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See also: [[followed by::IR 05000529/1986017]]


=Text=
=Text=
{{#Wiki_filter:Qi Arizona Nuclear Power Project P.o.BOX 52034~PHOENIX, ARIZONA 85072-2034
{{#Wiki_filter:Qi RK8~iEO HRI:
RK8~iEO HRI: iS86 JUL lt;PH l: 02 July 7, 1986 ANPP-00015-JGH/TDS/96.03
Arizona Nuclear Power Project P.o. BOX 52034 ~ PHOENIX, ARIZONA 85072-2034 iS86 JUL lt; PH   l: 02 July 7,     1986 ANPP-00015-JGH/TDS/96.03 hkGtON V lKf:
hkGtON V lKf: Mr.John B.Martin, Regional Administrator
Mr. John B. Martin, Regional Administrator U.S. Nuclear Regulatory Commission Region V 1450 Maria Lane, Suite 210 Walnut Creek, CA 94596-5368
U.S.Nuclear Regulatory
 
Commission
==Subject:==
Region V 1450 Maria Lane, Suite 210 Walnut Creek, CA 94596-5368
Palo Verde Nuclear Generating Station (PVNGS)
Subject: Palo Verde Nuclear Generating
Unit 2 Docket   No STN 50-529 (License NPF-51)
Station (PVNGS)Unit 2 Docket No STN 50-529 (License NPF-51)Notice of Violation:
Notice of Violation:         50-529/86-17-02 File:     86-001-493
50-529/86-17-02
 
File: 86-001-493
==Reference:==
Reference:
Letter from     A. E. Chaffee (NRC) to E. E. Van Brunt, Jr. (ANPP),
Letter from A.E.Chaffee (NRC)to E.E.Van Brunt, Jr.(ANPP), dated June 13, 1986, NRC Inspection
dated June 13, 1986, NRC Inspection Reports 50-528/86-16, 50-529/86-17 and 50-530/86-11.
Reports 50-528/86-16, 50-529/86-17
 
and 50-530/86-11.
==Dear Mr. Martin:==
Dear Mr.Martin: This letter is provided in response to the inspection
 
conducted by Messrs.R.Zimmerman, C.Bosted, G.Fiorelli and J.Ball of the NRC Staff on April 14 through May 26, 1986.Based on the results of the inspection, one (1)violation of NRC requirements
This letter is provided in response         to the inspection conducted by Messrs. R.
was identified (failure to follow procedure during contain-ment air lock seal leak test).The violation is discussed in Appendix A of the referenced
Zimmerman, C. Bosted,     G. Fiorelli     and   J. Ball of the NRC Staff on April 14 through May 26, 1986. Based on the results of the inspection, one (1) violation of NRC requirements was identified (failure to follow procedure during contain-ment air lock seal leak test). The violation is discussed in Appendix A of the referenced letter. The violation and ANPP's response is provided in Attach-ment A. The response to the concern of general procedural adherence as discussed in the referenced letter is provided in Attachment B.
letter.The violation and ANPP's response is provided in Attach-ment A.The response to the concern of general procedural
Very   truly yours, 8608040233 860729 PDR   ADOCK 05000529
adherence as discussed in the referenced
                      , PDR~                                   J. G. Haynes Vice. President Nuclear Production JGH/TDS/kj Attachments cc: E. E. Van Brunt Jr.           (w/attachment)
letter is provided in Attachment
L. F. Miller                   (w/attachment)
B.Very truly yours, 8608040233
R. P. Zimmerman               (w/attachment)
860729 PDR ADOCK 05000529 , PDR~J.G.Haynes Vice.President Nuclear Production
E. A. Licitria                 (w/attachment)
JGH/TDS/kj
A. C. Gehr                     (w/o attachment)
Attachments
 
cc: E.E.Van Brunt Jr.L.F.Miller R.P.Zimmerman E.A.Licitria A.C.Gehr (w/attachment)(w/attachment)(w/attachment)(w/attachment)(w/o attachment)
Mr. John B. Martin Palo Verde Nuclear Generating Station Notice of Violation ANPP-00015-JGH/TDS/96.03 Page 2 bcc:   R. M. Butler         (all w/ attachments)
J. R. Bynum W. E. Ide
Mr.John B.Martin Palo Verde Nuclear Generating
: 0. J. Zeringue T. D. Shriver W. F. Quinn LCTS Coordinator
Station Notice of Violation ANPP-00015-JGH/TDS/96.03
 
Page 2 bcc: R.M.Butler J.R.Bynum W.E.Ide 0.J.Zeringue T.D.Shriver W.F.Quinn LCTS Coordinator (all w/attachments)
0 ANPP-00015-JGH/TDS/96.03 NOTICE OF VIOLATION Arizona Nuclear Power Project                                       Docket No. 50-529 Post Office Box 52034                                             License No. NPF-51 Phoenix, Arizona 85072-2034 Technical Specification 6.8.1.c requires that written procedures           be estab-lished and implemented   for surveillance   and test activities of safety-related equipment.
0  
PVNGS Manual Procedure   73ST-9CL03, Containment   Airlock Seal   Leak Test, Revision 1 (through procedure change notice number 3), effective February 7, 1986, paragraph   10.0, Contingencies,   states that   when the inner door fails the seal leak test and requires repair, the outer door shall remain closed until repair   and   retest have been satisfactorily   completed.
ANPP-00015-JGH/TDS/96.03
Contrary to the above, on April 'll, 1986, the Unit       2 140'ontainment air-lock inner door failed     a seal leak test performed 'using procedure 73ST-9CL03, and the   outer door   was opened prior to satisfactory repair       and retest of the inner door.
NOTICE OF VIOLATION Arizona Nuclear Power Project Post Office Box 52034 Phoenix, Arizona 85072-2034
 
Docket No.50-529 License No.NPF-51 Technical Specification
~ 8 ANPP's RESPONSE TO VIOLATION I. THE CORRECTIVE STEPS MiICH HAVE BEEN TAKEN AND THE RESULTS ACHIEVED As an immediate   corrective action the engineers involved were counseled on the importance of procedural adherence           and ANPP's   policy concerning deviations from that position.         Additionally, the Tech-nical Support Department     Manager issued a memorandum     to all personnel in the department addressing the importance of preventing personnel errors during the performance of assigned tasks         and reiterating the consequences   of committing errors through negligence.           The procedure,   which was being   utilized during the airlock seal I
6.8.1.c requires that written procedures
leak test, has been     revised to clarify the differences between Unit   I and Unit II's Technical   Specifications. An evaluation of the overall effectiveness of these measures         is discussed   in Attach-ment B.
be estab-lished and implemented
II. THE CORRECTIVE STEPS WHICH     MILL BE TAKEN TO AVOID     FURTHER ITEMS OF NONCOMPLIANCE An evaluation   was conducted   to determine the root cause of the identified deficiency.       Based upon the   results of the evaluation it was   determined that the event was caused by a conscious decision made by   the responsible personnel to violate the established           pro-cedural controls.     Their decision   was based on a known   difference between   Unit I and Unit II's Technical   Specifications. The dif-ference, as explained in the inspection report, permits the operable door to be opened     for a cumulative time not to exceed one hour per year in Unit   II. The procedure   being used during   this activity, 73ST-9CL03 "Containment     Airlock Seal   Leak Test",   was written to
for surveillance
 
and test activities
lf 1
of safety-related equipment.
 
PVNGS Manual Procedure 73ST-9CL03, Containment
address the requirements of Unit     I's Technical Specifications and does not provide the     option to open the operable   door. The respon-sible, personnel were aware that performing the tasks in the manner that they did,   had no   safety impact   and did not violate Unit II's Technical Specification 3.6.1.3.       They were also aware   that their actions were contrary to the requirements of the approved procedure.
Airlock Seal Leak Test, Revision 1 (through procedure change notice number 3), effective February 7, 1986, paragraph 10.0, Contingencies, states that when the inner door fails the seal leak test and requires repair, the outer door shall remain closed until repair and retest have been satisfactorily
Therefore, based on   ANPP Management's   continued attention to issues such as procedural adherence,     a broad scope plan has been developed.
completed.
This plan is discussed   in Attachment   B.
Contrary to the above, on April'll, 1986, the Unit 2 140'ontainment
III. THE DATE WHEN FULL COMPLIANCE WILL BE ACHIEVED Full compliance was achieved on     April ll,   1986 when the Containment Airlock Door was   successfully tested   and closed.
air-lock inner door failed a seal leak test performed'using procedure 73ST-9CL03, and the outer door was opened prior to satisfactory
 
repair and retest of the inner door.  
I ANPP-00015-JGH/TDS-96.03 ATTACHMENT B In response to the general issue discussed in the referenced letter, an evaluation   was conducted       to address not only the specific incidents identified but the generic question of procedural adherence. The in-spection report transmittal letter states that the potential for a more general problem exists based on two previous concerns of procedural noncompliance   identified in       1985. The specific incidents described were attributed to   willfullviolations          of procedural controls, committed by knowledgeable     individuals without         ANPP Management's   knowledge. The incidents cited,     when   evaluated in the overall context of procedural adherence,   appear to be     isolated cases which could only       be addressed as they were on a case by case basis.
However, during the course         of the evaluation, potential areas of         weakness I.
~8 ANPP's RESPONSE TO VIOLATION I.THE CORRECTIVE
in procedural adherence         were identified.     These areas have been   isolated to individual departments and           do not appear,,to represent   a generic con-II                             I cern. ANPP Management's     continued concern in this area       is demonstrated by the implementation       of various corrective measures whenever         a potential problem such as     this was   identified.
STEPS MiICH HAVE BEEN TAKEN AND THE RESULTS ACHIEVED As an immediate corrective
Since 1983,   ANPP Management       has implemented various programs and         initi-ated changes to existing programs to reduce both personnel errors and procedural violations. These efforts have included:
action the engineers involved were counseled on the importance
: a. Establishment of       a "Quality Improvement Report" (QIR) program in the   IRC Maintenance         area. This program was designed   to investigate various incidents, determine the             cause and develop the necessary       corrective action plan.       This program   was implemented   in   IRC Maintenance     initially because   of
of procedural
 
adherence and ANPP's policy concerning
  ~   ~
deviations
    ~     ~
from that position.Additionally, the Tech-nical Support Department
p
Manager issued a memorandum
~r specific concerns identified that         appeared   unique to that area.
to all personnel in the department
: b. Expansion of the QIR program to include           all areas of the Main-tenance Department.
addressing
: c. Modifying the existing administrative controls which specify how approved   procedures   may be   revised or changed. This   was done   to expedite the process and enable the user to easily modify an existing procedure whenever an error was discovered or a potential   enhancement   was   identified.
the importance
: d. Establishment of the "Operations Department Experience Report"
of preventing
                                                        \(
personnel errors during the performance
(ODER)   program. This program     was designed   to achieve the   same objecti'ves as the   QIR program.
of assigned tasks and reiterating
In conjunction with the specific programs described above additional generic actions were taken.         These included:
the consequences
: a. The   production of   a video tape by the Executive Vice President in which   he stressed   the   criticality of   procedural adherence.
of committing
This video   was required to   be viewed by   all PVNGS personnel and   is currently   being used during the new employee indoctrina-tion.
errors through negligence.
: b. The   topic of procedure adherence       was repeatedly used as   a topic in the "Quality Talks"       program.
The procedure, which was being utilized during the airlock seal I leak test, has been revised to clarify the differences
: c. Including the topic of "Procedural Adherence" in the "Site Access   Training" program (SAT).
between Unit I and Unit II's Technical Specifications.
As described above various approaches         had been taken   in the past to address not only the generic issue of procedural adherence               but to speci-fically   address   identified   weaknesses   and concerns. The individual successes   of these programs varied.         However, the implementation       of the QIR and accelerated       disciplinary   programs   in the I&C Maintenance area proved   effective. Based upon the success       achieved the decision
An evaluation
 
of the overall effectiveness
    ~ ~ ~
of these measures is discussed in Attach-ment B.II.THE CORRECTIVE
0 l
STEPS WHICH MILL BE TAKEN TO AVOID FURTHER ITEMS OF NONCOMPLIANCE
l(
An evaluation
 
was conducted to determine the root cause of the identified
area proved was made concerns.
deficiency.
to effective.
Based upon the results of the evaluation
utilize this The Based upon the success approach to address basic program reporting to the Plant Manager.
it was determined
is achieved the decision the recently being expanded to include The  initial implementation identified all program was begun on July 7, 1986, when the Plant Manager issued a memo-individuals of this randum to   all   PVNGS personnel stressing the necessity to reduce personnel errors and   to comply with   all station   procedures. The memorandum   also emphasized     the potential   for administering accelerated disciplinary action for any individual who, through willfullintent or negligence, commits an error or procedural violation. The Compliance Manager has been assigned     the responsibility to develop the remaining portions of the program which includes:
that the event was caused by a conscious decision made by the responsible
: a. Expansion of the     existing QIR program   philosophy to encompass all departments reporting to the       Plant Manager. This approach will ensure that a comprehensive       review   is conducted   for all incidents effecting the department, that 'the root cause is identified     and that effective corrective actions are initiated.
personnel to violate the established
I
pro-cedural controls.Their decision was based on a known difference
: b. Establishment of a committee, consisting of the Plant Manager and   his direct reports, to review incidents         and interview per-sonnel found to have     willfullyor    through negligence committed an error or procedural violation. This committee           will evaluate the incidents on     a case by case basis and recommend     appropriate disciplinary actions.
between Unit I and Unit II's Technical Specifications.
ANPP Management       believes that   full implementation     of this comprehensive program, expected by October 1, 1986,         will successfully control     and reduce both personnel errors and procedural           violations.
The dif-ference, as explained in the inspection
r
report, permits the operable door to be opened for a cumulative
 
time not to exceed one hour per year in Unit II.The procedure being used during this activity, 73ST-9CL03"Containment
P}}
Airlock Seal Leak Test", was written to  
lf 1  
address the requirements
of Unit I's Technical Specifications
and does not provide the option to open the operable door.The respon-sible, personnel were aware that performing
the tasks in the manner that they did, had no safety impact and did not violate Unit II's Technical Specification
3.6.1.3.They were also aware that their actions were contrary to the requirements
of the approved procedure.
Therefore, based on ANPP Management's
continued attention to issues such as procedural
adherence, a broad scope plan has been developed.
This plan is discussed in Attachment
B.III.THE DATE WHEN FULL COMPLIANCE
WILL BE ACHIEVED Full compliance
was achieved on April ll, 1986 when the Containment
Airlock Door was successfully
tested and closed.  
I  
ANPP-00015-JGH/TDS-96.03
ATTACHMENT
B In response to the general issue discussed in the referenced
letter, an evaluation
was conducted to address not only the specific incidents identified
but the generic question of procedural
adherence.
The in-spection report transmittal
letter states that the potential for a more general problem exists based on two previous concerns of procedural
noncompliance
identified
in 1985.The specific incidents described were attributed
to willfull violations
of procedural
controls, committed by knowledgeable
individuals
without ANPP Management's
knowledge.
The incidents cited, when evaluated in the overall context of procedural
adherence, appear to be isolated cases which could only be addressed as they were on a case by case basis.However, during the course of the evaluation, potential areas of weakness I.in procedural
adherence were identified.
These areas have been isolated to individual
departments
and do not appear,,to
represent a generic con-II I cern.ANPP Management's
continued concern in this area is demonstrated
by the implementation
of various corrective
measures whenever a potential problem such as this was identified.
Since 1983, ANPP Management
has implemented
various programs and initi-ated changes to existing programs to reduce both personnel errors and procedural
violations.
These efforts have included: a.Establishment
of a"Quality Improvement
Report" (QIR)program in the IRC Maintenance
area.This program was designed to investigate
various incidents, determine the cause and develop the necessary corrective
action plan.This program was implemented
in IRC Maintenance
initially because of  
~~~p~~r specific concerns identified
that appeared unique to that area.b.Expansion of the QIR program to include all areas of the Main-tenance Department.
c.Modifying the existing administrative
controls which specify how approved procedures
may be revised or changed.This was done to expedite the process and enable the user to easily modify an existing procedure whenever an error was discovered
or a potential enhancement
was identified.
d.Establishment
of the"Operations
Department
Experience
Report"\((ODER)program.This program was designed to achieve the same objecti'ves
as the QIR program.In conjunction
with the specific programs described above additional
generic actions were taken.These included: a.The production
of a video tape by the Executive Vice President in which he stressed the criticality
of procedural
adherence.
This video was required to be viewed by all PVNGS personnel and is currently being used during the new employee indoctrina-
tion.b.The topic of procedure adherence was repeatedly
used as a topic in the"Quality Talks" program.c.Including the topic of"Procedural
Adherence" in the"Site Access Training" program (SAT).As described above various approaches
had been taken in the past to address not only the generic issue of procedural
adherence but to speci-fically address identified
weaknesses
and concerns.The individual
successes of these programs varied.However, the implementation
of the QIR and accelerated
disciplinary
programs in the I&C Maintenance
area proved effective.
Based upon the success achieved the decision  
~~~0 l l(  
area proved effective.
Based upon the success achieved the decision t was made to utilize this approach to address the recently identified
concerns.The basic program is being expanded to include all individuals
reporting to the Plant Manager.The initial implementation
of this program was begun on July 7, 1986, when the Plant Manager issued a memo-randum to all PVNGS personnel stressing the necessity to reduce personnel errors and to comply with all station procedures.
The memorandum
also emphasized
the potential for administering
accelerated
disciplinary
action for any individual
who, through willfull intent or negligence, commits an error or procedural
violation.
The Compliance
Manager has been assigned the responsibility
to develop the remaining portions of the program which includes: a.Expansion of the existing QIR program philosophy
to encompass all departments
reporting to the Plant Manager.This approach will ensure that a comprehensive
review is conducted for all incidents effecting the department, that'the root cause is identified
and that effective corrective
actions are initiated.
I b.Establishment
of a committee, consisting
of the Plant Manager and his direct reports, to review incidents and interview per-sonnel found to have willfully or through negligence
committed an error or procedural
violation.
This committee will evaluate the incidents on a case by case basis and recommend appropriate
disciplinary
actions.ANPP Management
believes that full implementation
of this comprehensive
program, expected by October 1, 1986, will successfully
control and reduce both personnel errors and procedural
violations.
r  
P
}}

Latest revision as of 11:34, 29 October 2019

Responds to NRC 860613 Ltr Re Violations Noted in Insp Rept 50-529/86-17.Corrective Actions:Air Lock Seal Leak Test Procedures Revised & Engineers Counseled.Containment Airlock Door Successfully Tested & Closed on 860411
ML17300A292
Person / Time
Site: Palo Verde Arizona Public Service icon.png
Issue date: 07/07/1986
From: Haynes J
ARIZONA PUBLIC SERVICE CO. (FORMERLY ARIZONA NUCLEAR
To: Martin J
NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION V)
Shared Package
ML17300A291 List:
References
ANPP-00015-JGH, ANPP-15-JGH, NUDOCS 8608040233
Download: ML17300A292 (15)


Text

Qi RK8~iEO HRI:

Arizona Nuclear Power Project P.o. BOX 52034 ~ PHOENIX, ARIZONA 85072-2034 iS86 JUL lt; PH l: 02 July 7, 1986 ANPP-00015-JGH/TDS/96.03 hkGtON V lKf:

Mr. John B. Martin, Regional Administrator U.S. Nuclear Regulatory Commission Region V 1450 Maria Lane, Suite 210 Walnut Creek, CA 94596-5368

Subject:

Palo Verde Nuclear Generating Station (PVNGS)

Unit 2 Docket No STN 50-529 (License NPF-51)

Notice of Violation: 50-529/86-17-02 File: 86-001-493

Reference:

Letter from A. E. Chaffee (NRC) to E. E. Van Brunt, Jr. (ANPP),

dated June 13, 1986, NRC Inspection Reports 50-528/86-16, 50-529/86-17 and 50-530/86-11.

Dear Mr. Martin:

This letter is provided in response to the inspection conducted by Messrs. R.

Zimmerman, C. Bosted, G. Fiorelli and J. Ball of the NRC Staff on April 14 through May 26, 1986. Based on the results of the inspection, one (1) violation of NRC requirements was identified (failure to follow procedure during contain-ment air lock seal leak test). The violation is discussed in Appendix A of the referenced letter. The violation and ANPP's response is provided in Attach-ment A. The response to the concern of general procedural adherence as discussed in the referenced letter is provided in Attachment B.

Very truly yours, 8608040233 860729 PDR ADOCK 05000529

, PDR~ J. G. Haynes Vice. President Nuclear Production JGH/TDS/kj Attachments cc: E. E. Van Brunt Jr. (w/attachment)

L. F. Miller (w/attachment)

R. P. Zimmerman (w/attachment)

E. A. Licitria (w/attachment)

A. C. Gehr (w/o attachment)

Mr. John B. Martin Palo Verde Nuclear Generating Station Notice of Violation ANPP-00015-JGH/TDS/96.03 Page 2 bcc: R. M. Butler (all w/ attachments)

J. R. Bynum W. E. Ide

0. J. Zeringue T. D. Shriver W. F. Quinn LCTS Coordinator

0 ANPP-00015-JGH/TDS/96.03 NOTICE OF VIOLATION Arizona Nuclear Power Project Docket No. 50-529 Post Office Box 52034 License No. NPF-51 Phoenix, Arizona 85072-2034 Technical Specification 6.8.1.c requires that written procedures be estab-lished and implemented for surveillance and test activities of safety-related equipment.

PVNGS Manual Procedure 73ST-9CL03, Containment Airlock Seal Leak Test, Revision 1 (through procedure change notice number 3), effective February 7, 1986, paragraph 10.0, Contingencies, states that when the inner door fails the seal leak test and requires repair, the outer door shall remain closed until repair and retest have been satisfactorily completed.

Contrary to the above, on April 'll, 1986, the Unit 2 140'ontainment air-lock inner door failed a seal leak test performed 'using procedure 73ST-9CL03, and the outer door was opened prior to satisfactory repair and retest of the inner door.

~ 8 ANPP's RESPONSE TO VIOLATION I. THE CORRECTIVE STEPS MiICH HAVE BEEN TAKEN AND THE RESULTS ACHIEVED As an immediate corrective action the engineers involved were counseled on the importance of procedural adherence and ANPP's policy concerning deviations from that position. Additionally, the Tech-nical Support Department Manager issued a memorandum to all personnel in the department addressing the importance of preventing personnel errors during the performance of assigned tasks and reiterating the consequences of committing errors through negligence. The procedure, which was being utilized during the airlock seal I

leak test, has been revised to clarify the differences between Unit I and Unit II's Technical Specifications. An evaluation of the overall effectiveness of these measures is discussed in Attach-ment B.

II. THE CORRECTIVE STEPS WHICH MILL BE TAKEN TO AVOID FURTHER ITEMS OF NONCOMPLIANCE An evaluation was conducted to determine the root cause of the identified deficiency. Based upon the results of the evaluation it was determined that the event was caused by a conscious decision made by the responsible personnel to violate the established pro-cedural controls. Their decision was based on a known difference between Unit I and Unit II's Technical Specifications. The dif-ference, as explained in the inspection report, permits the operable door to be opened for a cumulative time not to exceed one hour per year in Unit II. The procedure being used during this activity, 73ST-9CL03 "Containment Airlock Seal Leak Test", was written to

lf 1

address the requirements of Unit I's Technical Specifications and does not provide the option to open the operable door. The respon-sible, personnel were aware that performing the tasks in the manner that they did, had no safety impact and did not violate Unit II's Technical Specification 3.6.1.3. They were also aware that their actions were contrary to the requirements of the approved procedure.

Therefore, based on ANPP Management's continued attention to issues such as procedural adherence, a broad scope plan has been developed.

This plan is discussed in Attachment B.

III. THE DATE WHEN FULL COMPLIANCE WILL BE ACHIEVED Full compliance was achieved on April ll, 1986 when the Containment Airlock Door was successfully tested and closed.

I ANPP-00015-JGH/TDS-96.03 ATTACHMENT B In response to the general issue discussed in the referenced letter, an evaluation was conducted to address not only the specific incidents identified but the generic question of procedural adherence. The in-spection report transmittal letter states that the potential for a more general problem exists based on two previous concerns of procedural noncompliance identified in 1985. The specific incidents described were attributed to willfullviolations of procedural controls, committed by knowledgeable individuals without ANPP Management's knowledge. The incidents cited, when evaluated in the overall context of procedural adherence, appear to be isolated cases which could only be addressed as they were on a case by case basis.

However, during the course of the evaluation, potential areas of weakness I.

in procedural adherence were identified. These areas have been isolated to individual departments and do not appear,,to represent a generic con-II I cern. ANPP Management's continued concern in this area is demonstrated by the implementation of various corrective measures whenever a potential problem such as this was identified.

Since 1983, ANPP Management has implemented various programs and initi-ated changes to existing programs to reduce both personnel errors and procedural violations. These efforts have included:

a. Establishment of a "Quality Improvement Report" (QIR) program in the IRC Maintenance area. This program was designed to investigate various incidents, determine the cause and develop the necessary corrective action plan. This program was implemented in IRC Maintenance initially because of

~ ~

~ ~

p

~r specific concerns identified that appeared unique to that area.

b. Expansion of the QIR program to include all areas of the Main-tenance Department.
c. Modifying the existing administrative controls which specify how approved procedures may be revised or changed. This was done to expedite the process and enable the user to easily modify an existing procedure whenever an error was discovered or a potential enhancement was identified.
d. Establishment of the "Operations Department Experience Report"

\(

(ODER) program. This program was designed to achieve the same objecti'ves as the QIR program.

In conjunction with the specific programs described above additional generic actions were taken. These included:

a. The production of a video tape by the Executive Vice President in which he stressed the criticality of procedural adherence.

This video was required to be viewed by all PVNGS personnel and is currently being used during the new employee indoctrina-tion.

b. The topic of procedure adherence was repeatedly used as a topic in the "Quality Talks" program.
c. Including the topic of "Procedural Adherence" in the "Site Access Training" program (SAT).

As described above various approaches had been taken in the past to address not only the generic issue of procedural adherence but to speci-fically address identified weaknesses and concerns. The individual successes of these programs varied. However, the implementation of the QIR and accelerated disciplinary programs in the I&C Maintenance area proved effective. Based upon the success achieved the decision

~ ~ ~

0 l

l(

t area proved was made concerns.

to effective.

utilize this The Based upon the success approach to address basic program reporting to the Plant Manager.

is achieved the decision the recently being expanded to include The initial implementation identified all program was begun on July 7, 1986, when the Plant Manager issued a memo-individuals of this randum to all PVNGS personnel stressing the necessity to reduce personnel errors and to comply with all station procedures. The memorandum also emphasized the potential for administering accelerated disciplinary action for any individual who, through willfullintent or negligence, commits an error or procedural violation. The Compliance Manager has been assigned the responsibility to develop the remaining portions of the program which includes:

a. Expansion of the existing QIR program philosophy to encompass all departments reporting to the Plant Manager. This approach will ensure that a comprehensive review is conducted for all incidents effecting the department, that 'the root cause is identified and that effective corrective actions are initiated.

I

b. Establishment of a committee, consisting of the Plant Manager and his direct reports, to review incidents and interview per-sonnel found to have willfullyor through negligence committed an error or procedural violation. This committee will evaluate the incidents on a case by case basis and recommend appropriate disciplinary actions.

ANPP Management believes that full implementation of this comprehensive program, expected by October 1, 1986, will successfully control and reduce both personnel errors and procedural violations.

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