been recommended. The team concluded that the program should be improved by providing direct feedback to the originator at the time of PIF closure. In addition, a provision should be included in the program requiring additional resiew if the originator does not agree with the initial PIF resolution.

b. Procedure Action Requests The Procedure Action Request process, ZAP 300-2A, has no feedback mechanism to the originator. The lack of a feedback process is considered unacceptable and represents a barrier to a robust Safety Conscious Work Environment. The team provided a recommendation to revise this process.

D. Operations Assessment in addition to conducting personrxl inteniews and assessing the Corrective Action Program, a revkw was condacted of the events leading up to the Operator Assessments;the .1eed for the assessments, and the assessment process itself. This resiew v conducted because it was evident from comments during the September inteniews that so.ne people, particularly from Operations, felt ilm Assessment was a source of significant friction between management and the bargaining unit, and therefore might interfere with employee involvement and confidence in raising and resching concerns. The team found no evidence that persons who raised concerns were singled-out for negative treatment in the assessment process. Additionally, the team determined that the assessment process was designed to be fundamentally fair by including an independent review board and independent appeals process. Nevertheless, some employees had the perception that the assessment process was overly subjective, lacked documentation, and was generally flawed.

5 During the inwestigation the team found that an administrative error had caused suspension of the "thank you" letters for two months. The Site Vice-President took immediate action to reinstate this feedback mechanism.

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This Operations Assessment process was developed to address human performance problems in the Operations Department. The assessment process was designed to include: (a) employee self-assessments;(b) an independent assessment interview of each employee facilitated by non-Zion Station human resources professionals; (c) Evaluation Boards comprised of senior Zion and non-Zion rnanagers and human resources professionals, to analyze historical personnel information, integrate other assessment information, and make selection recommendations; (d) a Review Board comprised of members of Comed's Equal Opportunity Employment department, a non Zion human resources representative, and a non Zion line manager to ensure the process was properly followed for each individual; and (e) a piocess to allow employees to appeal decisions that they believe were unfair or improper to an Appeals Board consisting of a non Zion Vice President and the Nuclear Operations lluman Resource Manager.

Most of the bargaining unit employees refused to participate in any part of the assessment process because the Union believed the improvement needed at Zion Station could be reached l through the Collective Dargaining Agreement. For those individuals, this meant that there could be no self assessment. As a result, Comed had to modify the process from the original design, and therefore replaced the self-assessment with structured input from supenisors. The personnel scheduled to interview each ernployee for assessment instead interviewed the employee's supenisor. In addition, the evaluation boards in some situations inteniewed one or more other supenisors familiar with the employee's performance.

Based on the information collected from the supenisors and other indirect sources, the evaluation boards determined the acceptability of the employees. A review board then evaluated the assessment forms and supporting documentation to ensure the decisions were supported, consistent with the original plan. Where the supporting documentation was not adequate, the review board returned the assessment forms to the evaluation board for addi:ional supporting documentation. Thus the review boards' function was to ensure that the assessment process was done fairly and that the assessments were supported by documentation by challenging the product of the evaluation boards. The review boards found that each assessment of an employee deemed unacceptable by the evaluation boards was adequately supported by the remarks in the assessment forms. WFle the review boards challenged several ratings and required additional support for the evaluations, the boards did not change any assessment conclusion.

The original assessment process contemplated removing all employees who were rated as

'bnacceptable"from the Operations Department. Once the results were reviewed however, the Zion Vice-President determined that the Station should consider whether, through training and counseling, it would be possible to return any of the employees rated 'bnacceptable"to the Operations Department. In support of this request, three Operations supenisers and two 22

human resources personnel conducted an additional review to divide those bargaining unit employees' who had Seen rated 'bnacceptable"into separate categories, based on whether they: (i) could return to the Zion Station Operations Department after prope; traming, (ii) could remain at Zion Station in a position outside of the Operations Depanment, or (iii) should be removed from 7. ion Station.

This classification process resulted in seven bargaining unit employees and five management employees initially being considered unsuited for continued work at Zion Statioit The final ratings of each Operations Department employee were reviewed by three Zion Station senior j maragers.

The team found no evidence that the evaluation or review boards were improperly influenced by whether an employee disagreed with a supenisor. The team found no evidence suggesting l the raising of safety concerns adversely afTected either the initial ' unacceptable" rating of u operator or the ultimate category in which the employee was placed. In fact, raising safety concerns was viewed as a positive attribute in this rating process as having a high sense of l

safety consciousness was considered a positive attribute among the core characteristics.

Specifically, many assessments complimented individuals for such attributes as 't uestioning l

attitude", " quick to point out ds xiencies", and " consistently identifies problems / issues."

The Assessment process included an appeals process if an employee believed he or she was not properly assessed. Ilowever, while some members of management used this appeals process, none of the Union represented employees who were assessed took advantage of this appeals process. Instead, members of the Union relied on their labor grievance process to seek reinstatement to their job positions. As a result of an agreement reached between the Union and management on August 5,1997, all grievances related to this assessment or actions by the Company resulting fiom the assessment and any National Labor Relations Board charges relating to the same have been withdrawn and are considered resolved without restoring individuals to their former job assignments. This process did not result in any findings that an operator had been unfairly treated for having raised safety concerns.

E. Causal Factors During the data gathering and analysis pheses, the team noted several themes or postulated causal factors expressed during the employee inteniews. For example, much of the Zion workforce exhibited strong feelings of uncertainty and apprehension. Some of the reasons for this stems from an uncertain future in the electrical energy business especially as the specter of deregulation approaches and some reasons stem from site specific concerns such as the recent decision not to fund the replacement of steam generators. From comments made during the September interviews, some workers have perceive over the last year that the Zion management team has not aligned itself as a cohesive entity with a clear and focused path for success.

A similar rating-by category process was completed with management employees.

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Fundamental change has been imposed on the Zion organization, especially in the area of personal accountability. The site has had a relatively long history of side stepping personal accountability in that there were few consequences or sanctions associated with non-performance. Personnel evaluations and other policies and practices frequently did not adequately deal with the link between performance and consequences. The changes needed for Zion to be successfulin the future have met strong resistance by some in the workfoice. This resistance coupled with the abrasive style of some managers has led to a high degree of strain in the organization.

j Communications at the Zion site have been poor. Many individuals do not see how their work connects with the overall success of the station. Additionally, feedback from the corrective action program has been weak and many individuals who have identified issues therefore have no idea if actions are being taken when they raise issues and frequently believe that their issues must be deemed unimportant. This leads to a sense of futility in using the CAP, and some i issues may not get taised because the perception is that nothing will be done anyway. l l

There was a basic lack of tmst and teamwork at the site. Long-standing strained relationships between manageme.it and elements of the bargaining unit led to this condition.- Part of this situation was caused by a relatively high turn over in management and the initiation of many improvement programs that haven't produced the intended results. Credibility has therefore suffered and the organization has taken a '\vait and see" attitude prior to committing its energy to improve performance. As previously stated, there are signs that the new management team is beginning to repair the trust and respect of the workforce. Fron remarks made during the November interviews, the team received indications that this condition has recently changed, and new management appears to be making some headway in regnining mutual tmst and respect within the organization.

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IV. EMPLOYEE CONCERNS PROGRAM EFFECTIVENESS A, Hackground 1

Although it is expected that nuclear safety concerns will be processed through the normal Commonwealth Edison Corrective Action and Non-conformance programs with the ,

individul's supenisor acting as an advocate for resolution of the concern, the Employee 1 Concerns Program (ECP) is designed for those employees who, for whatever reason, are not comfortable raising an issue through normal programs.

A comparison was made with the features of other successful industry programs of this type and the team felt that the Comed program had many of the most successful features. For example, the team found that:

The ECP is designed to provide a user-friendly and non threatening avenue for employees to raise concerns outside the line organization; The ECP Administrators are provided specialized training in Employee Protection Laws, investigating Employee and Quality Concerns, Documenting the Record, and l Communication Skills; The ECP Administrators report off site to the Director of Quality Programs, who reports to the Nuclear Oversight Manager; ECP Administrators are expected to be the advocate for resolution of the issue for the concerned individual, they track progress and provide direct feedback to the individual; Numerous postings with ECP brochures which furnish information about the program are prosided at strategic locations around the site which furnish information about the program; Prosisions exist to preserve confidentiality of the individual, if requested; and Employees leaving the Nuclear Operations Division are provided an opportunity for an exit intemew where they are asked to comment on any concerns they have about the ufe operation ofZion Station.

During September 1996, a Safety Culture Assessment was performed at Zion Station, which identified several areas where the Employee Concerns Program was in need ofimprovement including program visibility and the perception that the ECP was a contractor's program.

As a result, an Employee Concerns Action Team (ECAT) was assembled to develop and implement recommendations to improve the effectiveness of ECP, This team developed several recommendations regarding the need to increase program visibility, improve communication of successes, add program consistency and completeness, and develop 25

measurement standards that measure the effectiveness of the Employee Concerns function, ide,tify trends, and evaluate the performance of the Employee Concerns Program Administrators. These recommendations included:

Changing the name from Quality First to Employee Concerns Program to assist in eliminating confuslon with other programs; ,

Re-emphadzing the program purpose with Zion employees through communication with IDEW Leadership, station employees, and new posters, brochures, and reporting l forms posted at numerous visible site locations, and Re-establishing ECP Administratc; expectations regarding documentation, close-out, l reporting, and follow-up Additional improvement: were also implemented in an effort to better serve the customers.

These include relocating the EC." omce to inside the protected area to case access acd improve sisibility and privacy and adding one additional ECP Administrator temporarily to Zion Station to assist in resolving incoming concerns. The added benefit ofincreasing program visibility and provioing additional publicity about the program's purpose would be to correct the mis-perception aoout the ECP being exclusively a contractor's program.

H. Current Effectiveness Zion Station performed a self-assessment of the Employee Concerns Program in early May, 1997 to determine t.ie efTectiveness of ongoing improvements. While this assessment concluded that the program at Zion is a visible program meeting objectives and resolving concerns to the satisfaction of most employees using the program, three areas of weakness were identified:

) Zion Documentation and Feedback to Employees Documentation files do not contain adequate objective evidence to support the investigation and conclusions. Additionally, in some cases, personnel who filed concerns did not receive communication of the resolution of their concerns, adversely afTeeting employee perception of the program.

Escalation No process exists for personnel to escalate concerns who are dissatisfied with the results or for evaluating the efTectiveness of corrective action taken in response to a concern.

Contractor Employee Concerns Program Contractor programs are undocumented and may not ensure confidentiality or freedom from reprisal.

26 s .

During the independent inteniews, the inteniewers posed questions specifically designed to gain an understanding of the workers' general perceptions about the ECP. These interviews revealed that, although the existence of the Fmployee Concerns Program (ECP) is now generally recognized by the great majority of the interviewees, many inteniewees continue to have only a vague understanding of the purpose of the program or its processes. Also, a j number of those inteniewed confused this program with the Employee Assistance Program and some still perceived this program to only apply to contractors. The team also noted that the current site General Employee Training module still refers to the program by its old name,

" Quality First", which contributes to the confusion about this program.

Also, during the initial interviews, the team noted that a few of the inteniewed employees indicated that they would be nenous about using the ECP because of fear of breach of confidentiality. An inteniew with the site ECP Administrator indicated that he has met with all the site work groups within the past year, many on multiple occasions, to talk with employees about the provisions of the program in an effort to educate the Zion employees. He also has met informally with individuals and small groups of employees for the same purpose. In addition, NO-27, ' Employee Concerns Program," was revised to clarify the program's anonymity policy. During the second set ofinteniews, there was a higher recognition of the existence of the Employee Concerns Program. Several inteniewees indicated that they had recently been briefed on the ECP in workgroup meetings by the site program administrator.

Additionally, most inteniewees demonstrated knowledge about the program and how to access it. Also, during the second set of inteniews none of the personnel interviewed indicated that they would be nervous about using the ECP.

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V. CONCLUSIONS The team did not find evidence that safety concerns are disregarded when raised nor that persons are retaliated against for having raised concerns. Employees inteniewed felt that there was a high priority on safety and that the management team generally is setting an atmosphere in which reporting of safety concerns is encouraged. However, the team found that a few individuals nevertheless perceive that there was a relationship between the raising ofissues and the actions taken during the Operator Assessment process. Even though that perception is not supported by fact, the perception has inhibited the creaticr. of a trusting and cooperative relationship between bargaining unit and management personnel and therefore makes some

-workers feel that manager.rnt is not approachable. The vast majority of the employees interviewed feel comfortable taking any significant issue or recommended corrective action to i their immediate supenisor. Nonetheless, concerns have not always been addressed in a timely manner and feedback to employees who raised concerns is not consistently provided.

The team was concerned that many in the workforce have the perception that one or more of the corrective actions processes are not efTective. This perception appears to result from one or more of the following factors:

A perceived lack of Zion Station management support in resoking the issue; A perception that issues receive untimely resolution, commentaries specifically speaking about the backlogs in the resolution of some items in the corrective actions process; Comed has not always effectively communicated to persons who have raised concerns, how those concerns were resolved; There is no escalation process available if the problem originator does not agree with the resolution of an issue; The bargaining unit aversion to implicating other bargaining unit employees may to some extent inhibit the raising of non safety related concerns; and Although senior station management over the past year has issued the correct policies-on identifying and raising issues, an aggressive management style, coupled with the failure to ensure timely response to issues raised, has sent the work force a mixed message on expected conduct.

Based on the results of the November workforce inteniews, the team noted an improvement in the attitudes of workers, suggesting that current Statian management is making progress in resching issues that are critical to the health of the Safi ty Conscious Work Environment.

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Finally, the team concluded that the Zion Employee Concerns Program (ECP) had not been fully effective, largely due to a lack of awareness of the program and its objectives. Ilowever, during the second set of independent interviews,- there was a higher recognition of the existence of the Employee Concerns Program as compared with the initial sampling of inteniews. Several inteniewees indicated that they had recently been briefed on the ECP in workgroup racetings by the site program administrator _ Additionally, most interviewees during _

this latest set ofinterviews demonstrated knowledge about the program and how to access it.

This is also supported by the number of concerns being brought to ECP; 54 through October 1997 as compared to 18 in 1996.-

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VI. RECOMMENDATIONS Based on the conclusions reached c.s a result cfits investigation, the team believes that Station or Nuclear Division management, as appropriate, should:

o Ensure more timely resolution ofissues raised by personnel by applying appropriate resources to reduce the backlog of open corrective action and Nuclear Tracking System items, procedure change requests, work requests, and root cause repons.

Ensare more routine feedback to initiators ofissues, both as to the status and final resolution ofissues; Demonstrate in a visible manner support for all aspects of the issue resolution process, including holding accountable indniduals who act inconsistent with the purpose of these programs.

Create a screening mechanism that challenges the adequacy of LERs before they are issued, or, in the alternative, conduct additional training for people responsible for writing LERs to make them as complete as possible before they are issued; Site management should take steps to make employees more aware that they welcome employee participation in the issue identification and resolution processes through routine communications channels, discussions in small group or all hands meetings, and direction to all levels of Station supenision; Create a method to permit escalation of issues within the current processes and procedures if an employee is not satisfied with the initial response taken with a corrective action item; Conduct training or hold meetings to share the message that the corrective actions processes are not punitive in order to establish a common threshold for use of the corrective actions processes and to explain the need to document all problems, even where the PIF originator resolves the problem, so that all workers at Zion Station can appreciate the critical role that use of corrective action processes play in improvement at the Station; Continue initiatives to mitigate and eventually eliminate tension between management and the bargaining unit to promote better teamwork and restore tmst; Take aggressive steps, through procedural controls and management direction, to ensure worker overtime is kept to within Comed and NRC guidelines; a

Assist ECP representatives with the task ofincreasing program visibility and increasing Station worker awareness of Employee Concerns Program; The scope of the actions taken to improve the environment in the Operations Department should be expanded to include the Contract Security Force; Develop and implement actions to encourage contractor use of the PlF process; Nuclear Oversight should continue to work with site management to better publicize the Employee Concerns Program so that it is as well known as the other mechanisms for raising safety concerns; Take steps to monitor the quality and features of contractor-provided alternatives to Comed's Employee Concerns Program; and Develop and deliver an Employee Awareness Workshop to First Line Supervisors and above that provides an awareness of the importance of creating an open and receptive environment to employees issues and concerns.

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ENCLOSURE i Slans of Barriers to a Safety Conscious Work Environment Prepared for use by the Zion Employee Concerns Assessment Team l 11e following explanation, based on guidance published by the Nuclear Regulatory Commission (NRC) at 62 4 FR 8785 (Feb. 26,1997), is provided to guide investigation and inquiry into whether there are barricts to an effective Safety Conscious Work Environment at Zion Station. It must be clearly understoed at the outset that a Safety Conscious Work Emironment is not a commodity that exists in an absolute sense. Rather, it is a condition, measured on a subjective continutm, that is built on the perception ofindisiduals based on each

indisidual's fcclings about their freedom to raise concerns to members of plant management. The effectiveness

, of the Safety Conscious Work Emironment deteriorates when barriers inhibit an individual's ability to raise

concems to their management. Accordingly, to detemtine the quality of the Safety Conscious Work

Emironment at Zion Station the attributes of the existing emironment must be assessed (to determine the degree to which attributts of a Safety Conscious Wark Environment exist), and the degree to which barriers to a Safety Conscious Work Emironment exist at Zion Station must be determined.

l Attributes of a Safety Conscious Work Emironment

} 1. A site management attitude that promotes employee involvement awl confidence in raising and resolving 1

concerns;

11. a clearly communicated management policy that safety has the utmost priority, overriding, if necessary, the demands of production and project schedules; i 111. a strong, independent quality assurance organization and program; IV. a training program that encourages a positive attitude toward safety; j V. _ a safety ethic at all levels characterized by an inherently questioning attitude, attention to detail, i prevention of complacency, a commitment to excellence, and personnel accountability in safety matters; i

VI. self assessment activities are used to measure, identify and improve the organization's perfornnnce;

! Vll. management responds to problems, issues and concerns without defensiveness; 1

] Vill. an emironment is created that allows employees to actively contribute ideas that impact the success of j the Station;

._ IX. accurate root cause analysis, timely and thorough corrective action, and consistent verification of

corrective action efTectiveness is conducted to ensure problems are resolved;

X. an effective corrective action process that results in timely resolution and closure of concerns; i

) XI. Communichtion of the resolution of concerns is consistently prmided to involved parties; and X11. the Employee Concerns Program (ECP) has sufficient resources, independence, and authority to resolve issues.

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,i IndicMiens of a Potential Weaknenes within or Barriers to a Safett Conscious Work Emironrnent

1. Adverse fmdings by the Department of Labor (DOL) or NRC's Office ofInvestigations (01) that

] conclude discrimination has occurred against employees fer engaging in protected actisity;

11. a specific finding by the DOL or 01 that a hostile work emironment exists for an employec;'

y

111. a significant increase in the rate (or a sustained high number) of complaints to the NRC that plant j cmployees are being subjected to harassment and intimidation;

. IV. a significant increase in the rate (or a sustained high number) of technical allegations made to the NRC, j particularly i%ccompanied by a low usage or decrease in use of the ECP; and - 4 l

j V. other indications that the ECP or other programs for identifying and resolving problems are ineffective, e.g ,

A. delays or absence of feedback for concerns raised to ECP or through the site's corrective actions process; 3 B. breaches of confidentiality for concems raised to ECP; C. lack of effective evaluation, follow up, or corrective action for concerns raised through the j site's corrective action, process, to the ECP or to the site Quality Assurance (QA, or

! SQV/QSA) organization; i

j D. overall site ineffectiveness in identifying and resolving safety issues; j E. occurrence of repetitive or willful violations; F. site emphasis on cost-cutting measures at the expense of safety considerations; and/or G. poor communication mechanisms within or among site / corporate groups, l

it is strongly recommended that during the course ofinteniews or surveys determining the degree to which the

! attributes of and barriers to a Safety Conscious Work Emironment exist, that those surveys or inteniews  ;

i measure both the attributes and potential weaknesses or barriers at the same time, rather than separt:cly. The l goal of balanced measurement is to avoid biasing a result or appearing to predispose the person being surv:yed

or inteniewed. To the degree available, existing processes that provide some degree of objective evidence to

! support conclusions should be sampled. It is not only important that the current condition of programs are checked, but it is also important to check, where shortcomings are identified, whether improvement programs or

, - changes are undenvay that resolve the conditions that appear deficient.

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i-f A hostile work emironment is an attitude toward a worker that creates an emironment so severe and penasive that no one should have to take it.

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