ML20247M717
| ML20247M717 | |
| Person / Time | |
|---|---|
| Issue date: | 07/06/1989 |
| From: | NRC COMMISSION (OCM) |
| To: | |
| References | |
| REF-10CFR9.7 NUDOCS 8908020201 | |
| Download: ML20247M717 (105) | |
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'Y UNITED STATES OF AMERICA NUCLEAR REGULATORY COMMIS SION Tf(16l BRIEFING ON AGENCY HUMAN FACTORS INITIATIVES LOCatiOD: ROCKVILLE, MARYLAND b Dat6: JULY 6, 1989 72 PAGES haQ63l NEALR.GROSSANDC0.,INC.
COURT REPORTERS AND TRANSCRIBERS 1323 Rhode Island Avenue, Northwest Washington, D.C. 20005 (202) 234-4433
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- DISCLAIMER This is an unofficial transcript of a meeting of the United States Nuclear Regulatory Commission held on Julv 6, 1989, in the Commission's office at One White Flint North, Rockville, Maryland. The meeting was open to public attendance and observation. This transcript has not been reviewed, corrected or edited, and it may Icontain inaccuracies.
The transcript is intended solely for general 4
]informationalpurposes. As provided.by 10 CFR 9.103, it is not part of the formal or informal record of decision of the matters discussed. Expressions of opinion in this transcript do not necessarily reflect final determination I
or bd. Aef s . No pleading or other paper may be filed with the Commission in any proceeding as the result of, or addressed to, any statement or argument contained herein, except as the Commission may authorize.
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BRIEFING ON !
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{ AGFNCY HUMAN FACTORS INITIATIVES !
h I u + + + + 1 JtiLY 6, 1989 f i
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~tr toiefing was held at the Nuclear
'j vfe;1.'-ry Corrission, One White Flint North, t h P v: +, ' l l r- Mn vyJ alid , at 10:00 a.m., KENNETH M. CARR, g rh,;$ man, pr+.si M ng.
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ll TENTETM M. CARR, Chairman of the Commission
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EENNETH C. ROCEPS, Member of the Commission JAMEF R. CURTISS, Member of the Commission i
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1 ALSO PRESENI:
2 SAMUEL J. CHILK, Secretary 3 WILLIAM C. PARLER, General Counsel 4 FRANK COFFMAN 5 EUGENE TRAGER 6 DENNIS SERIG 7 JACK ROE 8 THOMAS E. MURLEY 9 JAMES TAYLOR l
l 10 ! ERIC S. BECIDORD 11 , BRIAN SHERON I2 ; EDWARD L. JORDAN 13 THOMAS NOVAK l
14 ROBERT BERNERO l
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(10:00 a.m.)
~t CHATEMAN CARR: Good morning, ladies and 4
j gentlemen. Commissioner Roberts will not be with us Ci to 3ay.
I I
6 The purpose of today's meeting is for the l
7 NRC staff to brief the Commission on the status of the I d
?h A c cm e y ' r- human factors initiatives. The Commission 0
4 l' war last briefed on the subject of human factors "o a e t :. v $ t i e s on May 2st, 1988 and subsequently on
- " October 13th, 1988. received responses to a number of 1? qun t 1ons which had been raised at that briefing. -
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copies of the slide presentation should be T
14 ava52ab2e at the entrance to the meeting roori.
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. Do ny fellow Commissioners have any opening if comments?
b (Ne response.)
17 3P Mr. Tay3cr, you may proceed.
t 19 l MR. TAYLOR: Good morning, sir. This 20 ,
briefing today is an integrated briefing reaching i
21 across all of the major program offices. And they 2? are represented here and will participate in the 23 briefing.
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24 ! It is, I think, important to note that the )
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1 25 staff worked collectivr.:1y across offices to pull the '
l NEAL R. GROSS COURT REPQRTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVENUE. N W
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.- i 1 ll various pieces of the human factors initiative and n
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v ra k together in its paper to you. The briefing today 4 i
? ,; vii' span across the program offices. !
u i 4 h Beginning, and in the lead role, was the I
il 5 he Office of Research. And I will ask Mr. Beckjord to ,
i 6i corrence the detailed briefing. !
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7 MP. BECKJORD: Thank you, Mr. Chairman. !
E Human performance contributes to about half l i
o # the significant events at nuclear power plants and l h l 10
- a larger prreentage at non-reactor facilities. An i
l' understanding of the factors that affect human 22 pt - f o r miume can focus regulatory attention and guide
.- 13 4 regulatory actions pertaining to licensee personnel.
i, 14 In ordcr to understand personnel error, more
-r reu arch is needed to characterize and measure human 1F vapabiJities and 3imi tations. The Human Factors 17 li Fegulatory Research Program provides the framework for i
Je th i s r c- s e ar ch into the many factors that shape human )
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- 19 l performance, such as thinking processes, training, ,
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J 20 ! qua3if$ cations, organization, supervision, procedures, 21 performance aids, and the relationship between people t
22 and the systems.
23 The human factors research supports 1
24 p r r m ' t
- ory deci si ons affecting operators, maintenance 0
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?E j pt
- anny : technicians, and managers within the l' NEAL R. GROSS i
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- nuclear industry and incorporates human reliability 3
analysis into probablistic risk assessments.
I think'that this program is a good response 3
to the various user needs that have been defined to 4
the Research Office, and I am enthusiastic about the 5
-program.
'6 Dr. Sheron will begin the presentation on 7
the program details.
8 COMMISSIONER ROGERS: If I could just ask.
9 I don't want to derail anything. This 50 percent 10 i figure of human factors, being responsible for that 11 I i kind of a percentage of incidence, without elaborating-12 on the point, certainly, right now, I wonder if i 13 someplace along the line of your presentation you 14 l could addres" this question of just where one draws 15 the line as to what you call a human factors-related 16 l event and not.
17 j l If you look deeper and deeper and deeper 18 l
l into the process, you can always find a person 19 l I someplace in there. How comfortable do we feel with 20 i i
making some kind of a separation into a human factors 21 1 l'
root cause versus in a plant event of some sort versus 22 a technical unreliability, which ultimately, if you g ; trace it back, might come to the designer of the ,
equipment in the first place? So we know there is 25 NEAL R. GROSS COURT REPORTERS AND TRANSCRIBER 5 1323 RHODE ISLAND AVENUE, N W.
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.6 this fuzziness in the definition.
1 I wonder if someplace along the line, you
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L, could just'say what your feelings are about.that.
3 MR. BECKJORD: Well, I use the word 4
" contributed," that the human error contributes to it 5
because when you_look into incidence, you find that it 6
is generally quite a mixture of human factors and 7
technical faults that occur in this system. So I' 8
agree with your point.
9 COMMISSIONER ROGERS: Well, this l
10 l' distinction, I wonder if it is purely an academic one, i
11 the concern, or whether there really is something we 1 12 L., ought to understand a little bit better about where to i 13 !
draw the line between a root cause being the human 14 f factors-related cause and something else.
i 15 f MR. BECKJORD: Yes, we Will.
16 l
l COMMISSIONER ROGERS: Okay.
17 i
! DR. SHERON: Could I have the first slide, 18 !
1 l please? The first one here just tells basically the 19 l I content of the briefing. We will tell you a little
- background again, the objectives of the programs and 21 l
! initiatives, and then we will give you an update on the various programs in the program offices and a 23 i i
, g quick overview of our first revision to the Human 5
Factors Research Program Plan.
25 NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS O23 RHODE 15 LAND AVENUE, N.W.
7
. Next slide, please. If you. recall, in May
,i-of '88, last year, about'a year ago, we submitted our 2
first Human Factors Research Program Plan, which was 3
4 In .Tuly of that same year, we received a
- staff requirements memo directing us to submit an
(: .g information paper on seven specific items, to update 7
our initiatives and to define issues addressed by the 8
Research Program.
9 We responda,2 in October of '88. We provided 10 a Commission paper which answered the seven specific 11 items, and we acknowledged our plans to update our 12 I Research Program, which is the initiatives and issues l 1 13 l ,
that were mentioned.
i
- i. 14 We were working with the ACRS all along in 15 developing this program. In January of '89, after we 16 l l
had completed our first draft of .tevision 1 to the 17 l
l research plan, we met with the ACRS Subcommittee on 18 !
! Human Factors and reviewed the draft research plan.
19 ! l This is chaired by Dr. Remick.
20 Then in February of '89, the EDO directed 21 l the staff to expand the scope of the proposed 22 Commission paper so not only did it provide you with 24 ,
an UPd ate of the Research Program, but provided you h i 25 with an update of the Agency-wide programs in the area NEAL R. GROSS COURT REPORTERS AND TRAN$CRIBERS 1323 RHODI l$ LAND AVENUE, N W.
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I 10 of human factors. i e I l i
j The ACRS also had made this recommendation. f i
1 i t And in April of 8 9 , we met again with the j! l [
l 4U Subcommittee on the Agency-wide programs. This was l ll !
5 . not just research, but NR2, A50D, and NMSS. We met !
l c f with the Subcommittee in Apri3. l l
7 In May.we gave a presentation to the full l i)l+Cormittee on these programs. On May the 9th we I
F[ !
9 I received a letter from the ACRS, which I am sure you havr al] seen. I think the key words in that letter 50 [
- j. were, "We recor nend proceeding with the proposed Human 72 i F6c* o: : Ec r-earch Program and initi atives . "
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. ji In June of '89 we sent to you the NRC human i e b
~4 h ft"*ern progrars and initiatives, which contained n l 7F Frv 1 of the human factors research plan. That was 16 '
in F.FCV-P9 ~E2.
1
Quickly, the objectives
) Next s3ide, please.
h 11 IE of.the human factors program plans in the Agency can 19 he summed up in the fo13owing four bullets. They are:
20 4 to assure that the human factors issues affecting I
i 2* safety are considered appropriately in all regulatory 22 activities; to provide an adequate human factors 23 ,
research resource to erisure all user needs are met and i
24 j a base research program is performed. It is to H
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[o i l! 1. v m factors and to assure that the research progrars 1
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? 'hi* we are carrying out are properly structured and l I l i
' L rwsponsive to the user offices. ;
4 I COMMISSIONER ROGERS: Just tell us who the l l ,
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5j " users" are, how that word is defined here. j 6 i
'R. SHERON* Okay. The users are the 1 ;
7 f program offices which carry out the regulatory I
h F9 ar+.ivities. Thi s would be AEOD, NMSS, and NRR. And h
o N. Cof fm,m will be telling you a lot more about who
~D these users are and the types of research requests i
1 *! i. t4' w .- have gotten. l l
ti iT COMM7FSIONER ROCERS: How realistic is it to .
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- r- Seet all user needs?
e.
12 h DR. SHERON: Right now I think I feel very 9E g con,f or t ablo that we have put together a program that U
16 is responsive to all the requests that we have gotten
!o 17 h so far.
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I think, as we learn more in this area, i
19 j there may be more requests cc:ning. And that may be a 20 I matter of balancing the resources.
I 21 MR. TAYLOR: May I add that during the 22 course of past months, we have had numbers of meetings
? '3 with key people across the staffs to try to get that 32 focus, you know, of knowing a3wayr t.h a t only some many
?e resnurces wi13 he there to try to focus the issue. So NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE !SLAND AVENUE N W (202)234 4 433 WASHINGTON DC.20005 (202) 232-6600
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- . : in most of the cases, there has been a lot of cross-discussion with staff to focus.
L , COMMISSIONER ROGERS: Well,.the problem that
'3 .comes to mind is that'this is a relatively new 4
initiative for us. We used-to do it. Then we stopped
. 5-it. Now we.are starting again.
6 MR. TAYLOR: Right.
7 COMMISSIONER ROGERS: As this kind of 8
expertise and knowledge begins to become available, 9- .
appetites will grow.
10 ;
MR. TAYLOR: They are big already, sir.
11-
'l j COMMISSIONER ROGERS: I think eventually you 12 won't be able to meet.all of the needs. You will have i 13 to prioritize and cut it off someplace.
14 DR. SHERON: I would point out, though, that 15 I l the research that is done is not like other research 16 where it involves big experimental facilities, which 17 are very expensive and financially draining. You can 18 perform a lot of research without the big experiments" ,
19 i that go along with it. So you can get a lot more done for the dollars.
21 On the next slide, Slide 7, this is just a quick summary of the resources that are being expended {
23 q in the program offices in '89 and '90. I think it is g
i self-explanatory. As you can see, I think that the NEAL R. GROSS COURT REPORTERS AND TRANSCRIBER $
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., '. level'of effort was pretty well-stabilized in most of _.
I the' offices.
2 I.see the research budget coming up in an 1 3
accent now towards a mature program. I would also 4
point out that this is not truly reflective of-all of 5
the activities that involve human factors.
6 There are many activities that are very 7
related to human factors that go on, like the operator 8
licensing and so forth, that are not really reflected-9 here. So if you wanted to have every FTE that was, 10.
you know, actually involved in human factors, T think
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11 I these numbers would be a lot larger.
l 12 With that, what I would like to do now would ,
13
{ be to let each of'the program offices give a brief 14 .
description of their programs. I think Dr. Murley 15 wants to introduce the NRR presentation. j
-16 DR. MURLEY: Yes. Thank you, Brian. l I
17 Commissioner Rogers, it is quite true that 18 ;
much of what we do in NRR, at least, touches on human I 19 factors. It is difficult to draw the line that 20 separates it, but one could kind of arbitrarily divide 1
i the aspects of reactor safety into three parts. !
One is the design of the plant, how it is
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l l j laid out. The second is how equipment and materials behave. The third would be how it is operated, how 25 NEAL R. GROSS court REPORTERS AND TRANSCRIBER 5 1323 RHoOf ISLAND AVENUI, N W.
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. humanc actually maintt.in and operate the plant.
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? Lu. As you know, we are in the phase'now where U
1 ji v~ arn almost purely looking at the operations, how 41 plants are maintained and operated. !
9 g The design, of course, we still look for I l F. weakhesses, and we still look at operating experience j l
l, ~7 te te?) us where weaknesses are. Where we see it, we 8 ccrrect it through backfits. ;
o .
. Materials, of course, are always a problem.
"O '% m wo have programs in aging, and whatever. But, o
l' d P; mvi large, today I would say a large part of our
.%fct3 focus in on aspects of human factors. '
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,. '? j! Jack Roc is going to describe in a moment b d
- a U tb buman factors activities in NRR that support the 1
h
't g safcty mi-sion Some of them, you will see, are a
S f, we22-defined programe, like the detailed contro3 room L
41 3 '7 h design review.
H 38 l Others are more of a loose, I would call it i
19 l a " loose," collection of activities, like the n
20 l eu rgency operating procedure inspections that we did.
21 The inspections themselves were well-focused, but it 22 is not a human factors program. It is detailed.
! We also work in collaboration with AEOD. In 23 lu
?4 1 cffect, I would say we are a user, probably the
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^^ pr'-'ry ueer, of the AEOD program results.
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,- 1q And, finally, we also support research in t
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their progr m to develop insights and methods that u
h ca: hulp us in our :ti ssi on .
!l l 4 hl We have carefully reviewed this human !
5 ,b f a c t o r t.: prog t .m pl an . In fact, I have reviewed it 6 myr,e]f persona 22y And so it reflects very much the 7 !!P P office view of what should be done in the Agency. l I
F F P.0F : First I would-like to talk !
o overviev and then about EOPs as the first program. We 1
20 0 ha rwvern? Progrnw in the human factors area. l
! i 11 q The w programs a y r. primarily operationally focused.
17 y Tb , a ,, vt '1-ecnrdinated with other program offices l
17 !l an' *n regional offices. Many of these programs are 4 h 92 h s yported by the activitdes of the Office of Research.
o 9 c. O The first slide, EOPs. The objectives of h
e J r. h ni.r i rispec t i ons are: to determine if the emergency h
l '7 l ap nting procedures are technically correct; second, I
18 can they be physi cal 3y carried out in the p3 ant; 19 third, can the control room crew perform the procedure 20 properly.
21 i The inspections are focused on walk-through 22 of t h c. procedures in the plant, simulator scenarios i
23 requ ! ri ng cont ro] roors to actua33y use the EOPs and I
24 walk
- be through
' 35 Ui havr had a three-phased approach. The NEAL R. GROSS l COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVENUE. N W
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W-reason for the three-phased approach was we did not 4
know exactly what we were going to find as we went-2 through these particular inspections.
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'The first phase was 16 inspections, F 4 primarily among the 4 vendor types.
5
'The second phase was inspections of 13 Mark 6'
.1' boiling water reactors because of our interest in 7-that particular cont 6inment type and the capability of 8
venting that' containment type.
9 We are now into our third phase of 10 ,
inspections, which is the remaining reactors. Those 11 l
are to be completed by the end of fiscal year '90.
12 In the transition period between the second 1 13 phase and the third phase, we issued a document, which 14 was " Lessons Learned From the Special Inspection 15 Program of EOPs." We wanted the industry to get the 16 word out on what we found at the various inspections 17 that we conducted across the country.
16 We also issued another document that was associated with techniques of preparing flow chart-formatted EOPs, provided that as guidance and 21 l information for the industry.
In addition, this last week we held two y
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l 24 l w rkshops for the industry on emergency operating
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and NUMARC.and they were well-received by the
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g , p . industry. We believe that this inspection program has 2
- had an impact and that'the results are. enhanced i
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reac' tor safety.
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'4 COMMISSIONER ROGERS: What has happened as a 5
result of NUREG 13587- Have you'seen any changes in 6
anything? You are not through your entire inspection 7
program. So do you have sone indications that people 8
are-using --
9 MR. ROE: Early indications. And I think we q l
10 .
l will have to wait until we see the results of the I
11
. l third-phase. inspection to get the word completely out i 12 l:
- l. , l since'we just issued the document and held the
- 1. : 13 workshops.
14 f We have sort of'a slow pace of the
.15
- inspections to allow people to accommodate the changes 16 until we pick them up again.
i 17 COMMISSIONER ROGERS: Do you expect to 18 update that as you complete more inspections?
19 MR. ROE: I think that time will tell 20 whether we need to update or not, depending upon what 21 j i
we find in the future.
22 DR. MURLEY: Commissioner, I would say that g
we have learned sometning from those inspections. It
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g . our recommendations on the Mark 1 vent, some of-the
.1 things that we found when we talked-w.ith operators 2 when we looked ~at their procedure. So, in that sense, 3
it has had an impact on our thinking.
L 4 I hink it is probably a little slmler to
- diffuse out to the industry, although I have heard 6
some indications from utility managers that they have 7
a high regard for this type of inspection.
8 They think it is focusing on the right thing 9
l and, presumably from that, they are looking at the I
'10 results at least, although, like Jack said, we haven't 11 l
got any specifics we can point to.
12 l MR. ROE: The emergency operating procedures 13 also are utilized in our re-qualification inspection 14 j
because it is a tool that the control room crew has'to 15 use. So there is a continuing inspection program in 16 that facet also.
17 1 COMMISSIONER ROGERS: On this flow chart 18 format for EOPs, is there any implication there that 19 that is an NRC-preferred tool or is this just an 20 assist for those who want to develop that kind of 21 thing?
22 MR. ROE: I would say it is preferred, but i
that is only in general guidance, not a requirement.
g
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They can use whatever --
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COMMISSIONER ROGERS: There is some ,
4 l
L 1 disagreement --
o MR. ROE: Yes.
3 COMMISSIONER ROGERS: -- in the plants as to 4
which is the best assist to have. I was just 5
wondering how we stand on that, whether we feel -- I 6
mean, the implication is that it is a preferred --
7 MR. ROE: That is the implication, but they 8
do have the latitude to develop and implement them at 9
their own discretion as long as they meet the needs of 10 ,
j the operators.
11 !
COMMISSIONER ROGERS: Well, I wot' hope we l
12 i j would understand what the realities are of the 13 k'
disagreement because I think there probably are some 14 good points.
15 Neither the narrative form or the flow chart 16 l
form is perfect on its own.
17 1 MR. ROE: That's right.
18 f
! COMMISSIONER ROGERS: And so I think we 19 l should be alert to ways to improve the entire proccss.
20 MR. ROE: The Office of Research is also 21 ; (
1 i
1 supporting our longer-term efforts in the area of j 22 1
accident management, which is related to this I 23 J
particular inspection program.
24 7'
The next slide deals with our man-machine ,
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i 18 1 interface. The objective of our efforts in this area i
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?p i: tn aggressively complete the actions associated d
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' w'ith our detailed control com design reviews and the
'i i
4 safety parameter display system.
5l For our detailed control room design I
6 re, Jews, we are conducting an acce7erated audit 7 program at the remaining facilities that we have not S 'Jonked at previously. We plan to cottplete all of 9 i these audits by March of 1990.
O Research is supporting our efforts in the
.h
[ 'so?rni room area with projects on, annunciator h .
'- p i d n y s t e <- designs of advanced control rooms, expert '
D
, l' An.puter systems, local control stations, and computer 4 [
- 4 !! rFmp3nys and controls.
b
- E In the area of SPDS, we have issued a h
16 l generic letter with an enclosed NUREG report. The 17 let i er requests that licensees certify that their SPDS 3S now reets the requirements of NUREG 737, Supplement 1 19 or certify that their SPDS will fully meet the 70 requirements of NUREG 737, Supp. I and if a 2 *2 ,
certification cannot be made, describe compensatory 22 netions.
23 CHAIRMAN CARR: On that one, it seemed to me 24 H that the rosearch is ongoing in both of those areas on I. I.
S " whnt we ought to be doing. Does this mean that these N
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< ' guys are' shooting at a moving target?
'MR. ROE:
No, sir. The requirements are l 2- well-established and articulated in our NUREG report'.
3
..3 There is information that will be devel'oped as far as our research activities'that will come into the 5'
regulatory environment later, but then.we.will have to I 6 I make a decision of whether or not to back-fit those
! 7 l requirements.
8 So as far as the utilities should be looking 9
at it is they have a firm target.
10 j CHAIRMAN CARR: Well, I guess my question, 11 l then, is: Is the research worthwhile in these two 12 i areas?
- t. - 13 MR. ROE: I believe that the research is 14 worthwhile. We are going to have advanced reactors.
15 We should take into consideration wnat we can learn 16 now and when they start to develop the requirements 17 for those control rooms and start developing them.
18 l
CHAIRMAN CARR: Okay.
l 19 l.
COMMISSIONER ROGERS: Those SPDS 20 requirements, how specific are they? Do they, for 21 ,
i l' example, set a specific time, elapsed time, between ccreon refreshments?
23 -
l MR. ROE: Many of the requirements are 24 s mewhat general in nature. What we have done is: In 25 NEAL R. GROSS COURT REPORTERS AND TRANSCRIBER $
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- . . . _ - -, - wa,1vvra
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.g .
- nur reviews, we have taken'and basically bracketed
'a tiva, I would say, in this particular instance.
' . ;U In the NUREG report, we have reported to the il 4O industry which screen update times we have found ii 0 acceptable and which ones we have found unacceptable ;
l l 6_ because.they rea))y don't meet the intent of the basic l l
7 requirement. The basic requirement is pretty much l l
1 F i quf.7itative and not quantitative.
o . COMMISSIONER ROGERS: Ts there a range of in tires, depending upon the parameters that are being 11 ,
displayed? For example, in some of the plants I i
1? "
v5r,'tec, -- at 3 east one I know of -- there seemed to il be n indication that there was as long as 5 to 10
, n
- 4 ! mi nu t e r- between screen refreshments for some i
1r l peu an c t ers
- . f 9 Do we have anything that says that that is 17 l neceptable or unacceptable?
l i 1? l MR. ROT- Yes, we de that wou3d address I
I 19 l that. L'h a t T recall in our previous reviews is that l
20 l is probab3y too long. That wou3d not meet the basic 21 requirement for even a logical interpretation of what 22 that requirement is directed at.
23 ,
COMMISSIONER ROGERS: Do we check for that?
N Arc we checking these?
, ii 25 L VR. ROE: That will be part of their
! NEAL R. GROSS COURT REPORTERS AND TRANSCRIBER $ 1 1323 RHODE ISLAND AVENUE, N W. l (202) 734.u23 WASHINGTON.DC 2tK105 (202) 03? ifdX) l l
y 9.
" 21-V ,
l certification. They will take a look at that and 4
1 e respond. If theirs falls within the brackets of what MfM- 2' ji!; we have previously approved and found reasonably met 7 l 3
those requirements, then they will be able to certify.
s If it is outside, then they will have to bring that to 5
our attention.
l 6
COMMISSIONER, ROGERS: Okay.
7 MR. ROE: The staff plans to finish our 0
.l'reviewsandclosetheseoutforthoseplantsthat i
9 >
certified their SPDS's meet or will-meet the 10' !
l requirements of NUREG 737, Supp. 1.
I 11
- As of today, we understand we have received 12 l
, ! two responses to that part.cular generic letter and d 13 expect a large amour, of responses in the very near I
14 l future.
15 l
! The next area we would like to discuss is 16
{
{ training and qualification. As tne Commission is 17 aware, the staff has worked closely with INPO and 18 i NUMARC on this particular area of training and 19 l l qualification, with the Nuclear Training Academy, and 20 l with program accreditation over time.
g We are now evolving our focus to include IMP l ementation of training programs at facilities, 23 j
I along with the accreditation of the programs and f 24
+
25 i continued work with NUMARC and INPO.
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- i. We have developed and pilot-tested a new f- .
inspection procedure for plant training programs. We 2
pilot-tested it as part of a special team inspection, 3
which was conducted at Nine Mile Point. And our first 4-inspection was conducted at Turkey Point after the 5
facility was found unsatisfactory in the operator 6
recall area.
i 7-We had planned to conduct an inspection, and 8
Turkey Point's performance provided us a reason to 9
pick that particular facility. We plan on continuing
. 10 l-l these inspections and conducting several each year.
11 l-l Research is also supporting us in this area 12 by developing criteria and methods to assist in the
- 13 measurement of training effectiveness, which is a very 14 l difficult task.
15 f Next, I would like. .) talk just briefly 16 about operator examinations and licensing. The 17 ;
l Commission has received several briefings from the 18 ;
i staff recently about this particular subject.
i 19 As you know, the objective of our program s
here is to examine operators using content-valid, i
- operationally focused activities and methods. Our 22 g initiatives in this particular area are on target and a
! we feel are very successful.
24 Cdr re-qual Program is running rather well.
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83 The second pilot test of our fundamentals examination.
I was conduct'ed on June 28th, and we are planning on 3
2 fully implementing the program in October.= We are-3 currently evaluating the results of that particular examination.
Also, we have implemented a national exam 6
schedule that. generally provides.for two site visits 7
for each site per year from now into the future. This 8-approach will provide stability for our and the 9
facilities' schedules and will allow us to use our 10 l
certified examiners in a more effective manner, one 11 l' that will be more stable and where we would have exams 12
,. given at various times in the year that were pretty
(' 13 much driven by the utilities.
14 This.will straighten out and provide a lot 15 of stability to both their process and our process and 16 allow us to give re-qual exams and initial exams at 17 l the same period of time.
18 CHAIRMAN CARR: Does that meet with general 19 l utility acceptance?
20 l '
MR. ROE: Yes. All they needed was a little 21 !
bit of negotiating room on the date and also the capability to make changes if something happened with respect to their operations.
t.
We gave them sufficient time. Now they find 25 NEAL R. GROSS court RfpoRTER$ AND TRANSCRIBER $
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.: =i it quite satisfactory, and they'are looking forward to A
it. i
?
In the area of. organization and management, 3
in this area, we support the team inspections i
conducted by NRR and the diagnostic evaluations by 5
AEOD. We put a large amount of effort into that.
l I would like to go on to the next area, 7
which.is additional programs incorporating human 8'
performance data. .First of all, in the maintenance 9
area in the inspections, we in our inspection at the 1 10 l
- j. site use.a review of the human performance evaluation 11 !
l system developed by INPO and implemented by the 12 utilities to determine their approach towards human
( . 13 )
factors.
l We also look at human factors in the 15 l
- engineering support area, how they are actually 16 carrying out the support to the overall design
!?
implementation and operation of the facility.
l- 18 Also, we have human factors branch members 19
! who, upon occasion, will participate in a maintenance 20 i team inspection.
21 In the SALP area, we have recently revised the SALP manual chapter. Now the evaluation criteria
~
l g
! are more specific to incorporate human performance issues.
25 NEAL R. GROSS COURT REPORTERS AND TRANSCRIBER $
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l 25 1 Uith respect to the senior management .
^
l
- m. M i r, g , vc have provided a great deal of support to :
i i
ih ti t particular process from the staff from all the j
. i' 4
h aspects of human factors endeavors, whether it be from ii E dt a
' ep:rator licensing, emergency operating procedures
'l f I o vid u a t i on s , SPDF.
7 Wherever we have information that is
! i 8 rF . mt to the performance of a facility, we provide C *h
- fn the senior management process.
r, 7:r " t I wou]d Jike to speak about our efforts
- ~
L in ti-ur at :eliability area. The objective of our 3? ,
t-- gre 1
' +e understi4nd the sensitivity of risk to ;
, *! "i q how error rates.
13 L E N v. concluded part of our program on b
-t tb particular subject, and we recently published a 1 f. ve q j nt r res t i us ?!URFG on risk sensitivity to human 17 ' erve+ ra'cr Uc are planning to incorporate the 38 g Jeuons we have learned from that particular project 19 l into our inspection program.
20 The Office of Research is continuing t6 t
l 21 suppc:t us in this particular area.
2? 1.a s t J y , I wou2d like to talk about a future 23 in *
' c r- which is root cause ane.'ysis l of events
?z a in" . n~ homnn factors. The objective of this ll e
?; '
pa -uiar f':ture initiative is to coordinate with NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVENUE, N W (202) 234.4433 WASHINGTON. O C. 20005 (202) 232 6600
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- 26
- AEOD and Research and our regions: to look at the development of an effective method to assess the root cause of human errors; secondly, to obtain detailed 3
event-related human performance information; and then 4
to evaluate the effectiveness of the LER system in l 5
providing us the information from the industry.
6 Research is supporting us fully in this 7-particular effort.
8 These are highlights that I have brought out 9
non the programs conducted by NRR. There are other 10 aspects of our program that we have not highlighted, 11 l
but to give you the highlights, we will conclude at 12 this particular point.
? 13 MR. TRAGER: The AEOD programs involving 14 l human factors are integrated into the AEOD programs.
15 We feel we have very close communications with NRR, 16 Research, NMSS in this integration. We both obtain 17 support and provide support in human factors reviews.
18 i The six program areas that I think most 19 l nearly typify the level of human factors support are listed on the slide. The routine operational event 21 assessment; for instance, case studies on motor operated valves and the service water system, some of l' their dominant findings were regarding training and 25 procedures, human factors-driven aspects.
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' The performance indicator program, we
-briefed the Commission earlier this year on a 2
L developed, validated performance indicator based on 3
licensee event reports that extract cause codes and 4
corrective actions from that data and is available for 5
use by the Agency.
6 Those performance indicators were developed 7
with Research. support.
8 Incident investigations program, that
- 9-l ' program, AEOD provides the oversight, the staffing 1
10 ~
f through the other offices. We provide an annual 11 !
j training program.
12 i l That program emphasizes the human k 13 contribution to help the investigators if they were 14 I called to do an investigation to look deeply into the 15 root cause of that particular event in terms of the 16 human contribution.
17 The diagnostic evaluation program, as was 18 l l mentioned earlier, utilizes NRR and Research personnel in the human factors area of management training. And 20 so we use the Agency's resources, I think, very well 21 j i
in the diagnostic program. Certainly the findings include management aspects of training, personnel g errors.
?
4' The non-reactor assessment program, the 25 NEAL. R. GROSS COURT REPORTER $ AND TRANSCRIBERS 1323 RHODE f5 LAND AVENUE, N.W.
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- staff is developing, with contractor assistance and with NMSS coordination, a training video on medical
-2 naministrations, the personnel errors side of medical 3
misadministration.
-4 A'nd, finally, through the Technical Training-5 Center in Chattanoc7a, a very important aspect of that 6
is understanding for the inspectors and for the 7
reviewers the role that the operator plays, that the 8
operating personnel play in human errors that they may 9
. commit, their response to events, to give an 10 j appreciation through our inspection programs and 11 1 through our review programs for those potential human 12 I errors..
13
$' So, in summary, we feel that the program is 14 well-integrated with the other offices, and we both 15 receive support and provide output related to human 16 factors.
17 l CHAIRMAN CARR: What is the status of that l 18 training video for non-reactor assessment?
19 MR. TRAGER: We have a contract with Oak l 20
- Ridge to produce it. I believe it is with Oak Ridge.
i Is that right?
- 22 1
MR. NOVAK: Yes. Tom Novak of the staff, sir. Yes, the contract is in place with Oak g
Ridge-associated universities. We have formed a 25 NEAL R. GROSS CoUPT REPORTER $ AND TRANSCRIBER $
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- technical committee that will provide the input. It j 1
is moving along. We clearly expect to have it by the 9
fall of this yu'r.
3 CHAIRMAN CARR: Thank you.
4 MR. SERIG: NMSS' interests encompass a 5
broad spectrum of dctivities related to the production 6
and use of nuclear material. Potential impact of 7
human error on public health and safety is common to 8
all of those activities.
9 In response, Bullet 1 indicates that NMSS 10 ,
j has developed a human factors program with two key 11 l functions. One is the direct application of existing 12 human factors technology now. The second is the 4 13 i l identification of needed research to improve 14 !
applications tomorrow.
l 15 I would like to illustrate how these two 16 !
j functions are being conducted through discussion of 17 l several priority areas. In the area of medical use, 18 l I
j shown in Bullet 2, there has been a direct application 19 l 20 l of human factors effort.
l Those applications have involved the participation and development of contractor surveys to survey training and medical industry, participation in 23 ,
! l l the review of the " Quality Assurance Rule and 24 l ? .
Regulatory Guide," which the Commission now has just 25 HEAL R. GROSS COURT REPORTERS AND TRANSCRIBER 5 l 1323 RHODE ISLAND AVINUE H.W.
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- 30 4 : reviewed.
I In addition,_we have had early and extensive i ..
l 2
participation in regular and special inspections. /
3 One is That participation has had a mix of purposes.
4 to provide assistance where possible; in particular, 5
to show the errors are not random, that they have a 6
cause, and that, once that cause is determined, a 7
proper cure can be developed.
8 The second is fact-finding. As a result of I
9 several inspections, human factors notes have been 10 prepared, and those have been distributed to the I
11 j office, to the region, and to licensees as 12 i f, l appropriate.
$ 13 l There have also been a number of briefings l
L 14 of meetings. They have included activities with the 15
! Food and Drug Administration, regional workshops I
16 involving medical licensees and other groups. These l
17 activities serve to provide information, again, to 18 l NMSS and to develop awareness in others.
19 l Now, we feel it is particularly important to 20 develop early awareness in others of human factors l problems because the solutions to these problems may be beyond NRC purview in some cases. We are trying to
! promote willingness to contribute to the solutions to
. 24 -
those problems now rather than later.
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4 Direct application activities, I have just I discussed.- I.have shown that the technical basis for 2
dealing with human errors in medical use is 3
o inadequate.
4 As a result, we have developed several 5
o research needs. Some of these are based on 6
interactions with AEOD and have fed into user need 7
statements to the Office of Research. of particular 8
interest are user needs developed in the area of 9
teletherapy, brachytherapy, and use of computers in l 10 1
- treatment planning.
11 The first objective of each of these 12 projects is te identify the factors contributing to
$' 13 human errors leading to medical misadministration, to l
14 l prioritize problems those factors cause in terms of 15 I j their safety impact of their resolution, and then to 16 identify and evaluate alternative resolutions for 17 those problems.
18 A key example of a problem area is the use 19 of high-dose rate after loading brachytherapy devices, where humans are being subjected, either internally or 21 q l
j on their skin, to high-dose sources being used for very short durations and in very few fractions. The consequence of error is fairly high. It appears at this time that there is room for improvement in that HEAL R. GROSS CoWRT REPORTERS AND TRANSCRIBER 5 1323 WHoDE ISLAND AVENUE, N.W. i 1
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\ f arra.
1
< D ,
Another priority area is industrial :
.i d radiography. Direct application has involved d
4 participation in review of the equipment rule, which 5
]i was recently forwarded to the Commission, and l
i 6 participation in the discussions involving 7 certification of radiographer.
8 l As in the medical use area, direct l l
9 application has shown the technical basis to be slim.
10 l And so we have developed a user need statement for
.1' ii imman factore evaluation in industrial radiography.
i
.i i
- T At this time, the development of the 13 ll staterent of work is in process, as it is for
% b 34 H teletherapy and the medical area.
1" Othcr areas are getting attention as time 16 and resources p9rmit.
1 ~'
DR. COFFMAN: My purpose is to briefly
'l P summarsze the Human Factors Regulatory Research 19 Program. The purpose of the research itself is to 20 provide the technological bases for regulation.
t
~
21 On Page 19, you will see that it is 2? characterized by a multi-discip31 nary endeavor. It
! ?? relies heavily on the bahavioral sciences and involves 24 ,, variety of engineering disciplines. !
L
?5 l The program is mainly to support regulatory t
NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVENUE, N W
33
. actions and the regulatory programs and initiatives
. listed in the SECY paper 89-183. From these 2
regulatory programs and initiatives come the user 3
needs.
4 There is also some base research, which is 5
to anticipate human performance issues. I will describe that briefly.
7 on the next page, 20, to support the 8
regulation, regulatory user needs are identified.
9 i i These come out of the regulatory offices, where they 10
- identify their user needs under different conditions
11 l l one, where the technical basis for regulation or 12 I l regulatory action is not mature or needs confirmation.
e' 13 And then another is where the actual nature of the 14
, potential safety problem is not well-defined.
15 On the next page, 21, the development of the 16 i f user needs itself is an important and an interactive 17 process. Following the April '87 reorganization, the 18 l user offices were busy organizing their own programs, 19 l and little effort had been.given to the definition of 20 user needs. So Research actively sought human factors 21 i
. research needs from the user offices.
22 [
i Research is now currently working in the
- human factors area on a total of 11 user need memorandi
- . from the 4 of fices. Out of these 11 NEAl. R. GROSS COURT REPORTER $ AND TRAN5CRIBER5 1323 RHODE ISLAND AVENUE, N.W.
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. memoranda, there are 35 specific user needs, which I I will- summarize briefly in just a moment.
2 The Human Factors Regulatory Research 3
Program is reaching maturity, as Dr. Sheron had 4
mentioned. ,
j 5
Some nore comments aboat'the development of 6
user needs on Page 22. The Research Program is 7
interactive, and the projects are'. revised as the 8
regulatory needs change or evolve with the regulatory 9
process.
l 10 i l- Formally, we raeet with users approximately 11 !
quarterly at the division director level. And then 12 formally we have meetings at the branch chief level
.i 13 more frequently. Plus, there is this backdrop of 14 frequent interactions, discussions, and phone calls.
15 At the staff level, it is almost daily 16 interaction. And, on some occasions, there are 17 interactions more than once a day.
18 CHAIRMAN CARR: I guess while we are at this 19 point, I need to '.sk: Who is responsible for 20 i coordination and monitoring to ensure we are consistent and accurate in our outcome?
22 I aean, we have spread this across a lot of ground, t.s you have said. There are the 35 projects e
g ing n, as y u say, alm st daily. So where does it j 25 NEAL R. GROSS COURT REPORTER $ AND TRAN$CRISER$
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- ' I m, n together? Who is making sure we are all marching h
^
ir> the same direction? '
d i
h DR.'COFFMAN: Well, it comes together at the 4 different levels, beginning with the staff up, but it comes together more formally when, at the branch ll 6 Jave], we have what are ca31cd "research project 7 review group" meetings. There are two research n
II S ;; project review groups within the branch. j h
98 We call those meetings to review specific 1C projects that are at the stage where they need to be 1" revi ewed at where there is some question about the i? neyt stet ta be taken on the project.
I' U Formal meeting minutes are issued on those 1? g nertings. They are issued to the division level 1r q ..
review group, steering group, which is also an
'l 6 interoffice steering group.
17 li That is probably the most effective way of I.
i 38 I; doing it. We have other layers of review for L
I 19 coordination and consistency.
l 20 l MR. TAYLOR: I believe that we would want to i
21 at least each year, and certainly as the results are 2? attained fro.T research, review it across the office 23 directer level to be sure, r
I 24 d I think your question is, really: Are we N
l 7' getting a payoff?
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.36
-4 .
CHAIRMAN CARR: I want to be sure I know who '
1 is following.the plan and making sure the plan is being carried out and the budget.is going to meet the 3
plan.
4 I am looking for the guy in charge, I guess, 5
instead of all these different offices.
6 MR. TAYLOR: That-is the EDO.. It took work 7
from the EDO's office to help pull this together. And 8
I think the effort paid off.
9 .
CHAIRMAN CARR: That is all I am encouraging l
10 {
you to-do, is to tighten the noose a little bit, 11
, because --
12 MR. TAYLOR: We can do that, t 13 CHAIRMAN CARR: Okay.
14 l COMMISSIONER ROGERS: How about just 15 shortening the chains?
16 l l CHAIRMAN CARR: Chains?
17 !
! DR. COFFMAN: If I could go to Page 23, I 18 j l will mention that, alongside the user need research,.
19 !
I j there is some base research that is done, and this is 20 l human factors research in areas where there is no i
, 21 l-g explicit or documented user need.
This base research is dene to provide an
! 23 ,
1 I g ,
information base, and it is in anticipation of future l ', !
25 regulatory needs.
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1 COMMISSTO!!EF ROGERS: Could you give us some
- i 2 'y uanpl.w there, just a littie bit, of how decisions i
r.
3 jj ge made w i th respect to whether you are going to do a
\
s I j 4 particular )<ind of hasc research for which there isn't l
]l l
5l an explicit usr? need identified?
6 DF. COFFMAli: Well, we have two ways. One 7 is that t h rs r e are others who advise us on the research ,
l 8 t im ! Is needed, i ncluding ?!ationa] Academy of l t
4 Fciences, and we have a fluclear Safety Research Review l
0 it 10 g C ^- : t t r < , and the ACRS. And so some of the base u
11 -searcb 14 developed from that source.
H ~
1^ '" U - in addition, through staff n
s
, 13 hy i r. ' a r a c t i n n son t ires we are able to anticipate t, c 14 tt <r -ch needs that are on their way, but not yet t-i 15 fc4 - ' ,~d and sent over to us. So that is the other i.
'i 5 P sorre: n' tb<+ 1 o f ormat i on .
ll 17 ll CHATEMai: CAFR: Uhat percentage of the i
IS ,
budget is base research?
l 39 I DF. COFFMAN: At this time it is about in i
t 20 the ?O percent category.
l 21 An cxarple of base research in this 22 anticipation area is this operator vigilance, which is Si wo r ); that was initiated in October of '88 at the h
74 lj Tns t ' t' . for circadian Physiology.
hi k ? r. *h r therc is, in addition, another type of NEAL R. GROSS COURT REPORTERS AND TRANSCR$ERS 1323 RHODE ISLAND AVENUE, N W (202) 234-4433 WASHINGTON. O C 20005 (202).'32 4600
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! 38 l
1 lu90 research, where we are 'looking to broaden our g ba w in selected areas. An example is the work we are a
3 doing as joint funders of liational Academy of Lq 4h Sciences' Human Factors Committee coro research. That 5h work was initiated in December of '88.
f CHAIRMAIJ CARR: I would also encourage you 7 to make sure you look and see if 20 percent is the F .right amount for base research when we are organized 1
1 9 i to a problem-solving area here.
i 10 h DR. COFFMAf!: Yes, sir.
11 i MR. JORD ATJ: I would add an example of where s,
h in tu base research has been beneficial. The operator o
, 11 h vigilanco review provided some useful information to
- 1. 4 un fr the Operations Center, which is a 24-hour 79 p station SF u We run 32-hour shifts there. And so we were b
17 { examining the shift time and duration with respect to i
18 that research, to see if there were improvements we 19 could make in our arrangement. So it is very 20 beneficial.
21 .- CHAIRMAll CARR: Well, I am not against i
22 research as long as it is proportionate to the rest of
?3 the work we have to do.
24 COMMISSIOllER ROGERS: Well, I am just a
?E Jittle pu::: led here , too, as to how you finally arrive NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVENUE, N W WASHINGTON, D C. 20005 (202) 234-4433 (202) 232M w_____-_.----_-__- ._
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! 39 l i o a* what ynn are going to do, because it may be at this h
^
,tage t h a +. you aro able to do whatever is suggested, t
}
1h w *hin somcthing like 20 percent. l ,
a s t
4 i But how do you really get at how much of l
5l your resources you are going to direct to base i
6 rescarch that, at the moment, does not have an 7 explicit user need? !
i !
< l P Unw, 7 am not saying everything has to be l!
O tha+, but I wonder what the process is that, somehow in er othe- at least assists with users eventually using 7" y that or potential users using that. I 1? You know, if someone has not asked for it .
, i! or? t is done, they may just forget about it. And it t L 14 ;4 nits en th( nhel f , even though it might be useful to i
"C ther if .
I wonder if you shouldn't have some H
17 p mechanism of the potential users being alerted to the 1P status of this base research for their own purposes in i
19 N the future 20 j DR. COFFMAN: If I might address the process l
01 whereby we pick up base research, the recommendations 22 -- anybe the best thing to do is pick an exam 1,le. The 23 th t i o n a l Acadery of Sciences, you recall, last year i
?4 ! recor-nnded 4a differt,.- areas to do research in. We !
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40 n\ne.
I Subsequently, over the year, ve have, in
- 2. looking into their recommendations, rethinking where 3
it might fit into the. program,Lhow it might support 4
user needs or broaden the base'for supporting the user 5
needs, as we can and as the funding can be justified, 6
we then fold that into the overall program; where, as 7
this point, I think we are pretty much addressing all 8
but two of the NAS recommendations.
9 So it is somewhat of an evolutionary l
10 !
process, where we have to find the right place that it 11 ^
is, in fact, coherent to the program in the 12 reliability sense, that it contributes to the program.
I- 13 But it is an evolutionary process.
14 MR. BECKJORD: This matter of the base l
15 research, the number that Frank gave you of 20 percent 16 is not just a number that comes out of human factors.
17 I think, looking at the rest of our programs, it is in 18 the 20 to 25 percent range that we spend on base research.
20 I don't know of any theoretical argument 21 that says that that is what it ought to be. But, based on experience, that has worked out pretty well, long experience, that a lot of the things that come e
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< perhaps not immediately,'but after a couple of years.
1 And so I think that is just a general rule 2
of thumb that we are applying now. We want to 3
maintain the basic work at about that level. It has 4-
. worked in the'past.
5 CHAIRMAN CARR: My number is usually 10 6
l percent in that same area, but we have worked on 7
different things, obviously.
8 DR. SHERON: I would just add that the L 9
- philosophy that we tend to follow is that we develop 10 !
t research programs that first meet the users' needs.
11 If there is a user need, we make sure that the 12 l research needed to address that is funded at the right l' i '
13 level and that the users are satisfied that that is 14 i
! the right program.
15 Then we turn our attention to the base 16 program. As Eric said, it seems to historically have 17 come out around that level. When we get additional 18 needs; for example, NRR just sent us one on 19 interfacing system LOCA. That research we estimate 20 now is going to be about $1 million in various 21 disciplines.
So what we are doing is we are again shifting and moving money and the like so we can meet that user need.
25 NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVENUE. N W.
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. CHAIRMAN CARR: I.think'that.is the right.
'I' way to go as long as we can afford to' level budgets, 2 the level of'research budget that works.
3 MR. TAYLOR: The program put quite a high 4
priority on'that effort. 'So we are prepared to make 5
the necessary adjustments, I think, to fund that.
Right, Brian?
7 DR. SHERON: Yes.
8 MR. TAYLOR: That is the intention. Okay.
9 DR. COFFMAN: User needs are mostly 10 3 j satisfied by the completion of the research projects.
'11 I However, some user needs are met by intermediate 12 results and some by expected byproducts.
13 To manage the research, the projects are 14 !
grouped. Similar projects from the different offices 15-are combined, and these related projects are directed 16 by the appropriately qualified human factors analysts.
17 )
To provide you with a descriptive overview I 18 of some 35 specific user needs across 54 research 19 projects would be excessive detail. So what you see 20 in the following 5 view graphs, pages 24 through 28, l 21 is I provide an overview by combining the 54 projects into their nine 5-year-plan activities. l 23 i These are the formal 5-year-plan budget l s l activities, and it combines the 35 specific user needs y5 NEAL R. GROSS court REPoATER$ AND TRANSCRIBER 5 ]
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l 43 li 1 into ?6 titice and the associated office that provided 2 t i,, w r. , need, i
1 y On Pogr 24, you will see that the underlined 4 " human factors" is a five-year-plan program element.
F Ti a t is just the hierarchy.
6 Then the first activity is personnel i
7 pcrfnrmance measurement. It is in this area where we I i !
F ! ari looking to get more credible evidence on exactly ,
d o b hm the causem of human error can be divided and u
10 , + ; .1 : ' l l
~1 .
it was earlder there was a question about !
I l
+~ - * - ' , < nr human error from hardware error.
13 [ Probnbly the closest roference for that is an AEOD 1
14 g vr: 'r' tho* ins?cated about 65 percent. There are i 1E y ( t it t - r r- p r .tc 1 f, The Trojects in this personnel performance 1* p ,wrcrert activity are those projects which relate
.ii 3? l! to d e v r:1 opi n g the methods, improved methods, for data n,
lo ! cc11ection and screening, for storage and retrieval 20 ; a mi analysis of data on the causal factors involved in l'
21 huv pe*fermance as it relates to safe operation.
?? It is in this area that all of the NMSS 21 i. octtv:-ies. prejeets are located because that is the H
?! ] stag, -f *- L research process that the NMSS effort for
?S u c. 3c a+
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h.
i.
i l ! 44
. . l.
. i
. 1l Personnel subsystem is another activity.
o
? '"htt contains those projects that are for developing
' the objective bases for regulatory actions related to 4
l staffing qualification and training.
5! COMMISSIONER ROGERS: Shift scheduling and 6 overtime.
7 DR. COFFMAN: Yes, sir?
l
- COMMISSIONER ROCERS: That is kind of old as 9 the h i. 3 3 s , isn't it? What really has to be done there 10 h in the way of research? What are open questions? And 11 . wha', in a sense, really, should we, as a regulatory ll l:
1? p bad; , bc concerned with? '
j 13 Some of the considerations in shift s a 12 H srbeduling have to do with the morale of the staff, J
15 9 and so on and so forth, that is on shift. But what 26 : should we be dealing with, from a purely safety point h
17 L cf view?
18 '
What represents unanswered questions in 19 shift scheduling? I know there have been many, many 20 studies of the way you rotate shifts forward, t
21 backwards, the number of pecple, length of shift, all 22 this sort of thing.
I 23 Ts there something new that has to be done I 1
?4 ,
herr, or is this simply just getting together some l l
25 reason M e collection of what has been done and then i I
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sorting it out,1 from our point of view,-to see if there is some basic safety issue involved?
-DR. COFFMAN: The work we are doing I can 3'
address. As far as the position for the whole Agency, 4
others would have to address. -But we are doing work 5
basically in two areas.
6 There is a policy that has been issued 7
through a generic letter'on shift scheduling and 8
overtime. That policy was based upon evidence taken 9
from industries other than nuclear.
-10 l So the one task we have in that area is to 11 !
confirm. It is confirmatory research to assure that, 12 in fact, the policy based upon non-nuclear evidence
( 13
! applies to nuclear. That is one area.
14 I The other area is the more base research, 15 l where we are looking at operator vigilance. There we 16 l are doing some rather physiological life science work 17 to determine effects on performance between 8-hour and 18 12-hour shifts.
19 To do that, we are doing that at the 20 Institute for Circadian Physiology. It is extended 21 research over several weeks. It involves the use of 22 -
actual operators, not in power plant simulation, but in high tech simulation, measuring things like Potassium levels, body temperatures, and then some 25 NEAL R. GROSS court REPoRTIAS AND TRANSCRIBER $
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taore subjective measurement for operator vigilance, I all in support of the basic research thrust to provide 2 objective evidence for regulation to support some of 3
these other areas.
4 COMMISSIONER ROGERS: These studies have not 5
been done anywhere else prior to this time?
DR. COFFMAN: No , sir. I don't think we are 7
duplicating anything.
8 DR. MURLEY: So the answer, Commissioner, is 9
that there is both some new work that needs to be l
10 !
done. What Frank has just mentioned is aimed at: How l
11 !
! do we assure that operators stay alert during boring l
12 ;
I night hours?
13 l There is another aspect, though, which is l
I 14
--you are quite right -- to collect the information 15 .
l that has been done in the past on the information 16 l regarding forward rotation, backward rotation, and so 17 forth. We are embodying that and we have embodied 18 that in policy statements on working hours.
19 l
I think there are still some questions open, 20 l though, with regard to whether, for example, 8-hour 21 {
shifts are optimal for some, whether 12 hours1.388889e-4 days <br />0.00333 hours <br />1.984127e-5 weeks <br />4.566e-6 months <br /> are best 22 for others. And it is not clear to me that there is a 23 universal answer.
24 So I think we still need to be probing in 2a NEAL R. GROSS COURT REPORTERS AND TRANSCRibf R5 1323 RHoDE ISLAND AVINUE, N W.
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I COMMISSIONER ROGERS: I guess what my 2 concern is -- I have a number, but one of.them is to 3 what extent we are really getting into what amounts 4
to, in a way, a management decision at the plant'in 5
how to deploy their human resources'in'the most l
p 6 effective and efficient and safe way and whether we
' 7 really have an objective, well-documented basis for 8
some kind of intervention on our part and how that is 9
carried out.
10 And if we do and we have a real concern, 11 .
then I think we should pursue it, but I think we 12 should be careful that we are not simply stepping into
! 13-what might be a management prerogative that doesn't 14 have a high safety implication.
15 I don't know what the answer is there, but I 16 think we have to be very careful that, just because 17 something is interesting and naturally follows from 18 what we have been doing, we don't automatically pursue 19 it. You know, we have to be careful on how far we go 20 there.
21 DR. MURLEY: I agree we have to be careful.
22 We have to draw the distinction between having the 23 knowledge and the information and what we do with it.
i~
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carefulyabout drawing up regulations or guides, or I whatever, in things that are management prerogative.
2 I understand'that.
3' However, I think at least I would very much
^ like to know the impact on alertness of forward 5
rotation versus backward rotation,' and these kinds of 6
things, even though we' don't feel we know enough yet i to write any regulations or something in this area.
8 CHAIRMAN CARR: I think that is the point of 9
l the research, is to come up with --
10 DR. MURLEY: Yes.
11 CHAIRMAN CARR: -- a definite decision one l
12 way or the other that you can substantiate, f ( 13 l DR. MURLEY: Yes.
I 14 ,
l l MR. TAYLOR: And you would be aware of that 15 i
if we did reach that in our justification.
l 16 COMMISSIONER ROGERS: I would hope that if 17 we can't identify a right way to go, that we decide
-18 that we can't, I mean, that that is the answer, that 19 there is no better way that is substantially different 20 and that we should face up to that if that is the 21 result.
22 I am not saying that is what the result should be, but we should be prepared for that
'l p ssibility.
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DR..COFFMAN: Go to Page 25. This activity,.
the'fiv2-year-plan activity, human system interface, g 2 is:where we have grouped'the projects that provide-3- Eneasures-for evaluating.the interface or the surface 4
between the machine and its operators and maintainers.
5 As was mentioned earlier, the focus here is on advanced' instrumentation and controls.
~
The 7
industry is already implementing expert systems in 8 .
some non-safety-related systems and processes.
9=
These expert systems offer the potential to 10 improve safety by reducing initiating events. We are 11-working to establish measures, subjective measures, 12 for verification and validation of both the software V 12-and the interface design.
14 We completed an international workshop in 15 !
Jr'dary, which was to define measures and experiments 16 !
to evaluate advanced instrumentation cnd control. One 17 experimental method was identified already as a result 18 of our participation in the Halden project.
19 T
Also, planned Halden work is to compare the 20 effective differences between computer-based procedure 21 formats and paper-based procedures.
In the area of organization and management, this activity combines those projects to develop t-
" methods and measures for systematically assessing the NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHoDE ISLAND AVENUE, N W.
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safety impacts of orysnizational practices.
I We. completed an international 1 workshop in 2
November to' define research models and methods to assess organizational practices. So an approach was ;
4 developed in December of '88, and the approach is 5
being tested at,a fossil fuel p1' ant even now.
Back in October of '88 we issued a report on
~7-La method for developing programmatic performance 8
indicators. And then we also have used the Technical 9
l Training Center simulators already for developing some 10 5 I methods to evaluate control room team performance.
- 11. i On the next page, 26, a shift to a new 5-year-plan program element, reliability assessment.
T 13 This combines the activities that are research i
14 projects that will contain both the human and the 15 hardware contributions.
16 Not only is it helpful to separate out and 17 focus in on what are human causes versus hardware 18 causes and to explore the mechanisms that lead to 19 human error, but in order to look at total system 20 reliability, one has to also combine these in a 21 balarced way. That is what the activities and projects in this five-year-plan program element do.
The results of these projects are to provide methods and tools to do two things: rank the safety NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS
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51 4 issues'and resolve between sources of uncertainty in a ;
l I manner that gives balanced consideration of both i 2
h'ardware and human' contributors. Some of our results 3 today are being used in PRA reviews.
4 This first activity, data acquisition and 5
- quantification, is to be contrasted with the.first
'6 activity under the human factors program element in 7
'that this is probablistic data, reliability data for 8
'use in probablistic analyses. It is on causes of 9
operator error.
10 The data management systems. In July of 11 !
'88, we issued Version 1 of the Nuclear Computerized 12-g.
Library for Analysis of Reactor Reliability, NUCLARR.
{' 13 j
Then Version 2 was issued in March of this year.
14 i NUCLARR is a computerized database 15 management system that contains both human error 16
- j. probabilities and hardware failure rates. It was 17 issued in both diskette form for direct application on 18 a PC and in paper format.
In addition to being used by the NRC offices 20 and the ACRS, NUCLARR is currently being used by seven 21 utilities, six firms who practice PRAs, two universities, research groups in six countries, NASA Ames, Army Research Institute, and Electrical Power Research Institute.
NEAL R. GROSS COURT REPORTERS AND TRANSCRIBER 5 1323 RNODE ISLAND AVENUE, H W.
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.2 C 52 e COMMISSIONER ROGERS: How often does.that I
.ge't updated,'the database?
I~ DR. COFFMAN: We are at the front end of 3
these updates, and it is about six to nine months, 4
depending upon the flow of data.
5 And we don't just take data. The data 11as 6
to be systematically screened so that we don't 7
duplicate data that is already in the system. It has 8
to be appropriately qualified for the citation. So 9
our two revisions ran about nine months apart.
10 On the next page, 27, the projects in the 11
- j. human reliability analysis and probablistic risk 12 ,
assessment integration five-year-plan activity are to 13 integrate human factors expertise into the 14 l l probablistic safety assessments.
15 I We are doing work for modeling cognitive 16 errors. We are using currently a code called 17 "Slimmod," a technique called "Slimmod,a which was 18 developed by research. There are four applications of 19 that that are ongoing.
20 We are developing some work further in this 21 l
area of cognitive errors, developing a cognitive environment simulation method. And we are exercising 23 this method at the NRC's Technical Training Center
+
simulators.
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!I We are ticing the analysis of human error 7 ,
inte having the simulator drive the plant response.
o.
- i. 3 q This work is being done with researchers from two 4 llp universities. I d
5y For modeling execution errors, we are making 6 use of a code, simulation code called " maintenance i
7 personne; performance simulation." We are doing work
, i 8 l tn make that more u s er-f ri endl y ., l
- j 9 j I This item here on organization and 70 l management, O and M, organization and management 13 factors, is the quantification algorithm part of the 12 L organfration and management activity that I mentioned 0
, 13 ear 3ier.
%. H 14 h As far as HRA and PRA results applications, 9E I +here are two, the tech spec configuration control 3F [ work that is ongoing in NRR. Our project is to 17 h develop evaluation methods for measures that -- I'm i
18 sorry -- eva]uation measures for this work, where they i
i 19 l are trying to manage the configuration so that they 20 F contio] to minimize risk, even within what is allowed 21 by tech specs.
2? As far as risk-based performance indicators, 23 we briefed the Commission and issued a research 24 information letter on an indicator called " safety 5
?5 I systri function trend." This was in support of AEOD l
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- 54
. . 1 work and the maintenance policy. ;
J I RES Human Factors Branch also provided some 2 guidance on the human reliability analysis part of the 4
3 And we individual plant examinations document.
4 participated in the IPE workshop at Fort Worth.
0 COMMISSIONER ROGERS: Just before you leave 6
that slide, the tech spec configuration control work, 7
does that relate to the risk-based tech spec 8
activities?
I 9
! DR. COFFMAN: Yes. Yec, that is it.
10 COMMISSIONER ROGERS: That is it.
11 l DR. COFFMAN: That is our part of it.
12 !
l COMMISSIONER ROGERS: Yes.
1 13 I DR. COFFMAN: On Page 28, there is one 14 l activity in the five-year-plan program element called 15
" generic and unresolved safety issues." There are 16 come human factors issues which we inherited, and they l
17 are listed there.
18 In addition to these that are listed there, 19 l l we have already closed out some that we had inherited.
20 l
< It was TMI Action Item 1D4 on control room design 21 l
{ standards, Human Factors Generic Issue 1.1, which 22 involved a revision to Reg. Guide 1.114; and than a 23 f
i TMI Action Item 2C4, which was done in October.
, 24 i
?
i On the last page, there are listed other NEAL R. GROSS COURT Rf #ORTER$ AND TRANSCRIBER $
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, 1 !I r m arch human factors activities that are there to
" i i 'Ju s t r a t r the integration and coordination of the l 4 j 1h h u r a. * . factors within the NRC.
4 jl h are working on four of the Chernobyl h
u e, i 'M7 0w-up iter- In fact, last month we issued a ,
I i
6 ei nseout report on 3.2B, the NRC testing requirements. ;
i 7 This was done jointly with NRR because of work that l m
i 8 j thev had been doing in this area. We were able to l n
li o j rirse t h a t- out 10 1 CHATRMAN CARR: The Chernobyl database is i i
l i' i; five? Tt is not moving, is it? Are we still getting l 32 ,
in? A' r v: grit 5ng more follow-up from the Soviets?
i 33 h MF. TAYLOR: The only data that we are s ,,
14 !l g . * ' i n t. or intrnd to ort is health physics and n
1R ? environmental effect type of information.
16 ;. CHA7EMAN CARR: Are we getting that?
17 MF TAYLOF- Tha* is part of the cooperation with --
JS la' CHAIRMAN CARR: We've got a promissory note i
19 ! for itt 20 h i MR TAYIOR: Right. The first meeting'on 1
23 that lu in September in the Soviet Union. In fact, we 22 di s cu.s s ed that yesterday with the Department of l- 23 Enrrg3 Thou trips are set for Kiev and Moscow.
24 i CHAIRMAN CARR* Okay.
m
^
? c, DF. COFFMAN: Ed Jordan has already I'
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56
.c
'- mentioned that we are doing some support for the 4 .
l' design of the new NRC Operations Center. We provide 2 direct staff support on some management inspections 3
and some human system interface reviews on the SPDS.
4 We are participating with AEOD in looking at what simulator upgrades.might be beneficial. And, in 6'
. fact,'I might say that our program.is progressively 7
using more and more the NRC simulators. ArI we are 8
. working to use other simulators that are available in 9
the industry?
10 CHAIRMAN CARR: Have they made those 11 .
available? Has the industry made their simulators l
12 available to us?
- 13
-DR. COFFMAN: - Not directly available to us, 14 but, in working through standards committees and 15 i working with EPRI, we are participating in work that 16
- we will benefit from.
17 CHAIRMAN CARR: So they are being used in 18 this?
19 DR. COFFMAN: Yes, sir. 1 20 Then the last item is the direct support to 21 NMSS in defining their human factors issues on material licensees.
23 What I have tried to do is briefly summarize the Human Factors Regulatory Research Program on NEAL R. GROSS COURT REPORTER $ AND TRAN5CRl8ER5 1323 RHODE 15 LAND AVENUE, N.W.
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C 57 methods and models development, on causal data, and on I val'id measures of human performance because~the 2
. program is focused to provid'e the' technical basis for 3
adequate regulation.
Then, in addition, there is the base of 5
information that we are trying to develop in 6
anticipation of regulatory issues.
7 MR. TAYLOR: That concludes our formal 8
presentation, sir.
9 CHAIRMAN CARR: Any questions from my fellow l
10 l l Commissioners?
11 i
. COMMISSIONER ROGERS: Well, I have asked 12 quite a few, but it has been very helpful, I think.
1 13 But I didn't hear anything about the recommendation 14 .
! that the ACRS made in its May 9th letter that you 15 develop a human factors research effort to improve the 16 methodology for selection and training of resident 17 inspectors. And they made quite a little point of 18 that.
19 I wondered what the fol3cw-through is that 20 is projected.
21 DR. COFFMAN: I can't say much because the Office of Research doesn't control the resident 23 l inspectors, and that would be a user need that would have to be identified.
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- DR. MURLEY: 'ie' are still looking at that, I Commissioner, but I have asked the staff to go back o
and list for us the process that we go through now in 3
selecting resident inspector.
4 In fact, it is quite a lengthy screening 5
process. We almost never hire someone straight from 6
outside and put them in a resident's spot. We train 7
them. We observe them, and so forth.
8 So it is not clear that we need to undertake 9
a research program, but we are still looki:'g into 10 j that.
11 l CHAIRMAN CARR: The ACRS didn't have any 12 specifics.
13 DR. MURLEY: No.
14 !
COMMISSIONER ROGERS: No.
l 15 j i DR. MURLEY: They just pointed out the 16 importance of the resident inspector to our program, 17 and we agree with that.
18 CHAIRMAN CARR: It might be worth having them look at the current --
20 l DR. MURLEY: Yes.
21 CHAIRMAN CARR: -- way you do it and see if 22 we can come with some because, certainly, it is 23 important to us to have the best qualified inspectors i out there we can.
25 !
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. 59
- 1. COMMISSIONER ROGERS: Do we run potential I- candidates 'for resident inspector jobs through some s
2- . kind o'f a'-- well, I will say a psychological-3 I am not talking capability test? I don't know.
4 L about psychological state of mind, but --
CHAIRMAN CARR: Aptitude test.
COMMISS'ONER ROGERS: Aptitude test..
7' Thanks. That is what I was groping for here.
8 Do we run them through some kind of a e
standardized aptitude test that'is tailored for this 10 particular kind of activity?
.11 )
l DR. MURLEY: No, we don't. We get into 12 questions about treating these special groups of NRC
\ f q'. 13 employees different from other special. groups. But I 14 don't know that that is absolutely necessary either.
15 If we do have a rigorous-management 16 oversight procedure where we observe the candidates 17 for a year or two in other settings, I think we can 18 come to some management judgments that are probably as 19 good.
20 _,
1 MR. TAYLOR: We lean to hiring -- even when 21 we have in view a resident-type assignment, we lean to 22 hiring people with experience, either in the industry l
23 i; or military applications, heavily. l t'
Then usually the process is to get them in a 25 NEAL R. GROSS l- court REPORTERS AND TRANSCRIBER $
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.. ,a 60 region assignment if-they are new type hires. Then j
)
I they can get familiar with the whole process of the r
4 2 So that is the way this has evolved Agency better.
3 through the years.
4 And, of course, we do have a prescribed 5
training program and qualification criteria set up i
6 through the regional office that the residents go 7
through.
8 So there is structure, and I think the ACRS 9
l question is reasonable. We will respond to it, but 10 I with what we do do. Perhaps there will be suggestions l
11 l of things we aren't.
I 12
, l CHAIRMAN CARR: I guess it would be of
'( 13 .
interest to know the dropout rate in the trair,ee I
14 l program through the TTC the first year or so before 15 i j they become qualified RIs.
16 i l MR. TAYLOR: We do have some who fail. I 17 know. I can't give you their names.
18 COMMISSIONER ROGERS: And also any kind of a 19 longitudinal study of people who somehow we have felt 20 l
i ultimately were inappropriate for that job, even 21 l I though they did get into it and could we have picked that up earlier, and so on and so forth.
That is all I have. Thank you.
COMMISSIONER CURTISS: I don't have any NEAL R. GROSS COURT REPORTERS AND TRANSCRIBER 5 1323 RHODE ISLAND AVENUE, N W.
I _ _ _ _ _ _ . _ m n-- mo cymaa em smsm83
61
~
further guestions. Thank you.
t I, CHAIRMAN CARR: We mentioned earlier on 2
about other researchers wanting access to our 3 I simulators in order to fini answers to questions. Are ]
you able to do that?
5 I guess these were outside consultants and 6
laboratories who wanted to be able to get use of 7
simulators.
8 \
MR. JORDAN: As time is available, we are l l
9 ,
making them available for research purposes through !
10 the Office of Research, not for an outside request, 11 I and so that it is integrated with our programs.
12
,. CHAIRMAN CARR: So do we get to monitor i 13 their program a little bit to make sure that they are 14 using our simulators for something we think would be 15 useful to us or is it for basic research for them?
16 l MR. JORDAN: Well, the availability is: The l
17 Agency's training has first priority. And if there is 18 time available after that, then we will provide it, 19 but through the Office of Research ascertaining that 20 it is worthy and coordinated through them, rather than 21 directly with the Training Center.
CHAIRMAN CARR: Okay. On the NMSS area, g given the potential consequences for exposure from human error in that area, I noticed we are zero-funded 25 NEAL R GROSS 00URT REPORTIR$ AND TRANSCRIBER 5 1323 RHODI 15 LAND AVINUE. N W. 3
-n~ m c8 r> avman MM @%%dKKdh
h 62
, 1 {l in90 for the NMSS part and only 2 FTE.
ii
^
. I noticed the ACRS also asked the question.
!i ll Ate the current levels of resources devoted to human H
4 factors in the NMSS area adequate, do you think?
5q MR. TAYLOR: The Office Director says the 1
6 I answer is, "Of' course not."
I i
7 f MR. BERNERO: My name is Bernero. I am 8 y Di rett or of MMSS. If you see, that one s3ide has a 9 l ecro. We did have an option. We could have plugged a 20 nun,ber in there; for instance, in the medical QA, we 11 have a n.ajor contract on medical quality assurance, J
12 It which, by another measure, could be counted as human !
il 3j factors. We are applying resources as quickly and as
- n 34 h- carefu23y as we can in the NMSS arena. As Dennis said L
l 15 h in his briefing, we are trying to get direct applica-h l!
16 L tion out in the fic3d and at the same time identify o
0
- 1. 7 ij intelligent, coherent needs, at the same time.
E h
18 U Ue treat this with high priority, and we b
19 j will apply the resources as rapidly as we can 20 l intc135 gent 3y identify them. I think we are giving it i
I 21 the necessary priority.
22 We do have a need, I would say, to identify l
l 23 what at e human factors and what is safety review, and 74 so forth, because a 2 0t of our material work, materia]
l l 25 'l licensing work in particular, is easily put into the NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVENUE. N W (202; 234-4433 WASHINGTON D C. 20005 (202) 232-6600
.. in y
..- 63
~
t human factors bin just.to make the number look big.
I 'And-so it was a conscious choice not to put 2
that in.
3 So zero doesn't really mean
. CHAIRMAN CARR:
4' ~
zero?
- MR. BERNERO
- No.
. CHAIRMAN CARR: Okay.
7 MR. BERNERO:- Zero is not really 8-npresentative, but if you would look at new 9
initiatives that come in under the umbrella of new 10
-human factors initiatives, the zero is accurate.
11 CHAIRMAN CARR: Okay. And I read that to 12 say that you have enough resources now to carry out 4
13
.your program since you are trying to do it as sensibly I
14 as you can?
15 MR. BERNERO: Yes. And as fast as we can 16 identify user needs to research, they have been 17 responsive to identifying particular projects, like in 18 the brachytherapy, and that sort of thing.
19 CHAIRMAN CARR: Thank you.
20 Human Factors Research Program Plan 21 discusses development of programmatic indicetors and 22 management and organizational culture. How do you plan to use these in the regulatory program once you figure out what they are? That is a kind of a I NEAL R. GROSS COURT REPORTERS AND TRAN5CRIBER$
1323 RHODE 1$ LAND AVENUE, N W.
-- -. -amm a ra svwn emtmdMD
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_.9 'e-
' 64.
~ ..
sensitive area.
DR. COFFMAN: Our work-in programmatic and
- 1.
2 risk-based indicators is in to support the work that 3
is ongoing with AEOD and the work that is being done-4 in maintenance.
5 As far as its impact on regulation, it goes 6
through AEOD and is input to the senior management 7
meeting that is -- the input is coordinated through 8
NRR.
9 Maybe I am not addressing --
10 l
CHAIRMAN CARR: Maybe I ought to ask 11 l l somebody else.
12 DR. MURLEY: I think I know what you are 13
$' getting at, Mr. Chairman. There were two studies that 14 we asked for at NRR sometime ago. One was the impact 15 of human errors on risk. In fact, that program got 16 started many years ago, and it is putting out very, 17 very good work, I think.
18 It shows us where human errors affect risk, 19 where we should be putting our attention, and our 20 I recources. In fact, I have used it quite a bit in 21 I restructuring our program at NRR and focusing on the importance of operations.
Now, the second aspect of it is more research. And that is, how do we get a handle on g
NEAL R. GROSS COURT RIPoRTER$ AND TRANSCRIBER 5 1323 RHoDE 1$ LAND AVtNUE, N W.
i ll - -- --
~ ~ w nexvren n ep cvxma ems mago
65 l
- human error rate at a plant?' That is, from the things I that we measure, like SALP reports, like performance l
2 ,,
indicators, and those observables, is there a model 3
that you can put those into so that the output is human error rate, so that we could use it in studies like this?
i- 6 I guess another way of saying it is: How 7
can we relate SALP reports, performance indicators to 8
the risk of a plant? And we don't have --
9 CHAIRMAN CARR: I am a little more 10 l
interested in the management and organizational 11
! culture and how you plan to use that particular 12 portion of it.
I 13 DR. MURLEY: That is the model that they are 14 !
attempting to develop; that is, to try to relate 15 observable things to human error rate through a kind 16 of a management model.
17 It is not at all clear that it can be done, 18 that it can be done successfully. So we are keeping a 19 very close eye on it. I have spoken recently with 20 Eric Beckjord, and we will keep a close eye on it. We 21 will reorient, as necessary, if it seems like it is not producing what we think we need.
But the output, what I would like at least, is pretty clear in my mind, is how to take the things NEAL R. GROSS COURT RfPO5.TIR$ AND TRAt45 CRIB [R$
1323 RHODE t$ LAND AVENUE, N.W.
WA$HINGTON, D C. 20005 (202) 232 6600 (202) 234-4433
L 1 66' we do' observe.and relate it to ri'k. s I- ' CHAIRMAN CARR: -Okay. Are you getting help 4
2- from the utilities in this program?
l-3 DR. MURLEY: Yes.
DR.-COFFMAN: Yes.
L 5
DR. MURLEY: Can you say-just a bit more.
about it?
7-DR. COFFMAN: Yes. I see'where I missed on 8
the question. I answered it from a programmatic 9
standpoint. I think you were more interested in the 10 technical aspect of the program.
11 I To answer your last question first,.yes, we
{
-12 1 I are getting cooperation from the utilities. Some g.
( 13 I utilities are more aggressive in it. It is a nuclear I
14:
utility, but a fossil plant that we are currently 15 3 i exercising the method on.
16 l As far as the technical aspect of the l
17 method, when you said " performance indicators," I was 18 thinking plant performance indicators, but you are really saying as an indication of organizational 20 effectiveness and the impact.
21 CHAIRMAN CARR: I think the word were 22
" programmatic indicators," is what your plan says, but
, I was trying to analyze the culture in the plant and decide --
25 NEAl. R. GROSS COURT REPORTERS AND TRANSCI.lBER$
1323 RHODE l$ LAND AVENUE, N,W, (202) 234-4433 WASHINGTON, D.C. 20005 (202) 232-6000
4; ,, a 67 DR. COFFMAN: Well, there are --
1 CHAIRMAN CARR: -- whether it was a good one 2
or a bad one, I suppose.
3 ~
DR. COFFMAN: There are established 4
instruments for measuring organizational culture.
5 Now, that.doesn't say that they are 100 percent-6
. accurate, always apply totally to the given situation, 7
but there are standardized instruments for measuring 8
cultural impact.-
9 And then, after making those measurements, 10 the next step is to translate those measurements-into 11 figures, into human error rates that can be accepted 12 by the risk assessment, which is a creative part of.
l 13 the work to try and take measures.
14 !
l CHAIRMAN ~CARR: How much? Define for me 15 l 1 ; what an-instrument is. Is that a public opinion poll 16 or is that a --
l 17 DR. COFFMAN: No, sir. The two --
18 )
CHAIRMAN CARR: -- bottom line on the 19 1 worksheet or --
l 20 DR. COFFMAN: No. The two instruments we 21 are using in the fossil plant, one is called an
" organizational culture inventory," involves some 120 questions where it asks about people's expectations as t
far as their communication with their supervisors, 1 25 NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS l-1323 RHODE ISLAND AVINUE. N W.
l' __ _ ___
- 4;. .
68 their peers, and their subordinates.
' ' I CHAIRMAN CARR: That is what I call a 2
"public opinion poll," but I understand what you mean.
3 Well, it is a soft area.
DR.'COFFMAN: It l is not something that -- well, yes. -Okay. It.is a-soft area. It is a softer science.
6 And then we are using an observational 7
technique, where the supervisors and managers are 8
observed and the way they allocate their time is 9
measured.
10 CHAIRMAN CARR: I understand that. How 11 !
about INPO? Are their human factors research area and
-12 l yours working together?
l ! 13 DR. COFFMAN: We are aware of several 14 initiatives that INPO has. We have tried to get with 15
! .them for the purpose primarily of sharing data out of 16 their human performance evaluation system and have not I
17 I been too successful in convincing them that they 18 should share that data with us.
19 CHAIRMAN CARR: Are we sharing ours with 20 them?
21 MR. BECIGORD: We had a briefing some months 22 ago from people at INPO on their human performance evaluation system. What I learned at that was that it t
has a very different focus and purpose than the work 25 NEAL R. GROSS COURT REPORTER $ AND TRANSCRIBER $
1323 RHODE l$tAND AVENUE, N W.
-____- _m , _ , - -
' ;n
~ 69 t.
- that we are doing.
1 Essentially, I think the way I would 3
2 characterize their effort is to help the' people at'a 3
plant conduct their own program to search out root 4
error causes. It is essentially the support of their 5
clients.
6 It does not have the purpose of gathering 7
~ human error data or anything like that.
8 CHAIRMAN CARR: I would hope that our.
9 programs weren't in disagreement. Do you think they 10
-are?
11 i i MR. BECKJORD: I don't think they are in 12 disagreement.
t 4 13 I
! CHAIRMAN CARR: Okay.
14 MR. BECKJORD: I think they just are 15
, different programs.
16 DR. COFFMAN: Another area, thcugh, that you.
17 may already be aware of is that we are relying upon 18 the INPO accreditation system for training programs.
And so we are beginning to do some work to look at 20 effective means for measuring that.
21 CHAIRMAN CARR: Okay. And would you talk a little bit more about your human factors notes that you are putting out from NMSS? And maybe would you i
mind sending them to the Commission?
HEAL R. GROSS COURT REPORTERS AND TRANSCRIBER 5 1323 RHODE 15 LAND AVENUE, N.W.
WASHINGTON, D.C. 20005 (202) 232-6600 (202) 234-4433
70
. 1 MR. BERNERO: Several of them have been sent T to the Commission, sir, h
3 Ud CHAIRMAN CARR: Are these just sporadic or I when-occurring type thing?
5l MF. BERNERO: Yes. Primarily they have 6 occurred as a result of an inspection accompaniment, 7 where someone will walk through a typical human i
8 factors protocol and try to determine what things in !
t 0 l this setting can contribute to the human errors we are 1 (' '
. meting 7ending to misadministration.
11 ,, Most of it confirms what we know from our 12 !i re,~tcr experience. Human-machine interfaces are ;
i e 13 ] certainly a problem and need to be looked into very
's l 14 ,j care f t0 3 y .
l 15 y But there are a number of other factors that 4.
16 li come into play as well, anything from something as I
37 ll si rtp] e as housekeeping and communications problems to 18 the social context of some of the operations and 19 l whether or not a person can make a decision, a safety t
20 decision, within that social context or whether it is i
23 a caucus that has to make the decision.
22 CHAIRMAN CARR: I would be interested in 23 seeing it if you would put us on the routing. I don't 24 know about my fellows.
25 COMMISSIONER CURTISS: I am happy to see.
NEAL R. GROSS COURT PEPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVENUE, N W (202)234 4 433 WASHINGTON. D C. 20005 (202) 232-6600
-i n .
a 71 CHAIRMAN CARR: Any other questions?.
r 1 COMMISSIONER' ROGERS: No.
'k 2
CHAIRMAN CARR: Well, I would like to thank 3
the staff.for our update here. I think it has been a 4
very informative briefing. And I think you have done 5
a good job in revising the plan. I think it is better 6 ~
described than coordinated. I am still worried a 7
little bit about the spa.n of control over the whole 8
operation.
I 9
I appreciate the ACRS letter and its 10 comments. I think that we can take a look at those 11 l and listen.
12 I think, in view of the continuing large
( 13 fraction of errors that can be contributed to 14 personnel, even if it is maintenance, or whatever, I 15 think it is very important. I think that we ought to 16 do all we can to help knock that number down.
17 l I encourage you also to continue to expand 18 the human factors initiative in the NMSS area, 19 especially in radiography, where we seem to be able to 20 have as many people exposed as any other part of the 21 area, and the medical use area.
22 As I say, that area concerns me, I guess, because the potential seems to be that we can expose I people there with a lot more frequency than we do in NEAL R. GROSS COURT REPORTER $ AND TRAN5CRIBER$
1323 RHODE ISLAND AVENUE. N W.
\ .--nn ~~ , arras aae mera
. 72 any other area that we work with.
1 Close coordination within the staff is s
t 2 obviously going to be necessary, and it seems that it 3 I encourage that.
is ongoing.
4 I also would encourage the continuing 5
interaction between the industry groups and the 6
professionals in the field so that we don't reinvent 7
the wheel and take advantage of as much data as is out 8
there.
9 Unless you have any other comments, why, we l
I 10 l stand adjourned.
11 i j (Whereupon, the foregoing briefing was 12 adjourned at 10:32 a.m.)
( 13 14 15 l 1
16 l 3 17 i i
18 19 !
I 20 l 21 l (
22 j 23 j 24 25 NEAL R. GROSS COURT R[ PORTERS AND TRANSCRIBER 5 1323 RHODE ISL AND AVENUE, N W.
(202) 234-4433 WASHINGTON. D.C. 20005 (202) 232-6600
. _ _ _ _ _ _ J
i eq _..
3; e :.
E CERTIFICATE ~0F TRANSCRIBER This is.to' certify that the attached events of a meeting of'the United States Nuclear Regulatory Commission entitled:
TITLE OF MEETING: CODIISSION BRIEFING ON AGENCY HUMAN FACTORS' INITIATIVES PLACE OF MEETING: ROCKVILLE, MARYLAND
.DATE OF MEETING: JULY 6. 1989.
were transcribed by me. I further certify ~that said transcription is. accurate and complete, to the best of my ability, and that'the transcript is a'true and accurate record of the foregoing events.
-- 44d fM/ f v.
Reporter's name: Trevor Goodchild l
NEAL R. GROSS COURT Rf>0eTEk$ AND TRANSCRIBER $
1323 RHODE i$ LAND AVENUE N.W.
(202) 234 4433 WA$N6NGTON. D.C. 20005 (202) 222-6600
4 4 i
NRC HUMAN FACTORS PRESENTATION WILL COVER:
BACKGROUND OBJECTIVES OF AGENCY HUMAN FACTORS PROGRAMS AND INITIATIVES
- UPDATE ON HUMAN FACTORS PROGRAMS IN NRR, ]
NMSS, AND AEOD OVERV!EW OF REVISION 1 TO HUMAN FACTORS RESEARCH PROGRAM PLAN l l
I i
A 1
l
4 BACKGROUND MAY 1988 HUMAN FACTORS RESEARCH PROGRAM PLAN TO COMMISSION (SECY-88-141)
JULY 1988 SRM M880531 DIRECTED THE l STAFF TO SUBMIT AN INFORMATION PAPER ON SEVENITEMS, UPDATE l INITIATIVES, AND DEFINE l ISSUES ADDRESSED BY THE RESEARCH PROGRAM l
1 2
\
'a >
l BACKGROUND (CONT)
OCTOBER 1988 STAFF RESPONSE TO SRM M880531 (SECY 88-294)
ANSWERED SEVEN ITEMS AND CONFIRMED PLANS TO UPDATE INITIATIVES AND ISSUES JANUARY 1989 ACRS SUBCOMMITTEE MEETING ON HUMAN FACTORS REVIEWED DRAFT RESEARCH PLAN
/
a f
f
l L... .
1 BACKGROUND l (CONT-2)
FEBRUARY 1989 EDO DIRECTION TO ADDRESS AGENCY-WIDE PROGRAMS FOR l THE CONTEXT OF THE RESEARCH APRIL 1989 ACF55 SUBCOMMITTEE MEETING ON NRC HUMAN FACTORS PROGRAMS, l INITIATIVES, AND RESEARCH i
l l
l l
i
)
i i
l f
l 4
1
~
'l l
1 BACKGROUND (CONT-3)
MAY 1989 ACRS FULL COMMITTEE ON NRC HUMAN FACTORS PROGRAMS, INITIATIVES, AND RESEARCH JUNE 1989 *NRC'S HUMAN FACTORS PROGRAMS
& INITIATIVES
- WITH REVISION 1 OF HUMAN FACTORS REGULATORY RESEARCH PROGRAM PLAN TO COMMISSION (SECY-89-183).
9 t
t______- '
.i. s l
t OBJECTIVES OF AGENCY HUMAN FACTORS PROGRAMS
- ASSURE THAT HUMAN FACTORS AFFECTING SAFETY ARE CONSIDERED APPROPRIATELY IN ALL REGULATORY ACTIVITIES
- PROVIDE ADEOUATE HUMAN FACTORS RESEARCH RESOURCES TO ENSURE Alk USER NEEDS ARE MET AND A BASE RESEARCH PROGRAM PERFORMED e TO COORDIN ATE AND INTEGRATE AGENCY ACTIVITIES IN HUMAN FACTORS
- TH AT RESEARCH PROGRAMS ARE PROPERLY STRUCTURED AND RESPONSIVE TO USER OFFICES.
9 f
a s m
RESOURCES FY 89 FY SD 05 SiCE FTE CONTRACT S FTE CONTRACT 8 NRR 11 $1.3M 11 81.3M RES B $6.5M 10 $8.4M AEOD 3 $ .4M 3 5 .4M NMSS 2 5 .3M 2 SOM ALL 8 ARE CONS;$ TENT w TM FYP am o
en 4
6 M' *
' 5 m
. j HUMAN FACTORS PROGRAM AND INITIATIVES OFFICE OF NUCLEAR REACTOR REGULATION 1-l l
i f I
1.
CURRENT EOP INSPECTION PROGRAM O THREE PHASES:
-EOP-1: PtLOT PROGRAM,16 NSPECTONS DfVDED AMONG VENDOR TYPES
-EOP-2: FOCUSED ON BWR'S WTTH MARK I CONTANMENT; EMPHASIS ON CONTANMENT VENTNG PROCEDURE
-EOP-3: NSPECTONS OF REMANNG U.S. PLANTS DURNG TWO YEAR PEPOO NUREG 1358 ' LESSONS LEARNED FROM 'HE SPECIAL INSPECTON PROGRAM FOR EOPs' NUREG/CR 5228 *TECHNOUES FOR PREPARING FLOWCHART-FORMAT EOPs*
er i
I;
}* ,
l
- l. , ,
l ,*
l MAN-MACHINE INTERFACE:
TWO INITIATIVES DETALED CONTROL ROOM DESIGN REVIEW ,
IMDAOVE THE ABILITY OF OPERATORS TO PREVENT ACCOENTS OR COPE WITH ACCCENTS IF THEY OCCUR BY IMPROVING THE INFORMATION PROVOED SACETY PARAMETER DISPLAY SYSTEM AO OPERATORS IN RAPOLY AND RELIABLY DETERMIMNG THE SAFETY STATUS OF THE PLANT OURING AN EMERGECY GENEA:C LETTER 69*06
..CENSEES CEATifY THAT THEIR SPDS FULLY MEETS REOS. OR WLL FULLY MEET REOS OR PROVOE REASONS FOR NOT CERTIFYING.
0*
4 0
TRAINING INSPECTIONS
. PROGRAM
+ NEW INSPECTION PROCEDURE (41500)
- FIRST TRAINING IMPLEMENTATION INSPECT;ON AT TURKEY POINT, ...
MAY 1-5,1989
- SEVERAL MORE BEING PLANNED l
i e
OPERATOR EXAMINATIONS AND LICENSING PROGRAM INITIATIVES
- REQUALIFICATION PROGRAM
- FUNDAMENTALS EXAMINATION
- NATIONAL EXAM SCHEDULE W
ess w-_--_--________ ____
f 4
f
(
ORGANIZATION AND MANAGEMENT l SUPPCRT FOR:
- TEAM EVALUATIONS
- AEOD DIAGNOSTICS
- NRR SPECIAL INSPECTIONS m
8 e
f
l .
l l
l r
ADDITIONAL PROGRAMS INCORPORATING HUMAN PERFORMANCE DATA
- MAINTENANCE INSPECTIONS
- SENIOR MANAGEMENT MEETING i l
l O
n-.--- - - _ - l_.-_.-- -._ - - _ _ _ _ - - - _ . - - - -
., )
1 1
l l
ROOT CAUSE ANALYSIS OF EVENTS INVOLVING HUMAN ERRORS FUTURE INITIATIVE (IN CONJUNCTION WITH RES AND AEOD)
- DEVELOP A STRUCTURED PROTOCOL FOR ASSESSING ROOT CAUSE OF EVENTS INVOLVING HUMAN ERROR
- OBTAIN DETAILED HUMAN PERFORMANCE INFORMATION M
e
,4 DREP/NRR PROGRAM SENSITIVITY OF RISK TO HUMAN ERROR I
RATES
- ESTIMATE THE SENSITIVITY OF PRA RESULTS TO VARIATIONS IN HUMAN ERROR RATES
- IDENTIFY RISK-lMPORTANT CATEGORIES OF HUMAN ACTIONS
- INVESTIGATE DIFFERENCES IN THE SENSITIVITY OF NSSS DESIGNS TO THESE VARIATIONS l
4 e
- a u
4
.4..
.~
AEOD PROGRAMS INVOLVING HUMAN FACTORS
- ROUTINE OPERATIONAL EVENT ASSESSMENT
- Pc.6FORMANCE INDICATOR PROGRAM e INCIDENT INVESTIGATION PROGRAM
- DIAGNOSTIC EVALUATION PROGRAM
- NONREACTOR ASSESSMENT PROGRAM
- TECHNICAL TRAINING CENTER ACTIVITIES
.~
NMSS HUMAN FACTORS PROGRAM
- DIRECT USE TODAY AND IDENTIFICATION OF TOMORROW'S NEEDS
- MEDICAL USE: TELETHERAPY BRACHYTHERAPY TREATMENT PLANNING PHARMAClES
= INDUSTRIAL RADIOGRAPHY
- OTHER I
i l
l
'E R.___.___ . _ _
.; e t'
I L ,e HUMAN FACTORS REGULATORY RESEARCH PROGRAM
+ PURPOSE: TO PROVIDE THE TECHNOLOGICAL BASIS FOR REGULATION
- CHARACTERISTICS:
- 1. A MULTIDISCIPLINARY ENDEAVOR RELYING HEAVILY ON THE BEHAVIORAL SCIENCES AND INVOLVING A VARIETY OF ENGINEERING DISCIPLINES. ,,.
- 2. MAINLY SUPPORT TO REGULATORY PROGRAMS & INITIATIVES.
- 3. SOME BASE RESEARCH ON ANTICIPATED HUMAN PERFORMANCE ISSUES.
i
l
~
[
i-1 I
l l l
l RESEARCH USER NEEDS
- REGULATORY OFFICES ORIGINATE NEEDS WHERE (1) THE TECHNICAL BASIS FOR A REGULATORY ACTION ,
IS NOT MATURE OR NEEDS CONFIRMATION OR (2) THE NATURE OF THE POTENTIAL SAFETY PROBLEM IS NOT WELL DEFINED.
i.,.
p . .
-' g 4 I'
.. e -
RESEARCH USER'NEEDS DEVELOPMENT e FOLLOWNG APRL 1987 AGENCY REORGANIZATION, USER
' OFFCES WERE ORGAN!ZNG THEFI OWN PROGRAMS. LITTLE EFFORT TO DEFNE USER NEEDS.
e RES ACTIVELY SOUGHT HUMAN FACTORS RESEARCH NEEDS FROM USER OFFCES e CURRENTLY WORKNG ON A TOTAL OF 11 USER NEED MEMORANDA FROM 4 OFFCES.
e PROGRAM 15 NOW REACHING MATURITY (SETTLNG DOWN).
9 L___ ._ . . - _ _ _ _ _ _ _
- e. ,
li RESEARCH USER NEEDS DEVELOPMENT (CONT.)
- THE RESEARCH PROGRAM IS INTERACTIVE AND PROJECTS ARE REVISED AS REGULATORY NEEDS CHANGE.
- WE MEET WITH USERS APPROXIMATELY OUARTERLY AT DIVISION DIRECTOR LEVEL
- MEETINGS AT BRANCH CH'EF LEVEL MORE FREQUENT
- STAFF INTERACTIONS ARE ALMOST DAfLY 22 f-
j
- i. .
I BASE RESEARCH e HF RESEARCH IN AREAS FOR WHICH THERE IS NO EXPLICIT USER NEED
- BASE RESEARCH IS DONE TO PROVIDE AN INFORMATON BASE IN --
ANTICIPATION OF FUTURE REGULATORY NEEDS (E.G., OPERATOR VIGILANCE)
BROADEN KNOWLEDGE BASE IN SELECTED AREAS (E.G., NAS HF COMMITTEE) em m e h-_______ _ _ _ _ . _ . _ _ _ _ _ _ _ _
l ,' .
i .' e ,
/
OVERVIEW OF USERS NEEDS BY RESEARCH ACTIVITIES HUMAN FACTORS
INVESTIGATION PROTOCOLS (NRR, AEOD)
MEDICAL USES (NMSS)
INDUSTRIAL RADIOGRAPHY (NMSS)
- PERSONNEL SUBSYSTEM TRAINING EFFECTIVENESS (NRR)
PERSONNEL QUALIFICATIONS (NRR)
OPERATOR LICENSING (NRR)
SHIFT SCHEDULING & OVERTIME (NRR)
==
I f
/
OVERVIEW OF 'JSERS NEEDS BY RESEARCH ACTIVITIES (CON'T)
+ HUMAN-SYSTEMINTERFACE ADVANCED I&C INTERFACES (NRR)
EXPERT SYSTEMS (NRR)
- ORGANIZATION & MANAGEMENT O&M INFLUENCES ON RISK (NRR, REG.1)
HF OF ACCIDENT MANAGEMENT (NRR, RES)
CONTROL ROOM TEAM PERFORMANCE (NRR) l l
l
'lj
- r'--
f p
p .. .
i, .-
1 l
l OVERVIEW OF USERS NEEDS BY RESEARCH ACTIVITIES (CONT)
RELIABILITY ASSESSMENT
- DATA ACOUIS! TION & QUANTIFICATION PERFORMANCE INDICATORS (AEOD)
CAUSES OF OPERATOR ERROR & RELIABILITY DATA (NRR, RES) ,
- DATA MANAGEMEr4T SYSTEMS CAUSES & FREQUENCY OF BOTH HUMAN ERRORS AND HARDWARE FAILURES (NRR, AEOD, RES) i 2b
,.c a i D r
s' OVERVIEW OF USERS NEEDS BY RESEARCH ACTIVITIES (CONT)
MODELING EXECUTION ERRORS IN PRA (NRR)
O&M FACTORS (NRR, REG.1)
- HRA/PRA RESULTS APPLICATION TECH SPEC CONFIGURATION CONTROL (NRR)
RISK-BASED Pls (NRR, AEOD) 27 f
-n ,
4 6
OVERVIEW OF USERS NEEDS BY RESEARCH ACTIVITIES (CONT)
GENERIC & UNRESOLVED ISSUES
- HUMAN FACTORS ISSUES ALARM REDUCTION (NRR, HF 5.2) .
LOCAL CONTROL STATIONS (NRR, HF 5.1)
OTHER FROCEDURES (HF 4.4)
CRITERIA FOR ACTIONS (B-17) l 28 m___________ _
4 .
D' OTHER RES HUMAN FACTORS ACTIVITIES
- CHERNOBYL FOLLOWUP
- SUPPORT TO DESIGN OF NEW OPERATIONS CENTER
- DIRECT SUPPORT ON MANAGEMENT INSPECTIONS AND HUMAN-SYSTEM INTERFACE REVIEWS
- SIMULATOR UPGRADES AT TTC
- DIRECT SUPPORT TO NMSS FOR DEFINING HUMAN FACTORS ISSUES AT MATERIALS LICENSEES er
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TP.AM5MITTAL TO:
/ Document Control Desk, 016 Phillips f
ADVANCED CCPY TO: The Public Document Room DATE: 7 /31 [d l 5 FROM: SECY Correspondence & Records Branch
!' Attached are copies of a Comission meeting transcript and related meeting i document (s). They are being forwarded for entry on the Daily Accession List and i: placement in the Public Document Room. No other distribution is requested or
,ll required.
Meeting Titie: kd4 4 d-*w N::u ~ j I
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Meeting Date: 7/6/f#/
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Copies
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Advanced DCS
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!l 1. TRANSCRIPT i
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- PDR is advanced one copy of each document, two of each SECY paper.
3" 3 C&R Branch files the original transcript, with attachments, withcut SEGY j! j papers. Ok 3a 3
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