ML070180564: Difference between revisions
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| number = ML070180564 | | number = ML070180564 | ||
| issue date = 12/20/2006 | | issue date = 12/20/2006 | ||
| title = | | title = CAL Closure Request Letter | ||
| author name = Pearce L | | author name = Pearce L | ||
| author affiliation = FirstEnergy Nuclear Operating Co | | author affiliation = FirstEnergy Nuclear Operating Co | ||
| addressee name = Caldwell J | | addressee name = Caldwell J | ||
| addressee affiliation = NRC/RGN-III/ORA | | addressee affiliation = NRC/RGN-III/ORA | ||
| docket = 05000440 | | docket = 05000440 | ||
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== | == | ||
Description:== | Description:== | ||
"Issues dealing with the quality of maintenance procedures including quality control inspection hold points. Revision of the Quality Control Inspection Program to focus additional attention on items that have experienced repeat failures." 1.2 Purpose: The above CAL commitment contains three (3) actions. First, FENOC stated in response to NRC IP 95003 inspection report (IR 2005003), that one hundred eight (108) of the one hundred nineteen (119) procedures been updated and issued. The remaining maintenance procedures will be updated and owner's review completed. | "Issues dealing with the quality of maintenance procedures including quality control inspection hold points. Revision of the Quality Control Inspection Program to focus additional attention on items that have experienced repeat failures." 1.2 Purpose: The above CAL commitment contains three (3) actions. First, FENOC stated in response to NRC IP 95003 inspection report (IR 2005003), that one hundred eight (108) of the one hundred nineteen (119) procedures been updated and issued. The remaining maintenance procedures will be updated and owner's review completed. | ||
[CAL Commitment l.a] | [CAL Commitment l.a] | ||
Attachment PY-CEI/OIE-0683L Page 2 Second, FENOC stated that it would revise Nuclear Quality Assurance Instruction NQI-1001, "QC Inspection Program Control," to specify a method to establish additional QC inspection items for items that have experienced repeat failures. | Attachment PY-CEI/OIE-0683L Page 2 Second, FENOC stated that it would revise Nuclear Quality Assurance Instruction NQI-1001, "QC Inspection Program Control," to specify a method to establish additional QC inspection items for items that have experienced repeat failures. | ||
This method was to include consideration of failure analysis, the risk-significance of the item, and the probability of failure occurrence in determining the extent of inspection activity. | This method was to include consideration of failure analysis, the risk-significance of the item, and the probability of failure occurrence in determining the extent of inspection activity. | ||
[CAL Commitment 1 .b]Third, FENOC stated that it would revise Generic Mechanical Instructions (GMI)-0039, "Disassembly/Re-assembly of Divisions I and II Emergency Service Water Pumps," and GMI-0040, "Disassembly | [CAL Commitment 1 .b]Third, FENOC stated that it would revise Generic Mechanical Instructions (GMI)-0039, "Disassembly/Re-assembly of Divisions I and II Emergency Service Water Pumps," and GMI-0040, "Disassembly | ||
/ Re-assembly of Division III Emergency Service Water Pump," to include QC inspection points for work activities associated with pump shaft couplings, as specified by QC.[CAL Commitment 1.c]1.3 Basis For Commitment Closure: The CAL commitments for addressing the IP 95002 follow-up issues are complete. | / Re-assembly of Division III Emergency Service Water Pump," to include QC inspection points for work activities associated with pump shaft couplings, as specified by QC.[CAL Commitment 1.c]1.3 Basis For Commitment Closure: The CAL commitments for addressing the IP 95002 follow-up issues are complete. | ||
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Attachment PY-CEI/OIE-0683L Page 6 Establish a management process to routinely monitor CAP performance at the site and department | Attachment PY-CEI/OIE-0683L Page 6 Establish a management process to routinely monitor CAP performance at the site and department | ||
/ section levels (e.g., operations, electrical maintenance, plant engineering, etc.). Perform a self-assessment that evaluates the overall health of the CAP following implementation of specific improvement initiatives." 2.2 Purpose: The above CAL commitment contains four (4) actions. First, FENOC stated in response to NRC IP 95003 inspection report (IR 2005003), that expectations necessary for successful implementation of the corrective action program (CAP) will be developed and site personnel will be trained to the expectations and accountability methods that will be used to improve implementation of the CAP. [CAL Commitment 2.a]Second, FENOC stated it would implement management controls to improve line ownership and accountability at the individual level for successful implementation of the CAP. [CAL Commitment 2.b]Third, FENOC stated it would establish a management review process that routinely monitors the site's and section level CAP performance. | / section levels (e.g., operations, electrical maintenance, plant engineering, etc.). Perform a self-assessment that evaluates the overall health of the CAP following implementation of specific improvement initiatives." 2.2 Purpose: The above CAL commitment contains four (4) actions. First, FENOC stated in response to NRC IP 95003 inspection report (IR 2005003), that expectations necessary for successful implementation of the corrective action program (CAP) will be developed and site personnel will be trained to the expectations and accountability methods that will be used to improve implementation of the CAP. [CAL Commitment 2.a]Second, FENOC stated it would implement management controls to improve line ownership and accountability at the individual level for successful implementation of the CAP. [CAL Commitment 2.b]Third, FENOC stated it would establish a management review process that routinely monitors the site's and section level CAP performance. | ||
Take action to improve performance when expectations are not met and hold the organization accountable for overall CAP effectiveness. | Take action to improve performance when expectations are not met and hold the organization accountable for overall CAP effectiveness. | ||
[CAL Commitment. | [CAL Commitment. | ||
2.c]Fourth, FENOC would perform a self-assessment that evaluates the overall health of the CAP, including an aggregate assessment of key performance indicator trends. Assess whether substantial progress has been made in CAP performance. | 2.c]Fourth, FENOC would perform a self-assessment that evaluates the overall health of the CAP, including an aggregate assessment of key performance indicator trends. Assess whether substantial progress has been made in CAP performance. | ||
[CAL Commitment 2.d]2.3 Basis For Commitment Closure: The CAL commitments for improving the implementation of the corrective action program are complete. | [CAL Commitment 2.d]2.3 Basis For Commitment Closure: The CAL commitments for improving the implementation of the corrective action program are complete. | ||
Provided below are basis for closure of the individual CAL commitments and summary of actions taken to achieve sustained improved performance in each of the CAL areas.In 2004 mid-cycle plant performance assessment letter (dated August 30, 2004), the NRC identified a substantive cross-cutting issue in the area of problem identification and resolution involving a number of findings.Examples included: | Provided below are basis for closure of the individual CAL commitments and summary of actions taken to achieve sustained improved performance in each of the CAL areas.In 2004 mid-cycle plant performance assessment letter (dated August 30, 2004), the NRC identified a substantive cross-cutting issue in the area of problem identification and resolution involving a number of findings.Examples included: | ||
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/ section Training Review Committee meetings on human performance. | / section Training Review Committee meetings on human performance. | ||
The Human Performance Program purpose and key activities will be communicated to all site personnel. | The Human Performance Program purpose and key activities will be communicated to all site personnel. | ||
Group-specific needs analysis will be performed to identify the scope and content of human performance fundamentals and error preventative tool training." 3.2 Purpose: The above CAL commitment contains four (4) actions. First, roles and responsibilities of the Site Leadership Team in implementing the human performance program will be defined and communicated. | Group-specific needs analysis will be performed to identify the scope and content of human performance fundamentals and error preventative tool training." 3.2 Purpose: The above CAL commitment contains four (4) actions. First, roles and responsibilities of the Site Leadership Team in implementing the human performance program will be defined and communicated. | ||
[CAL Commitment 3.a]Second, approximately monthly Site Training Advisory Committee and department | [CAL Commitment 3.a]Second, approximately monthly Site Training Advisory Committee and department | ||
/ section Training Review Committee meetings have been held and will continue to be conducted with a strong focus on human performance through fourth quarter 2005. [CAL Commitment 3.b]Third, the purpose and key activities of the Human Performance Program will be communicated to Perry Nuclear Power Plant (PNPP) personnel. | / section Training Review Committee meetings have been held and will continue to be conducted with a strong focus on human performance through fourth quarter 2005. [CAL Commitment 3.b]Third, the purpose and key activities of the Human Performance Program will be communicated to Perry Nuclear Power Plant (PNPP) personnel. | ||
[CAL Commitment 3.c]Fourth, group-specific needs analyses will be performed by training committees to determine the scope and content of initial and continuing training needs on human performance fundamentals and error prevention tools and training will be provided. | [CAL Commitment 3.c]Fourth, group-specific needs analyses will be performed by training committees to determine the scope and content of initial and continuing training needs on human performance fundamentals and error prevention tools and training will be provided. | ||
[CAL Commitment 3.d] | [CAL Commitment 3.d] | ||
Attachment PY-CEI/OIE-O683L Page 14 3.3 Basis For Commitment Closure: The CAI_ commitments for improving human performance are complete.Provided below are basis for closure of the individual CAI_ commitments and summary of actions taken to achieve sustained improved performance in each of the CAI_ areas.In 2004 end-of-cycle plant performance assessment letter (dated March 2, 2005), the NRC identified a substantive cross-cutting issue in the area of human performance involving a number of findings related to personnel performance, with a common theme of failure to follow procedures or inattention to detail. Examples included: | Attachment PY-CEI/OIE-O683L Page 14 3.3 Basis For Commitment Closure: The CAI_ commitments for improving human performance are complete.Provided below are basis for closure of the individual CAI_ commitments and summary of actions taken to achieve sustained improved performance in each of the CAI_ areas.In 2004 end-of-cycle plant performance assessment letter (dated March 2, 2005), the NRC identified a substantive cross-cutting issue in the area of human performance involving a number of findings related to personnel performance, with a common theme of failure to follow procedures or inattention to detail. Examples included: | ||
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Additionally, training materials were developed for new employees (similar to the training provided for existing employees) and training materials were developed for supplemental personnel (i.e., tailored for contract outage workers). | Additionally, training materials were developed for new employees (similar to the training provided for existing employees) and training materials were developed for supplemental personnel (i.e., tailored for contract outage workers). | ||
Continuing training needs will be specifically identified within the Needs Analysis as prescribed by procedure NOBP-TR-1102, and by Training and CRC/TRC.During the NRC inspection (IR 2006012), the NRC team concluded that actions adequately implemented the commitment. | Continuing training needs will be specifically identified within the Needs Analysis as prescribed by procedure NOBP-TR-1102, and by Training and CRC/TRC.During the NRC inspection (IR 2006012), the NRC team concluded that actions adequately implemented the commitment. | ||
3.4 Sustained Improved Performance: | |||
Improved Performance: | |||
The Human Performance program promotes the prevention of events due to human error by focusing on sustaining error-prevention behaviors. | The Human Performance program promotes the prevention of events due to human error by focusing on sustaining error-prevention behaviors. | ||
The actions taken above in concert with implementation of the Perry Performance Improvement Initiative for Human Performance drove improvements in the behaviors resulting in a decline in consequential events that reset the Station Clock. The initiative actions were organized in three distinct stages; program structure, behavior modifications, and discipline in execution. | The actions taken above in concert with implementation of the Perry Performance Improvement Initiative for Human Performance drove improvements in the behaviors resulting in a decline in consequential events that reset the Station Clock. The initiative actions were organized in three distinct stages; program structure, behavior modifications, and discipline in execution. | ||
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== | == | ||
Description:== | Description:== | ||
"Expand the population of qualified EP responders to increase the emergency response organization's depth and conduct drills to demonstrate appropriate emergency response times." 4.2 Purpose: The above CAL commitment contains two (2) actions. First, FENOC stated in response to IP 95003 inspection report (IR 2005003), that it would expand the population of qualified emergency planning (EP) responders to increase the depth of the emergency response organization. | "Expand the population of qualified EP responders to increase the emergency response organization's depth and conduct drills to demonstrate appropriate emergency response times." 4.2 Purpose: The above CAL commitment contains two (2) actions. First, FENOC stated in response to IP 95003 inspection report (IR 2005003), that it would expand the population of qualified emergency planning (EP) responders to increase the depth of the emergency response organization. | ||
[CAL Commitment 4.a]Second, FENOC stated that it would conduct additional EP ddlls to demonstrate appropriate emergency response organization (ERO) response times. [CAL Commitment 4.b]4.3 Basis For Commitment Closure: The CAL commitments for improving the performance in the emergency preparedness area are complete. | [CAL Commitment 4.a]Second, FENOC stated that it would conduct additional EP ddlls to demonstrate appropriate emergency response organization (ERO) response times. [CAL Commitment 4.b]4.3 Basis For Commitment Closure: The CAL commitments for improving the performance in the emergency preparedness area are complete. | ||
Provided below are basis for closure of the individual CAL commitments and summary of actions taken to achieve sustained improved performance in each of the CAL areas.CAL Commitment 4.a / DAMP Appendix EP 1 This commitment involves expanding the population of qualified EP responders by approximately 125 persons to increase the depth of the ERO.In a letter dated, January 30, 2006, FENOC stated that the above CAL commitment was completed in fourth quarter 2005.The above commitment was achieved by designating and training additional plant staff to fulfill ERO positions thereby, increasing the depth of the organization. | Provided below are basis for closure of the individual CAL commitments and summary of actions taken to achieve sustained improved performance in each of the CAL areas.CAL Commitment 4.a / DAMP Appendix EP 1 This commitment involves expanding the population of qualified EP responders by approximately 125 persons to increase the depth of the ERO.In a letter dated, January 30, 2006, FENOC stated that the above CAL commitment was completed in fourth quarter 2005.The above commitment was achieved by designating and training additional plant staff to fulfill ERO positions thereby, increasing the depth of the organization. | ||
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Additionally, in 2006, two (2) additional off-hours unannounced drills were conducted in March and April to verify the ability of the ERO to staff the Technical Support Center (TSC), Operation Support Center (OSC) and Emergency Operation Facility (EOF). After each drill critique process (self-assessment) was used to identify areas for improvement. | Additionally, in 2006, two (2) additional off-hours unannounced drills were conducted in March and April to verify the ability of the ERO to staff the Technical Support Center (TSC), Operation Support Center (OSC) and Emergency Operation Facility (EOF). After each drill critique process (self-assessment) was used to identify areas for improvement. | ||
Corrective actions were generated and implemented prior to the performance of the next drill. All drill objectives were demonstrated satisfactory during the December 2005, March 2006 and April 2006 unannounced drills. Additionally in October 2006, a successful Graded EP Exercise was conducted with no significant issues identified in ability to staff the ERO facilities. | Corrective actions were generated and implemented prior to the performance of the next drill. All drill objectives were demonstrated satisfactory during the December 2005, March 2006 and April 2006 unannounced drills. Additionally in October 2006, a successful Graded EP Exercise was conducted with no significant issues identified in ability to staff the ERO facilities. | ||
4.4 Sustained Improved Performance: | |||
Improved Performance: | |||
During the past year the depth of the ERO responders was increased to provide for improved staffing capability for responding to site emergencies thereby, providing additional assurance in maintaining adequate measures to protect the public health and safety. To monitor this, a periodic review will be conducted by Manager of Emergency Response Section (ERS) to verify that adequate staffing is maintained to support the ERO at PNPP. This review will be performed in accordance with procedure PYBP-ERS-0009, "Annual Review of the Perry Plant Emergency Plan." As stated above, FENOC demonstrated sustained performance during the last three (3) performances of the off-hours drills. Additionally, FENOC committed to performing more frequent off-hours unannounced ddll in the future. An off-hour unannounced drill will be conducted at least once per fuel cycle even though the Emergency Plan requirement is to conduct the drill once every six years. This frequency for performing the drill is discussed in procedure PYBP-ERS-0033, "Off-hour Unannounced Drill Conduct." These actions demonstrate the commitment by FENOC to continue the improved performance of Emergency Preparedness at PNPP going forward.Following each drill, a critique is conducted and areas for continuing improvement are identified and acted on. This process provides assurance that the PNPP performance in the area of Emergency Preparedness will continue to improve.During the NRC inspection (IR 2006010), the NRC team concluded that actions taken to address issue in the emergency preparedness have been effective. | During the past year the depth of the ERO responders was increased to provide for improved staffing capability for responding to site emergencies thereby, providing additional assurance in maintaining adequate measures to protect the public health and safety. To monitor this, a periodic review will be conducted by Manager of Emergency Response Section (ERS) to verify that adequate staffing is maintained to support the ERO at PNPP. This review will be performed in accordance with procedure PYBP-ERS-0009, "Annual Review of the Perry Plant Emergency Plan." As stated above, FENOC demonstrated sustained performance during the last three (3) performances of the off-hours drills. Additionally, FENOC committed to performing more frequent off-hours unannounced ddll in the future. An off-hour unannounced drill will be conducted at least once per fuel cycle even though the Emergency Plan requirement is to conduct the drill once every six years. This frequency for performing the drill is discussed in procedure PYBP-ERS-0033, "Off-hour Unannounced Drill Conduct." These actions demonstrate the commitment by FENOC to continue the improved performance of Emergency Preparedness at PNPP going forward.Following each drill, a critique is conducted and areas for continuing improvement are identified and acted on. This process provides assurance that the PNPP performance in the area of Emergency Preparedness will continue to improve.During the NRC inspection (IR 2006010), the NRC team concluded that actions taken to address issue in the emergency preparedness have been effective. | ||
As a result, the NRC stated that they do not intend to conduct any additional inspection in this area beyond that which is normally prescribed by Reactor Oversight Process baseline inspection program.In October 2006, subsequent to the above NRC Inspection, a graded EP exercise was performed with no findings. | As a result, the NRC stated that they do not intend to conduct any additional inspection in this area beyond that which is normally prescribed by Reactor Oversight Process baseline inspection program.In October 2006, subsequent to the above NRC Inspection, a graded EP exercise was performed with no findings. | ||
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Take action to improve Third 2005 Complete performance when expectations are not met and hold the organization accountable for overall CAP effectiveness. | Take action to improve Third 2005 Complete performance when expectations are not met and hold the organization accountable for overall CAP effectiveness. | ||
2.d Perform a self-assessment that evaluates the overall health of the CAP, including an aggregate assessment of key performance indicator Fourth 2006 Complete trends. Assess whether substantial progress has been made in CAP performance. | 2.d Perform a self-assessment that evaluates the overall health of the CAP, including an aggregate assessment of key performance indicator Fourth 2006 Complete trends. Assess whether substantial progress has been made in CAP performance. | ||
3.0 Excellence in Human Performance 3.a Roles and responsibilities of the Site Leadership Team in implementing the human performance program will be defined and Fourth 2005 Complete communicated. | |||
in Human Performance 3.a Roles and responsibilities of the Site Leadership Team in implementing the human performance program will be defined and Fourth 2005 Complete communicated. | |||
3.b Approximately monthly Site Training Advisory Committee and department | 3.b Approximately monthly Site Training Advisory Committee and department | ||
/ section Training Review Committee meetings have been held Fourth 2005 Complete and will continue to be conducted with a strong focus on human performance through fourth quarter 2005.3.c The purpose and key activities of the Human Performance Program will be communicated to Perry Nuclear Power Plant (PNPP) personnel. | / section Training Review Committee meetings have been held Fourth 2005 Complete and will continue to be conducted with a strong focus on human performance through fourth quarter 2005.3.c The purpose and key activities of the Human Performance Program will be communicated to Perry Nuclear Power Plant (PNPP) personnel. | ||
Fourth 2005 Complete 3.d Group-specific needs analyses will be performed by training committees to determine the scope and content of initial and continuing First 2006 Complete training needs on human performance fundamentals and error prevention tools and training will be provided.4.0 Emergency Preparedness 4.a FENOC is expanding the population of qualified EP responders by approximately 125 persons to increase the depth of the emergency Fourth 2005 Complete response organization. | Fourth 2005 Complete 3.d Group-specific needs analyses will be performed by training committees to determine the scope and content of initial and continuing First 2006 Complete training needs on human performance fundamentals and error prevention tools and training will be provided.4.0 Emergency Preparedness 4.a FENOC is expanding the population of qualified EP responders by approximately 125 persons to increase the depth of the emergency Fourth 2005 Complete response organization. | ||
4.b Additional drills will be conducted to demonstrate appropriate Emergency Response Organization response times.Fourth 2005 Complete Attachment PY-CEI/OIE-0683L Page 22 LIST OF ACRONYMS USED CAL Confirmatory Action Letter CACB Corrective Action Closure Board CARB Corrective Action Review Board CR Condition Report CRC Curriculum Review Committee DAMP Detailed Action and Monitoring Plan EOF Emergency Operation Facility EP Emergency Planning ERO Emergency Response Organization ERS Emergency Response Section ESW Emergency Service Water GMI General Maintenance Instructions HPCS High Pressure Core Spray IPA Integrated Performance Assessment IR Inspection Report KPI Key Performance Indicators LTA Less Than Adequate MPR Management Performance Review MRB Management Review Board OSC Operation Support Center PAT Plant Access Training PII Performance Improvement Initiative PNPP Perry Nuclear Power Plant PRA Probabilistic Risk Assessment QC Quality Control RAW Risk Achievement Worth RRW Risk Reduction Worth SAT Systems Approach to Training SLT Senior Leadership Team STAC Senior Training Advisory Committee TRC Training Review Committee TSC Technical Support Center}} | 4.b Additional drills will be conducted to demonstrate appropriate Emergency Response Organization response times.Fourth 2005 Complete Attachment PY-CEI/OIE-0683L Page 22 LIST OF ACRONYMS USED CAL Confirmatory Action Letter CACB Corrective Action Closure Board CARB Corrective Action Review Board CR Condition Report CRC Curriculum Review Committee DAMP Detailed Action and Monitoring Plan EOF Emergency Operation Facility EP Emergency Planning ERO Emergency Response Organization ERS Emergency Response Section ESW Emergency Service Water GMI General Maintenance Instructions HPCS High Pressure Core Spray IPA Integrated Performance Assessment IR Inspection Report KPI Key Performance Indicators LTA Less Than Adequate MPR Management Performance Review MRB Management Review Board OSC Operation Support Center PAT Plant Access Training PII Performance Improvement Initiative PNPP Perry Nuclear Power Plant PRA Probabilistic Risk Assessment QC Quality Control RAW Risk Achievement Worth RRW Risk Reduction Worth SAT Systems Approach to Training SLT Senior Leadership Team STAC Senior Training Advisory Committee TRC Training Review Committee TSC Technical Support Center}} |
Revision as of 07:34, 13 July 2019
ML070180564 | |
Person / Time | |
---|---|
Site: | Perry ![]() |
Issue date: | 12/20/2006 |
From: | Pearce L FirstEnergy Nuclear Operating Co |
To: | Caldwell J Region 3 Administrator |
References | |
PY-CEI/OIE-0683L | |
Download: ML070180564 (24) | |
Text
FENOC~e~,, Nuclear Power Station 10 Center Road FirstEnergy Nuclear Operating Company Perry, Ohio 44081 L. William Pearce 440-280-5382 Vice PresiderDecember 20, 2006 Fax: 440-280-8029 PY-CEI/OIE-0683L Mr. James L. Caldwell Nuclear Regulatory Commission
.Regional Administrator, Region III 2443 Warrenville Road, Suite 210 Lisle, Illinois 60532-4352 Perry Nuclear Power Plant Docket No. 50-440 License No. NPF-58
Subject:
Request for Closure of Perry Nuclear Power Plant Confirmatory Action Letter Commitments
Dear Mr. Caldwell,
By letter dated September 28, 2005, the NRC issued a Confirmatory Action Letter (CAL) to the Perry Nuclear Power Plant (PNPP). That letter confirmed the understanding of actions FirstEnergy Nuclear Operating Company (FENOC) was planning to take to improve the performance at PNPP and confirmed FENOC's specific commitments as stated in previous correspondence dated August 8 and 17, 2005. This letter is the first of two letters FENOC is submitting to NRC. This letter provides a summary of actions taken, results achieved and the basis for closure of each of PNPP's 13 CAL commitments.
FENOC implemented the PNPP Performance Improvement Initiative (PII), Phase 2 to drive completion of each of the CAL commitments and guide actions to improve performance in each of the areas identified in the CAL. The second letter will describe the performance improvements achieved thru the PII, Phase 2, the results of our closure assessments and the transition to FENOC Excellence Plans which provide reasonable assurance that the improvements will be sustainable.
Collectively, the closure of the individual commitments and the results of those actions demonstrate that FENOC has achieved sustained improved performance in the four areas listed in the CAL.As discussed in our letter dated, November 13, 2006, FENOC has completed 13 CAL commitments in the following four areas: IP 95002 Inspection Follow-up Issues, Corrective Action Program Implementation, Human Performance, and Emergency Preparedness.
The actions taken to complete these commitments and improve performance were implemented in 2005 and 2006. These actions, the resultant improvements achieved, and the basis for closure of each commitment are described in the attachment to this letter. During 2005 and 2006, the NRC conducted CAL follow-up inspections in these areas and confirmed that each of the 13 CAL commitments was adequately implemented.
As discussed at the NRC public meeting on December 13, 2006, FENOC has demonstrated that it has substantially improved performance at PNPP in the four areas addressed by the CAL.FENOC is providing the basis for closure of all of the individual CAL Commitments in the attachment to this letter and has demonstrated that it has achieved sustained improved performance in each of the CAL areas. Therefore, FENOC requests that NRC close the Confirmatory Action Letter consistent with the criteria set-forth in the CAL.As noted above, in addition to implementing the individual commitments in the CAL, PNPP also established and implemented the PNPP Performance Improvement Initiative.
FENOC and the PY-CEI-OEI-0683L Page 2 NRC will discuss overall improvement of station performance achieved thru the PNPP Performance Improvement Initiative, the closure of the individual Performance Improvement Initiatives and the transition to the FENOC Fleet and PNPP Site Excellence Plans during the forthcoming public meeting scheduled for January 10, 2007. Prior to this meeting, FENOC anticipates sending a follow-up letter to request transition from Column IV of the Action Matrix to an appropriate reduced level of regulatory oversight consistent with the guidance in set forth in NRC MC 0305.There are no additional commitments contained in this letter. If you have questions or require additional information, please contact Mr. Jeffrey Lausberg - Manager, Regulatory Compliance at (440) 280-5940.Attachments cc: Document Control Desk NRC Project Manager NRC Resident Inspector E. Duncan, NRC Rill Attachment PY-CEI/OIE-0683L Page 1 BASIS FOR CLOSURE OF CONFIRMATORY ACTION LETTER (CAL) COMMITMENTS The NRC performed the Inspection Procedure (IP) 95003 supplemental inspection in three phases in early 2005. The results of the inspection were documented in Inspection Report 05000440/2005003, dated July 8, 2005. Subsequent to the issuance of the inspection report, First Energy Nuclear Operating Company (FENOC) provided response to the inspection report in letters dated August 8 and 17, 2005 and initiated the Perry Nuclear Power Plant (PNPP) Performance Improvement Initiative, Phase 2. In those letters, FENOC described its plans to improve performance and provided 13 specific commitments in the areas of IP 95002 Inspection Follow-up Issues, Corrective Action Program, Human Performance, and Emergency Preparedness.
Those specific commitments in the FENOC letters were later identified as PNPP Confirmatory Actions Letter (CAL) commitments in the NRC letter dated, September 28, 2005. Through the implementation of the PNPP Performance Improvement Initiatives, FENOC has made consistent improvements in the four areas identified in the CAL. This attachment describes the results of the actions taken to complete each of the thirteen CAL commitments.
Additionally, as requested in the NRC CAL, FENOC had provided quarterly updates to those specific actions specified in Attachment 3 of FENOC letters dated August 8 and 17, 2005.The quarterly updates were provided in letters dated October 28, 2005, January 30, 2006, April 17, 2006, July 28, 2006, October 31, 2006 and November 13, 2006.For each of the four areas identified in the CAL, this attachment restates the CAI_commitment for ease of reference, describes the purpose of the commitment, describes the results of actions taken to complete each commitment, provides the basis for closure of the commitment, and demonstrates that there has been sustained improved performance in the area.In order to provide focused management oversight of these commitments, FENOC placed actions to implement the commitments in the Detailed Action and Monitoring Plan (DAMP) the Perry Performance Improvement Initiative (PII). The following discussion references the applicable DAMP actions. The four areas and thirteen commitments are listed in table 1 of this attachment.
1.0 IP 95002 Inspection Follow-up Issues 1.1 CAL Commitment
==
Description:==
"Issues dealing with the quality of maintenance procedures including quality control inspection hold points. Revision of the Quality Control Inspection Program to focus additional attention on items that have experienced repeat failures." 1.2 Purpose: The above CAL commitment contains three (3) actions. First, FENOC stated in response to NRC IP 95003 inspection report (IR 2005003), that one hundred eight (108) of the one hundred nineteen (119) procedures been updated and issued. The remaining maintenance procedures will be updated and owner's review completed.
[CAL Commitment l.a]
Attachment PY-CEI/OIE-0683L Page 2 Second, FENOC stated that it would revise Nuclear Quality Assurance Instruction NQI-1001, "QC Inspection Program Control," to specify a method to establish additional QC inspection items for items that have experienced repeat failures.
This method was to include consideration of failure analysis, the risk-significance of the item, and the probability of failure occurrence in determining the extent of inspection activity.
[CAL Commitment 1 .b]Third, FENOC stated that it would revise Generic Mechanical Instructions (GMI)-0039, "Disassembly/Re-assembly of Divisions I and II Emergency Service Water Pumps," and GMI-0040, "Disassembly
/ Re-assembly of Division III Emergency Service Water Pump," to include QC inspection points for work activities associated with pump shaft couplings, as specified by QC.[CAL Commitment 1.c]1.3 Basis For Commitment Closure: The CAL commitments for addressing the IP 95002 follow-up issues are complete.
Provided below are basis for closure of the individual CAL commitments and summary of actions taken to achieve sustained improved performance in each of the CAL areas.CAL Commitment 1.a / DAMP Appendix Action B.2.2.3.1 This commitment involves upgrade of the key maintenance procedures.
In letter dated, October 28, 2005, FENOC stated that the above CAL commitment was completed in third quarter 2005.In third quarter 2005, FENOC completed upgrade of the remaining key maintenance procedures.
The scope of this upgrade project included those maintenance procedures that are directly or indirectly associated with select key components at PNPP. These key components included both the high safety-significant components, those having a risk achievement worth (RAW)of greater than 2.0 and a Risk Reduction Worth (RRW) of greater than 1.005, and other risk-significant components, including the Emergency Service Water (ESW) pumps. Also, the scope included those additional maintenance procedures that the Senior Leadership Team considered to be important based on their significance and other select multi-use maintenance procedures.
The upgraded maintenance procedures were an improvement to the previous revisions, both in content, formatting, and ease of use.However, several potential deficiencies were identified with the upgraded maintenance procedures.
They included:
typographical errors, formatting inconsistencies, proper step sequencing, faulty references, missing information, and proper use / identification of critical steps. To address these potential deficiencies, FENOC generated Condition Report (CR) 06-00418 and commenced supplemental procedure review to revalidate the upgraded maintenance procedures.
As part of the supplemental review effort, FENOC undertook the following actions to improve the quality of the maintenance procedures:
Developed new procedure writer's guide for improved formatting
/ sequencing of procedures (PAP 500, "Perry Technical Procedure Writer's Guide")
Attachment PY-CEI/OIE-0683L Page 3 o Revised the definition for "Critical Stop" to align with industry standards o Provided training for procedure writers o Provided training on procedure use and adherence training for Maintenance personnel (NOP-LP-2601, "Procedure Use and Adherence")
Additionally, procedures that were not verified by field use or through the supplemental review effort were put on hold.The following dgorous review and approval process is being applied during the supplemental review of the maintenance procedures:
o Technical and Craft review, such that the users of the procedures involved in the review process o Cross-Discipline review (PAP 507, "Perry Supplemental Procedure Requirement Guidance"), such that other site organizations (e.g., engineering) who provided input to the procedure develop are involved in the review process o Validation of procedures (PAP 550.3, "Procedure Validation")
o Independent Qualified Review (NOP-SS-3001, "Procedure Review and Approval"), such that independent review/approval of the procedures is performed prior to issuance.At the August 15, 2006 public meeting, FENOC stated that at least 70 of the original 119 maintenance procedures (now 121 procedures since some procedures were split into two or more procedures for ease during the revalidation effort) will be re-validated, approved and made effective by October 23, 2006. This action was accomplished.
The remainder is scheduled for completion by December 21, 2006.In October 2006, the NRC inspected a number of of those revalidated maintenance procedures and found them to be effective and improved in quality. The results of this inspection were discussed during the Decmber 13, 2006 public meting. No findings were identified during the inspection (IR 2006015).CAL Commitment 1.b / DAMP Appendix Action B.2.2.3.:~
This commitment involves identification of criteria for the Quality Control (QC)inspection hold points based on failure history, risk significance and failure probability.
In letter dated, October 28, 2005, FENOC stated that the above CAL commitment was completed in third quarter 2005.In third quarter 2005, FENOC revised procedure NQI-1001, "QC Inspection Program Control," Revision 5, to identify criteria for assigning QC inspection hold points, including failure history, risk significance and failure probability in assigning QC inspection hold points. Although, the change to the procedure was deemed appropriate during the NRC follow-up inspection of IP 95002 (IR 2006007), the inspectors identified that the methods identified and in use did not take full advantage of all site programs.
In particular, the procedure did not prescribe the review of the maintenance rule database, which collects Attachment PY-CEI/OIE-0683L Page 4 pertinent component failure data, nor did it integrate the probabilistic risk assessment (PRA) model, which provides component-specific risk information.
To address this observation, CR 06-00366 was generated and corrective actions have been taken, as discussed below. Also, on December 19, 2005, NQ1-1001 was superseded by fleet common procedure Nuclear Operating Procedure, NOP-LP-2018, "Quality Control Inspection of Maintenance and Modification Activities." As discussed in our response to Inspection Report 2006007 (FENOC letter dated May 09, 2006), use of the Maintenance Rule database is not an optimum method to identify additional QC/witness points. Since the condition reports drive the maintenance rule evaluation through the corrective actions, historical failure data can be obtained through the review of condition reports for those components that are considered to be a maintenance rule failure.Therefore, historical data from the condition reporting system will be used for the identification of repeat failure items for potential assignment of hold /witness points.The following enhancements were added to procedure NOP-LP-2018:
o Use of pre-established "Critical Steps" as a factor when assigning QC hold / witness points o Use of risk significance assessment tool at a component level as a factor when assigning hold / witness points o Use of risk significance, maintenance rule, critical components, and maintenance modifications as factors that the QC supervisor will utilize when assigning process monitoring During the subsequent NRC inspection conducted in July/August 2006 (IR 2006014), the inspectors observed that the QC inspection point assignment program was currently effective and likely to be effective in the future based upon the program that has been established.
CAL Commitment 1.c / DAMP Appendix Action B.2.2.3.3 This commitment involves updating General Maintenance Instructions (GMI)GMI-0039 and GMI-0040 to include QC inspections points for work activities associated with ESW pump shaft couplings.
In letter dated, October 28, 2005, FENOC stated that the above CAL commitment was completed in third quarter 2005.During the NRC inspection conducted in first quarter 2006 (IR 2006007), the NRC inspector confirmed that the licensee had added appropriate QC hold points to coupling reassembly sections of ESW pump rebuild procedures GMI-0039 and GMI-0040.
Additionally, during the subsequent NRC inspection (IR 2006014), the inspectors concluded that the licensee's corrective actions had been effective in addressing the ESW Pump Coupling Assembly concern area. In particular, the inspectors concluded that the licensee had established an adequate QC Inspection Point Assignment program; had properly assigned QC inspection hold pints to all work order packages that were reviewed; and had concluded an adequate self-assessment of the QC Inspection Point Assignment program.
Attachment PY-CEI/OIE-O683L Page 5 1.4 Sustained Improved Performance:
With respect to the upgraded maintenance procedures, they were used during recent maintenance activities (e.g., Division 2 Outage work activities, motor operated valve work) with minor or no issues. The issues identified were further enhancements to those procedures.
These procedures provided instructions to perform quality work with maintenance craft buy-in since they were directly involved with the upgrade project.Administrative controls have been established for addressing the upkeep and upgrade of future maintenance procedures.
For example, the procedure wdters guide, PAP-500, "Perry Technical Procedure Writer's Guide" provides appropriate guidance for establishing consistent maintenance procedures (e.g., format, technical content, sequencing of steps). The use of station maintenance craft personnel for procedure reviews and training provide for better quality procedures.
Additionally, the maintenance personnel were trained to procedure use and adherence in accordance to procedure NOP-LP-2601, "Procedure Use and Adherence," both in classroom and dynamic training settings.The supplemental review of the original 119 key maintenance procedures are on schedule and are scheduled for completion by December 21, 2006. As part of the continuing focus area for the site, a backlog reduction effort for outstanding procedure change requests will commence in 2007. Additionally, maintenance will commence Phase 2 of the maintenance procedure upgrade in 2007 (i.e., upgrade of next set of approximately 105 maintenance procedures).
These actions are incorporated in the Perry Excellence Plan.As discussed above, procedure NOP-LP-2018 was revised to provide appropriate controls for establishing QC inspection points for work activities at PNPP. Additionally, appropriate QC hold points were established in GMI-0039 and GMI-0040 for work activities associated with ESW pump shaft couplings.
In October 2006, the NRC inspected a number of revalidated maintenance procedures and found them to be effective and much improved in quality. No findings were identified during the inspection (IR 2006015).1.5
References:
-NRC IR 2006007, dated March 30, 2006-NRC IR 2006014, dated September 20, 2006-NRC IR 2006015 (to be issued in December 2006)-FENOC letter ID PY-CEI/NRR-2959L, dated May 09, 2006-FENOC letter ID PY-CEI/NRR-2996L, dated October 26, 2006 2.0 Corrective Action Program Implementation Improvement 2.1 CAL. Commitment
==
Description:==
"Develop and train site staff on expectations for successful corrective action program (CAP) implementation, Implement management controls to improve line ownership and accountability for successful CAP implementation.
Attachment PY-CEI/OIE-0683L Page 6 Establish a management process to routinely monitor CAP performance at the site and department
/ section levels (e.g., operations, electrical maintenance, plant engineering, etc.). Perform a self-assessment that evaluates the overall health of the CAP following implementation of specific improvement initiatives." 2.2 Purpose: The above CAL commitment contains four (4) actions. First, FENOC stated in response to NRC IP 95003 inspection report (IR 2005003), that expectations necessary for successful implementation of the corrective action program (CAP) will be developed and site personnel will be trained to the expectations and accountability methods that will be used to improve implementation of the CAP. [CAL Commitment 2.a]Second, FENOC stated it would implement management controls to improve line ownership and accountability at the individual level for successful implementation of the CAP. [CAL Commitment 2.b]Third, FENOC stated it would establish a management review process that routinely monitors the site's and section level CAP performance.
Take action to improve performance when expectations are not met and hold the organization accountable for overall CAP effectiveness.
[CAL Commitment.
2.c]Fourth, FENOC would perform a self-assessment that evaluates the overall health of the CAP, including an aggregate assessment of key performance indicator trends. Assess whether substantial progress has been made in CAP performance.
[CAL Commitment 2.d]2.3 Basis For Commitment Closure: The CAL commitments for improving the implementation of the corrective action program are complete.
Provided below are basis for closure of the individual CAL commitments and summary of actions taken to achieve sustained improved performance in each of the CAL areas.In 2004 mid-cycle plant performance assessment letter (dated August 30, 2004), the NRC identified a substantive cross-cutting issue in the area of problem identification and resolution involving a number of findings.Examples included:
the repetitive failure of the Division 1 emergency service water pump, an inadequate extent of condition review following the failure of the HPCS pump to start, and missed opportunities to identify the low pressure core spray / residual heat removal system venting procedure deficiencies.
Further, the need to perform multiple revisions of root cause evaluations was considered to be indicative of significant organizational deficiencies.
During the IP 95003 inspection in early 2005, the NRC team identified similar performance issues in this area.As discussed in our letter dated August 17, 2005 (PY-CEI/NRR-2902L), FENOC conducted root cause analysis (CR 05-03986) to address continued performance issues with implementation of the CAP. The root cause concluded that although the programmatic aspects of the CAP are adequate, Attachment PY-CEI/OIE-0683L Page 7 the behaviors necessary for its effective implementation are not. Specifically, the root cause analysis identified the following root and contributing causes as the main contributors for ineffective implementation of CAP at PNPP: Root Causes The PNPP management team has not owned the CAP and has not used the program to effectively solve problems and improve station performance.
o Management has not established adequate expectations to ensure the CAP is effectively implemented at all levels in the organization.
Contributinq Causes o The PNPP organization has not accepted using the CAP to identify and solve problems in a timely manner.The PNPP management has not consistently monitored CAP health and effectively taken intervention actions to drive improvement in the CAP.o The existing expectations are not being reinforced by a consistent review process that includes appropriate rewards/accountability.
Appropriate corrective actions were developed and implemented to address the above root and contributing causes. The following provides the key actions taken for addressing the ineffective implementation of CAP at PNPP.CAL Commitment 2.a I DAMP Actions 1.1.1 and 1.2.1 This commitment involves developing expectations necessary for successful implementation of the CAP and training site personnel to the expectations and accountability methods that will be used to improve implementation.
In letter dated, January 30, 2006, FENOC stated that the above CAL commitment was completed in fourth quarter 2005.In fourth quarter 2005, FENOC trained site personnel to the CAP implementation expectations.
The course outline was based on procedure PYBP-SITE-0046, "Corrective Action Program Implementation Expectations." The expectation document identifies the correct behaviors for use of the CAP process. The training session also focused on the two root causes and the three prevent recurrence corrective actions identified in CR 05-03986, which pertains to the root cause analysis that was performed to address continued declining performance in CAP. The training session was piloted through the Perry Senior Leadership Team (SLT), managers and supervisors, and analysts prior to roll-out to site personnel to obtain their endorsement.
Also, the training was tailored to individual sections onsite so that emphasis could be placed on the expectations and accountability methods for their sections.For example, the maintenance training was more focused on problem identification and engineering sessions were more focused on timely and quality investigations.
This training provided the foundation for improving ownership of CAP and station focus on using the CAP through better Attachment PY-CEI/OIE-0683L Page 8 understanding of expectations and accountability for use of the FENOC corrective action program.One objective for the training included the role of a CAP in an environment of a learning organization and how it must be used to drive station improvement.
The training also emphasized the expectations of site individuals for implementing effective CAP that were not consistently reinforced in the past. The individual performance appraisal process was revised to ensure expectations were understood and accountability methods were established.
During follow-up NRC inspections (IR 2006008 / 2006015), the NRC inspection team determined that the actions were adequately implemented and effective.
The results of the inspection (IR 2006015)were discussed the December 13, 2006 public meeting.CAL Commitment 2.b / DAMP Action 1.1.2 This commitment involves implementing management controls to improve line ownership and accountability at the individual level for successful implementation of the CAP. In a letter dated, October 28,2005, FENOC stated that the above CAL commitment was completed in third quarter 2005.In third quarter 2005, FENOC revised the expectations in the staff performance appraisals.
In particular, the differences in responsibilities for implementing the corrective action program were identified and individual performance appraisal elements were modified for each department position.The purpose of this action was to establish individual accountability for use of the CAP to identify and solve problems in a timely manner and to reinforce existing expectations by a consistent review process. This action also established management accountability for monitoring CAP program health and taking effective intervention actions to drive improvement in CAP.During follow-up NRC inspections (IR 2006008 / 2006015), the NRC team determined that the actions taken were adequately implemented and effective.
The results of the IR 2006015 were discussed at the December 13, 2006 public meeting.CAL Commitment 2.c / DAMP Action 1.7.1 This commitment involves establishing a management review process that routinely monitors the site's and section level CAP performance and takes action to improve performance when expectations are not met and hold the organization accountable for overall CAP effectiveness.
In a letter dated, October 28, 2005, FENOC stated that the above CAL commitment was completed in third quarter 2005.The management review process is administratively governed in several FENOC Fleet and Site procedures.
These procedures guide the oversight of the CAP and initiate intervention activities to ensure weaknesses in CAP are addressed.
For example: fleet procedure NOP-LP-2001, "Corrective Action Program," directs FENOC management to ensure effective implementation of the CAP and to monitor CAP process performance to address programmatic Attachment PY-CEI/OIE-0683L Page 9 weaknesses; fleet procedure NOBP-LP-2008, "Corrective Action Review Board," requires CAP performance indicators to be periodically reviewed;and, site procedure PYBP-SITE-0046, "Corrective Action Program Implementation Expectations; directs the management team to provide oversight of the condition report process and specifically review the CAP performance indicators on a periodic basis.In July 2005, an improved set of CAP key performance indicators (KPIs)were developed.
These KPIs are periodically reviewed by the Corrective Action Review Board. Analyses of weak areas are addressed and gap closure plans developed and implemented to address those weaknesses.
Also, Perry CAP performance review has been a standing agenda item for the weekly Perry Senior Leadership Team meetings.Additionally, the following levels of management reviews were instituted to ensure adequate oversight of the health of CAP at PNPP. They include: o Corrective Action Review Board (CARB) Meetings:
The CARB activity is governed by procedure NOBP-LP-2008 and provides oversight of CAP. The CARB review includes:
root cause and full apparent cause evaluations and corrective actions, condition report effectiveness review plans and reviews, condition reports documenting adverse trends, operating experience evaluation reviews, and periodic review of CAP performance indicators.
Additionally, CARB has established a "CARB Focus Day" that provide review of specific CAP focus areas such as, review of CR/CA backlogs, analysis of KPIs. The focus day is typically conducted on a once per month cycle.o Mana.qement Review Board (MRB) Meetinqs:
The MRB activity is governed by procedure NOP-LP-2001.
The MRB meets daily during the normal work days to review newly generated condition reports. The MRB review includes:
review of condition report issues to ensure that they are assigned the appropriate significance level, ownership, level of evaluation and timeliness of the evaluation.
The MRB may also establish:
Maintenance Rule component/system evaluation, CARB review of non-root cause condition reports, effectiveness review for non-root cause condition reports, site or section human performance clock reset evaluations, nomination of good/great catches, need for immediate actions to address identified conditions, and need for common cause analysis.Senior Leadership Team (SLT) Meetin.qs:
The SLT consists of onsite senior management team that provides oversight of current plant activities that includes review of CAP performance.
The SLT meets on a weekly basis.Monthly Performance Review (MPR): The MPR is held on a monthly basis at each of the FENOC sites to review their performance.
The MPR is attended by fleet directors, managers, and the executive leadership team. The MPR includes review of the monthly performance reports that includes indicators for: plant Attachment PY-CEI/OIE-0683L Page 10 performance, site performance, NRC regulatory performance, human performance, CAP performance, plant operations, cost effectiveness and people, processes, and procedures.
During the NRC inspection (IR 2006008), the NRC concluded that the actions were adequately implemented for this CAL commitment.
However, the NRC team observed that a formal mechanism to address KPI issues within the corrective action program did not exist. In particular, written guidance was not available that prescribed the generation of a condition report to address declining KPIs, performance gaps between actual and expected performance, the development of action plans to reduce the gap between actual and expected performance, or the tracking of the success of action plans to address identified performance deficiencies.
Although specific guidance did not exist, the NRC team did not identify any declining KPIs for which appropriate corrective actions had not been implemented.
The NRC team concluded that the lack of a formal process to address KPI issue could impact the long-term effectiveness of the actions.To address this observation, FENOC revised procedure PYBP-SITE-0046 to develop and document a process that defined Section level responses to their KPIs, and defined when gap closure plans are to be developed and reviewed (and what communications will be disseminated from these reviews).
During the recent NRC CAL Follow-up Inspection for CAP (IR 2006015), the NRC team deemed that the changes made to procedure PYBP-SITE-0046 were effective.
The result of the IR 2006015 was discussed at the December 13, 2006 public meeting.CAL Commitment 2.d / DAMP Action 1.1.12 This commitment involves performing a self-assessment that evaluates the overall health of the CAP, including an aggregate assessment of key performance indicator trends. Also, the assessment will determine whether substantial progress has been made in CAP. In a letter dated, November 13, 2006, FENOC stated that the above CAL commitment was completed in fourth quarter 2006.In fourth quarter 2006, FENOC completed the self-assessment to evaluate the overall health of the CAP, including aggregate assessment of the KPI trends. The assessment evaluated whether significant progress has been achieved and whether there is reasonable evidence that improvements are continuous and sustainable in CAP. The assessment team consisted of industry and FENOC peers, as well as station personnel.
This self-assessment is documented in report number SA 846PYRC2006.
The self-assessment team used structured data collection and analysis methods for assessing the CAP. The methods included:
interviews with Condition Report (CR) analysts, evaluators and managers from operations, maintenance, engineering and radiation protection; interviews with root and apparent cause evaluators; observation of initial CR Screening Committee meetings, MRB, CARD, and Corrective Action Closure Board (CACB); review of CAP KPIs; review of select root and apparent cause evaluations relative to quality of analysis, quality and appropriateness of actions and effectiveness of implementation of corrective actions and extent of condition/cause; review Attachment PY-CEI/OIE-0683L Page 11 of CAP backlogs and work-off plans; and review of section cognitive binning and Integrated Performance Assessments (IPA) evaluations.
Corrective action products (e.g., root and apparent cause evaluations) from 2005 were reviewed and compared to 2006 products to assist in the determination of whether improvements have been made. The trends in KPls were also reviewed to assess changes in performance from 2005 to 2006.Overall, the self assessment concluded that: o Substantial improvement has been made in Station's ownership and implementation of the CAP since January of 2005 o Improvements are sustainable o Notwithstanding the improvements, opportunities for improvement still exist In summary, the following noteworthy improvements and areas for improvement were identified during the self-assessment:
Noteworthy Improvements o Station ownership and focus on CAP o Healthy threshold for identifying adverse conditions o Classification and priodtization of issues o Timely completion of root and apparent cause evaluations o Quality of closure documentation for CRs and CAs o Improved oversight of CAP Areas for Continuin.q Improvement o Timely review of CAP products by Corrective Action Closure Board o Owner manager attendance at CARB o Standard of 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> for root cause evaluation team assembly is sometimes missed o Standard of supervisory review of new CRs in less than 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> is sometimes missed o Standard for preparation of trend reports on time is sometimes missed o Additional training on extent of condition and extent of cause is warranted Condition reports were generated to document issues and Areas for Improvement (AFI) identified during the self-assessment.
These AFIs were incorporated into the Perry Excellence Plan for 2007 - 2008.During the NRC inspection (IR 2006015), the NRC team reviewed the above self-assessment and determined that the self-assessment adequately addressed the CAL commitment.
The result of the inspection (IR 2006015)was discussed at the December 13, 2006 public meeting.2.4 Sustained Improved Performance:
As discussed during the recent NRC inspection (IR 2006015), the CAP KPIs in conjunction with audits and self assessments, provide a basis to assess Attachment PY-CEI/OIE-0683L Page 12 the overall effectiveness of CAP. Corrective Action Program KPls show substantial improvement in many of the key areas since early 2005. In particular, the timeliness of completing the evaluations and the implementation of corrective actions has improved, demonstrating ownership by the line personnel.
The quality of the products from the Corrective Action Program has improved.
The improvement in the quality of apparent cause is a product of the improvement actions that increased the level of performance of Corrective Action Review Board. Also, as discussed during the recent NRC inspection (IR 2006015), the quality of the root cause evaluations has improved significantly in 2006 when compared to 2005.In summary, the threshold for capturing problems in the Corrective Action Program has lowered to levels where very low significance issues are being identified, providing confidence that problems are visible for management's attention.
Our staff is able to focus on evaluating and solving the problems with improved timeliness and improved quality. The ultimate benefit of good CAP performance is more reliable equipment performance enhancing safety.Also, as discussed above the root and contributing causes discussed in CR 05-03986 have been addressed through implementation of the corrective actions. Expectations, roles and responsibilities for management and site personnel were incorporated into FENOC Fleet and Perry procedures and business practices.
Site personnel, including supervisors and managers, have been trained to expectations and accountability methods used to measure the implementation of the CAP. Part of the training included the role of a corrective action program in a "learning organization" and how it must be used to drive station improvement.
The new employees receive introductory training of CAP during the Plant Access Training (PAT) and receive an orientation manual that contains key aspects of a successful CAP.In July 2005, an improved set of CAP KPIs was developed and are periodically reviewed by management.
Various levels of management review processes have been instituted or improved to ensure adequate oversight of the health of CAP going forward. They include CARB, MRB, SLT and MPR meetings, and these measures are institutionalized in procedures and business practices.
Intervention actions are implemented if declining performance
/ trends are identified.
Also, a self-assessment (as discussed above) was recently performed assess the overall health of CAP. The self-assessment concluded that substantial improvement has been made in Station's ownership and implementation of the CAP since January 2005 and those improvements are sustainable.
Fleet ownership of the procedures and expectations of CAP; and oversight provided by the senior leadership team and executive leadership team will provided reasonable assurance of sustained performance in CAP.Finally, the following key Fleet and Site CAP procedures and processes are in place to assure sustained performance going forward: o NOP-LP-2001, "Corrective Action Program" o NOP-LP-2100, "Operating Experience Program" Attachment PY-CEI/OIE-0683L Page 13 o NOBP-LP-2001, "FENOC Self-Assessment/Benchmarking" o NOBP-LP-2007, "Condition Report Process Effectiveness Review" o NOBP-LP-2008, "FENOC Corrective Action Review Board" o NOBP-LP-2010, "CREST Trending Codes" o NOBP-LP-2011, "FENOC Cause Analysis" o NOBP-LP-2018, "Integrated Performance Assessment
/ Trending" o NOBP-LP-2019, "Corrective Action Program Supplemental Expectations and Guidance" o PYBP-SITE-0046, "Corrective Action Program Implementation Expectations" 2.5
References:
-NRC Inspection Report 2006008, dated April 19, 2006-NRC IR 2006015 (to be issued in December 2006)-FENOC letter ID PY-CEI/NRR-2968L, dated May 24, 2006 3.0 Excellence in Human Performanc~
3.1 CAL Commitment
==
Description:==
"Define and communicate the Site Leadership Team's roles and responsibilities in implementing the human performance program. Focus Site Training Advisory Committee and department
/ section Training Review Committee meetings on human performance.
The Human Performance Program purpose and key activities will be communicated to all site personnel.
Group-specific needs analysis will be performed to identify the scope and content of human performance fundamentals and error preventative tool training." 3.2 Purpose: The above CAL commitment contains four (4) actions. First, roles and responsibilities of the Site Leadership Team in implementing the human performance program will be defined and communicated.
[CAL Commitment 3.a]Second, approximately monthly Site Training Advisory Committee and department
/ section Training Review Committee meetings have been held and will continue to be conducted with a strong focus on human performance through fourth quarter 2005. [CAL Commitment 3.b]Third, the purpose and key activities of the Human Performance Program will be communicated to Perry Nuclear Power Plant (PNPP) personnel.
[CAL Commitment 3.c]Fourth, group-specific needs analyses will be performed by training committees to determine the scope and content of initial and continuing training needs on human performance fundamentals and error prevention tools and training will be provided.
[CAL Commitment 3.d]
Attachment PY-CEI/OIE-O683L Page 14 3.3 Basis For Commitment Closure: The CAI_ commitments for improving human performance are complete.Provided below are basis for closure of the individual CAI_ commitments and summary of actions taken to achieve sustained improved performance in each of the CAI_ areas.In 2004 end-of-cycle plant performance assessment letter (dated March 2, 2005), the NRC identified a substantive cross-cutting issue in the area of human performance involving a number of findings related to personnel performance, with a common theme of failure to follow procedures or inattention to detail. Examples included:
the presence of unattended matedal in the pool swell region in containment, the failure to follow procedures for evaluating and dispositioning impaired tornado barriers, the improper installation of test equipment that subsequently damage a valve in the combustible gas control system, the improper installation of scaffolding underneath an annulus exhaust gas treatment system exhaust damper that rendered that train inoperable, and the improper use of the Fix-It-Now process on a containment isolation valve that resulted in inadequate post maintenance testing. During the IP 95003 inspection in early 2005, the NRC team identified similar performance issues in this area.As discussed in our letter dated August 17, 2005 (PY.-CEIINRR-2902L), FENOC conducted root cause analysis (CR 05-02517) to address continued performance issues with human performance at PNPP. The root cause concluded that weaknesses in human performance practices had degraded our barriers to prevent events. Specifically, the root cause analysis identified the following root and contributing causes as the main contributors for human performance issues: Root Causes o Less than adequate (LTA) management ownership of the human performance program at the appropriate levels in the organization.
o LTA program performance monitoring and trending Contributinq Causes o Program and process implementation weakness o I_TA procedure content o I_TA supervision o I_TA accountability and expectations o LTA expectations and standards Condition Report 05-02517 identifies the corrective actions that were implemented to address the root and contributing causes identified above.These actions strengthened the management support, expectation and ownership of human performance, established human performance Attachment PY-CEI/OIE-0683L Page 15 monitoring and trending, established expectations for use of human performance tools, developed qualification process for procedure writers, reinforced proper behaviors for using the field observation process and trained site personnel on human performance fundamentals.
The following provides the key actions taken for addressing the human performance issues at PNPP.CAL Commitment 3.a / DAMP 1.1.3.3 This commitment involves defining and communicating the Site Leadership Team's roles and responsibilities in implementing the human performance program. In the letter dated January 30, 2006, FENOC stated that the above commitment was completed in fourth quarter 2005.Roles and responsibilities of PNPP management (i.e., managers, directors, and site vice president) are defined in procedure NOBP-LP-2601, "Human Performance Program." Additionally, in September 2005, the President of FENOC issued Nuclear Operating Policy NOPL-LP-2008, "Human Performance." The intent of this policy is to establish clear expectations and principles for FENOC personnel to demonstrate event free behaviors throughout the organization to support safe and reliable plant operation.
Also, this policy reinforces that human performance tools will be used to establish a work environment in which individuals and leaders routinely exhibit behaviors which will reduce or even eliminate plant events caused by human error. This procedure establishes responsibilities and administrative controls that are required for safe and event-free performance at PNPP.In fourth quarter 2005, the PNPP management team was requested to review and to affirm their understanding of their roles and responsibilities as defined in Nuclear Operating Policy, NOPL-LP-2008 and procedure NOBP-LP-2601.
To further enhance the understanding of their roles and responsibilities, in first quarter 2006, site managers and directors were provided with a training session focused on managing human performance.
During this training session, group discussions were held that focused on leadership roles in promoting excellence in human performance.
During the NRC inspection (IR 2006012 / 2006017), the NRC team concluded that actions taken adequately implemented the CAL commitment and were effective.
The results of the inspection (IR 2006017) were discussed at the December 13, 2006 public meeting.CAL Commitment 3.b / DAMP Actions 1.2.3.1 and 1.2.3.2 This commitment involves focusing the Site Training Advisory Committee and department/section Training Review Committee meetings on human performance.
In the letter dated January 30, 2006, FENOC stated that the above commitment was completed in fourth quarter 2005.The purpose of the actions was to ensure that human performance issues that are resolvable by a training solution are systematically identified and Attachment PY-CEI/OIE-0683L Page 16 addressed by Section Training Review Committees (TRG), Curriculum Review Committees (GRG) and Senior Training Advisory Committee (STAG).The training team charter for TRC, CRC and STAG is discussed in procedure NOBP-TR-1117, Training Team Charter (this procedure is a FENOC fleet procedure that superseded the earlier PNPP procedure PYBP-PTS-0001).
The training team at FENOC sites is a functional coalition of line organizations and Training personnel that supports the identification, development, implementation and oversight of training programs through STAC, TRC and CRC. Curriculum Review Committees are representatives made up from the individual site sections (e.g., Chemistry, Maintenance, Operations, Radiation Protection).
The CRC determines the continuing training needs for their respective sections by reviewing industry and site performance data. The TRC provides oversight, coordination and direction to the CRC activities, performance standards, and changes that have potential impacts across training programs within their respective organizational areas.Radiation Protection and Chemistry Sections are not part of the TRC and oversight is provided by the STAC. The STAG oversees training for the site and ensures each training program is effectively implemented and meets or exceeds, industry standards.
Approximately, monthly meetings are held by these committees with a strong focus on human performance.
During the NRC inspection (IR 2006012), the NRC team concluded that actions adequately implemented the commitment.
The team determined that STAG, TRC, and CRC meetings were held about monthly and maintained a strong focus on human performance.
CAL Commitment 3.c I DAMP Actions 1.1.3.1 This commitment involves communicating the Human Performance Program purpose and key activities to site personnel.
In the letter dated January 30, 2006, FENOC stated that the above commitment was completed in fourth quarter 2005.The purpose and key activities of the Human Performance Program were communicated to site personnel through the following methods: 1) Site personnel participated in training sessions (Lesson Plan HU-TOOLSINTROFUND_PY-02), "Introduction to Human Performance Fundamentals," which focused on individual behaviors, leader behaviors, and organization processes and values; explained the human performance principles; and described how those principles provided additional barriers to plant events through individual behaviors, leader behaviors, and organizational processes and values; and 2) Site personnel participated in full day, "Human Performance Fundamentals" training session, with handouts that included procedures NOPL-LP-2008, "Human Performance Policy," and NOBP-LP-2601, "Human Performance Program." During the NRC inspection (IR 2006012), the NRC team concluded that actions adequately implemented the commitment.
CAL Commitment 3.d / DAMP Actions 1.1.3.4 and 1.1.3,5 This commitment involves performing group-specific needs analysis to identify the scope and content of human performance fundamentals and error Attachment PY-CEI/OIE-0683L Page 17 preventative tool training.
In the letter dated Apdl 17, 2006, FENOC stated that the above commitment was completed in first quarter 2006.FENOC performed the group-specific needs analyses by the following Curriculum Review Committees (CRC) and Training Review Committees (TRC): Maintenance TRC, Operations TRC, Engineering Support Personnel TRC, Chemistry CRC, Radiation Protection CRC, Supplemental CRC and balance of Perry personnel CRC. Gaps in training were determined by using appropriate Systems Approach to Training (SAT) methodology prescribed procedure NOBP-TR-1102, "FENOC Needs and Performance Gap Analyses." The analyses identified initial and continuous training needs. The initial training programs were further reviewed to determine training needs for station personnel.
The CRC/TRC determined that in addition to specialized human performance training provided at each section/department levels, personnel assigned to PNPP requires human performance fundamentals and error prevention tools training.
As a result, "Human Performance Fundamentals" and "Event Free Tools" training were provided to site personnel between October 2005 and March 2006. Site personnel received the necessary supplemental skills training with the exception of those individuals on long-term disability or on long-term offsite assignments.
Additionally, training materials were developed for new employees (similar to the training provided for existing employees) and training materials were developed for supplemental personnel (i.e., tailored for contract outage workers).
Continuing training needs will be specifically identified within the Needs Analysis as prescribed by procedure NOBP-TR-1102, and by Training and CRC/TRC.During the NRC inspection (IR 2006012), the NRC team concluded that actions adequately implemented the commitment.
3.4 Sustained Improved Performance:
The Human Performance program promotes the prevention of events due to human error by focusing on sustaining error-prevention behaviors.
The actions taken above in concert with implementation of the Perry Performance Improvement Initiative for Human Performance drove improvements in the behaviors resulting in a decline in consequential events that reset the Station Clock. The initiative actions were organized in three distinct stages; program structure, behavior modifications, and discipline in execution.
This program structure provided enhanced roles and responsibilities, management expectations, and improved processes.
Serving both to increase the skills and behaviors of the workers, the new level of awareness on human performance resulted in a decline in station events attributable to human error. Finally, the disciplined execution of the processes and behaviors continued this decline to a very low and sustained number of station events.Also, as discussed above the root and contributing causes discussed in root cause performed to address the human performance issues (CR 05-02517)have been addressed through implementation of the corrective actions.
Attachment PY-CEI/OIE-0683L Page 18 FENOC issued fleet Nuclear Operating Policy, NOPL-LP-2008 that clearly establishes the expectations for personnel throughout the organization to support safe and reliable plant operation.
Also, site procedure NOBP-LP-2601 establishes the roles and responsibilities of FENOC employees including management relative to human performance program.The management team also affirmed their understanding of their roles and responsibilities as defined in the policy and human performance program.The above policy and procedure provide the foundation for the management and employee engagement of human performance program at PNPP.Additionally, site personnel were trained to "Human Performance Fundamentals" and "Event Free Tools." These trainings reinforced their expectations of the human performance program and achieving error free performance while performing their jobs. A process has been developed to asses the need for continuing training programs based on performing needs analysis per procedure NOBP-TR-1102.
The group-specific needs analyses are conducted by CRC/TRC committees based on this process and STAC provides the oversight function.
Training matedal has been developed for new employees as well as for supplemental personnel (contract workers).Key performance indicators (KPI) for monitoring performance in the area human performance were established.
The "Human Performance Success Days" KPI monitors the site clock resets, and the "Section Clock Reset" KPI provides a means to focus on low level events and to increase focus on procedure use and adherence issues.Also, a self-assessment (SA886PYPII2006) was recently performed provide a focused evaluation of the effectiveness of the actions implemented to address human performance issues. The self-assessment concluded that significant progress has been achieved and there is reasonable evidence that improvement is continuous and sustainable.
Fleet ownership of the procedures and expectations of Human Performance, and oversight provided by the senior leadership team and executive leadership team will ensure sustained improved performance in Human Performance.
Finally, the following key Fleet and Site Human Performance policy and procedures are in place to assure sustained improved performance going forward: o NOPL-LP-2008, Human Performance Policy o NOP-LP-2601, Procedure Use and Adherence o NOBP-LP-2601, Human Performance Program o NOBP-LP-2602, Human Performance Success Clocks o NOBP-LP-2603, Human Performance Tools and Verification Practices o NOBP-LP-2604, Job Briefs o NOBP-LP-2607, Observation and Coaching Program o PYBP-SITE-2601, Perry Human Performance Team Charter Attachment PY-CEI/OIE-0683L Page 19 3.5
References:
-NRC Inspection Report 2006012, dated July 25, 2006-NRC IR 2006017 (to be issued in December 2006)-FENOC letter ID PY-CEI/NRR-2988L, dated August 25, 2006 4.0 Emergency Preparedness 4.1 CAL Commitment
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Description:==
"Expand the population of qualified EP responders to increase the emergency response organization's depth and conduct drills to demonstrate appropriate emergency response times." 4.2 Purpose: The above CAL commitment contains two (2) actions. First, FENOC stated in response to IP 95003 inspection report (IR 2005003), that it would expand the population of qualified emergency planning (EP) responders to increase the depth of the emergency response organization.
[CAL Commitment 4.a]Second, FENOC stated that it would conduct additional EP ddlls to demonstrate appropriate emergency response organization (ERO) response times. [CAL Commitment 4.b]4.3 Basis For Commitment Closure: The CAL commitments for improving the performance in the emergency preparedness area are complete.
Provided below are basis for closure of the individual CAL commitments and summary of actions taken to achieve sustained improved performance in each of the CAL areas.CAL Commitment 4.a / DAMP Appendix EP 1 This commitment involves expanding the population of qualified EP responders by approximately 125 persons to increase the depth of the ERO.In a letter dated, January 30, 2006, FENOC stated that the above CAL commitment was completed in fourth quarter 2005.The above commitment was achieved by designating and training additional plant staff to fulfill ERO positions thereby, increasing the depth of the organization.
This raised the population of the qualified ERO to 461 personnel at PNPP.CAL Commitment 4.b / DAMP Appendix EP 2 This commitment involves performing additional off-hours unannounced drills to demonstrate drill objectives have been achieved.
In a letter dated, January 30, 2006, FENOC stated that the above CAL commitment was completed in fourth quarter 2005.
Attachment PY-CEI/OIE-0683L Page 20 In 2005, three (3) off-hours unannounced drills were conducted in August, November and December.
Additionally, in 2006, two (2) additional off-hours unannounced drills were conducted in March and April to verify the ability of the ERO to staff the Technical Support Center (TSC), Operation Support Center (OSC) and Emergency Operation Facility (EOF). After each drill critique process (self-assessment) was used to identify areas for improvement.
Corrective actions were generated and implemented prior to the performance of the next drill. All drill objectives were demonstrated satisfactory during the December 2005, March 2006 and April 2006 unannounced drills. Additionally in October 2006, a successful Graded EP Exercise was conducted with no significant issues identified in ability to staff the ERO facilities.
4.4 Sustained Improved Performance:
During the past year the depth of the ERO responders was increased to provide for improved staffing capability for responding to site emergencies thereby, providing additional assurance in maintaining adequate measures to protect the public health and safety. To monitor this, a periodic review will be conducted by Manager of Emergency Response Section (ERS) to verify that adequate staffing is maintained to support the ERO at PNPP. This review will be performed in accordance with procedure PYBP-ERS-0009, "Annual Review of the Perry Plant Emergency Plan." As stated above, FENOC demonstrated sustained performance during the last three (3) performances of the off-hours drills. Additionally, FENOC committed to performing more frequent off-hours unannounced ddll in the future. An off-hour unannounced drill will be conducted at least once per fuel cycle even though the Emergency Plan requirement is to conduct the drill once every six years. This frequency for performing the drill is discussed in procedure PYBP-ERS-0033, "Off-hour Unannounced Drill Conduct." These actions demonstrate the commitment by FENOC to continue the improved performance of Emergency Preparedness at PNPP going forward.Following each drill, a critique is conducted and areas for continuing improvement are identified and acted on. This process provides assurance that the PNPP performance in the area of Emergency Preparedness will continue to improve.During the NRC inspection (IR 2006010), the NRC team concluded that actions taken to address issue in the emergency preparedness have been effective.
As a result, the NRC stated that they do not intend to conduct any additional inspection in this area beyond that which is normally prescribed by Reactor Oversight Process baseline inspection program.In October 2006, subsequent to the above NRC Inspection, a graded EP exercise was performed with no findings.
This exercise demonstrated the ability of the PNPP ERO responders to effectively respond to site emergencies and to protect the public health and safety.4.5
References:
NRC Inspection Report 2006010, dated May 22, 2006 Table 1" PNPP Comitments Attachment PY-CEI/OIE-0683L Page 21 ITEMS DESCRIPTION QUARTER STATUS DUE 1.0 IP 95002 Inspection Follow-up Issues 1.a To date, one hundred eight (108) of the one hundred nineteen (119) procedures have been updated and issued. The remaining Third 2005 Complete maintenance procedures have been updated and are currently going through the owner's review and acceptance review process.1.b CA 05-03655-01 is to revise Nuclear Quality Assurance Instruction NQ1-1001, "QC Inspection Program Control," to specify a method by Third 2005 Complete which classification can be established for additional inspection attention items that have experienced repeat failures.
This method will include consideration of failure analysis, the risk-significance of the item, and the probability of failure occurrence in determining the extent of inspection activity.1.c CA 05-03655-03 is to revise Generic Mechanical Instructions (GMI)-0039, "Disassembly/Re-assembly of Divisions I and II Emergency Third 2005 Complete Service Water Pumps," and GMI-040, "Disassembly/Re-assembly of Division III Emergency Service Water Pump," to include QC inspection points for work activities associated with pump shaft couplings, as specified by QC.2.0 Corrective Action Program Implementation Improvement 2.a Develop expectations necessary for successful implementation of the corrective action program (CAP). Train the site to the expectations Fourth 2005 Complete and accountability methods that will be used to improve implementation of the CAP.2.b Implement management controls to improve line ownership and accountability at the individual level for successful implementation of the Third 2005 Complete CAP.2.c Establish a management review process that routinely monitors the site's and section level CAP performance.
Take action to improve Third 2005 Complete performance when expectations are not met and hold the organization accountable for overall CAP effectiveness.
2.d Perform a self-assessment that evaluates the overall health of the CAP, including an aggregate assessment of key performance indicator Fourth 2006 Complete trends. Assess whether substantial progress has been made in CAP performance.
3.0 Excellence in Human Performance 3.a Roles and responsibilities of the Site Leadership Team in implementing the human performance program will be defined and Fourth 2005 Complete communicated.
3.b Approximately monthly Site Training Advisory Committee and department
/ section Training Review Committee meetings have been held Fourth 2005 Complete and will continue to be conducted with a strong focus on human performance through fourth quarter 2005.3.c The purpose and key activities of the Human Performance Program will be communicated to Perry Nuclear Power Plant (PNPP) personnel.
Fourth 2005 Complete 3.d Group-specific needs analyses will be performed by training committees to determine the scope and content of initial and continuing First 2006 Complete training needs on human performance fundamentals and error prevention tools and training will be provided.4.0 Emergency Preparedness 4.a FENOC is expanding the population of qualified EP responders by approximately 125 persons to increase the depth of the emergency Fourth 2005 Complete response organization.
4.b Additional drills will be conducted to demonstrate appropriate Emergency Response Organization response times.Fourth 2005 Complete Attachment PY-CEI/OIE-0683L Page 22 LIST OF ACRONYMS USED CAL Confirmatory Action Letter CACB Corrective Action Closure Board CARB Corrective Action Review Board CR Condition Report CRC Curriculum Review Committee DAMP Detailed Action and Monitoring Plan EOF Emergency Operation Facility EP Emergency Planning ERO Emergency Response Organization ERS Emergency Response Section ESW Emergency Service Water GMI General Maintenance Instructions HPCS High Pressure Core Spray IPA Integrated Performance Assessment IR Inspection Report KPI Key Performance Indicators LTA Less Than Adequate MPR Management Performance Review MRB Management Review Board OSC Operation Support Center PAT Plant Access Training PII Performance Improvement Initiative PNPP Perry Nuclear Power Plant PRA Probabilistic Risk Assessment QC Quality Control RAW Risk Achievement Worth RRW Risk Reduction Worth SAT Systems Approach to Training SLT Senior Leadership Team STAC Senior Training Advisory Committee TRC Training Review Committee TSC Technical Support Center