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{{#Wiki_filter:RbiNlPlt R o bi nson N uc l ear Pl an tAugust 25, 2011 RNPWhiteFinding | |||
-InitiatingEvents(95001) | |||
RNP White Finding Initiating Events (95001)EventCause(s)Status of Corrective Action(s) | |||
Feedwater Regulating Valve Control Circuit Failure Vendor design errors with Haganpower suppliesresulted in premature part failure Complete:*Identified and located all RNPHagan modules with Rev. 3 Ensign power supplies installed ReplacedEnsignRe5PoerSppliesithEnsign5A | |||
*Replaced Ensign Rev. 5 Po w er S u pplies w ith Ensign 5A power suppliesPlant Trip With 4KVFireInadequateimpactreviewofproblemresulted Complete:*Revisedworkmanagementprocesstoprovidespecific 4 KV Fire Inadequate impact review of problem resulted in wrong priorityBehaviors identified previously in training and crew assessment were not corrected and | |||
followed-up | |||
*Revised work management process to provide specific guidance for impact reviews of new Work Requests*Operator Fundamentalswere fully integrated into the RNP simulator evaluation grading, and students receive | |||
imm ed i a t e f eedbac k f o r im p r o v e m e nt oppo rt u niti es. Th e During the installation of design change MOD | |||
851 in 1986 the cable installed was different fthifitiiitfedaeeedbacopoeeoppoueseimprovement opportunities are included in the 'Crew Notebooks'*The Engineering Change process has been modified to include numerous sign-offs and reviews of plant designs f rom th e spec ifi ca tion, was i nappropr i a t e f or the application and was contrary to the manufacturer's data sheetto minimize the potential for a similar event to occur under the current process. (Historical) | |||
RNPWhiteFinding | |||
-InitiatingEvents(95001) | |||
RNP White Finding Initiating Events (95001)EventCause(s)Status of Corrective Action(s) | |||
Electro-hydraulic | |||
Control Circuit Board PinsCircuit board (1A08H) connection in the Electro Hydraulic control cabinet was found to have a degraded connection with the backplane connectorThecauseofthepoorconnection Complete:*Replaced the 1A08H circuit board*Revised existing PM Model to require testing to validate Pins connector. The cause of the poor connection was due to bent pins on the circuit board, but the cause of the bent pins is unknown.proper circuit card seating of any EH System circuit cards that are replaced. This PM revision includes checking circuit boards for bent pins prior to installation as well as verifying all installed and surrounding circuit boards are seated properly Reactor Coolant The end-turn insulation in the stator windings Complete:*Implement a Preventive Maintenance task to rewind Pump Winding Shorteddegraded and ultimately failed, resulting in a turn to turn shorteach of the RCP motors, including the spare, on a 20 year frequency Due 10/01/12: | |||
*Rewind the failed C RCP moto r and the motor currently installed on the C RCP using a design that provides for proper securing of all winding end -turns to reduce vibration and improvelong-term reliability RNPWhiteFindings | |||
-MitigatingSystems(95002) | |||
RNP White Findings Mitigating Systems (95002)FindingCause(s)Status of Corrective Action(s) | |||
Conduct of OperationsSenior Managementdid notimplement a formal program or process to continually monitor, evaluate, andimproveOperationcrewperformance Complete:*Implemented Standards for Operations Shift/Training Crew Performance Improvementto driveconsistentoperatorperformance and improve Operation crew performance drive consistent operator performance*Implemented Organizational Effectiveness Review Committees to assure SeniorManagement oversight is maintainedTraining did not identifyand remediate operator performance deficienciesSite did not maintain an appropriate level of CAP initiation threshold*Revised appropriate training processes*Established appropriate Leadership engagement to initiate a culture shift in NCR initiation GP-004 did not contain an appropriate level of detail*Revised procedure references and connections to other procedures RNPWhiteFindings | |||
-MitigatingSystems(95002) | |||
RNP White Findings Mitigating Systems (95002)FindingCause(s)Status of Corrective Action(s) | |||
Operations Complete: Operations Systematic | |||
Approach to TrainingOperations, Training, Senior Site Managers, and the Training Advisory Board did not provide the leadership necessary to ensure the integrity of Operations training infrastructure was maintained | |||
and monitored Complete:*Implemented requirements for Organizational Effectiveness Reviews; specifically addressing Staffing, Supervisor Effectiveness, Training and Qualifications, and Self-Evaluation Overview*Completed Management and Supervisory Leadership Assessments through panel process for all individuals new to positions since August 2010*Established and reinforcedmanagement standards within the training workforce RNPWhiteFindings | |||
-MitigatingSystems(95002) | |||
RNP White Findings Mitigating Systems (95002)FindingCause(s)Status of Corrective Action(s)Failureto Complete: Failure to Document EDG Output Breakerin | |||
Corrective A ction Employees did notuse a systematic method for problem identification and resolution for a safety significant component failure Complete:*Training Maintenance personnel for work package | |||
documentation Complete:*RevisedconductofMaintenancetoclearlyestablishProgramRNP personnel responded differently to a Diesel Generator breaker failure between outage and online conditions | |||
*Revised conduct of Maintenance to clearly establish expectations for "Skill of the Craft" Due 06/20/12:*Establish and implement methods forSiteLeadership engagementtoinitiateacultureshiftinordertochange engagement to initiate a culture shift in order to change behavior to embrace CAP RNPWhiteFindings | |||
-MitigatingSystems(95002) | |||
RNP White Findings Mitigating Systems (95002)FindingCause(s)Status of Corrective Action(s)WhiteFinding Complete: White Finding Common CauseSite and Corporate Senior Leadership allowed behavioral standards of performance to deteriorate while focusing on the attainment of other business planning | |||
ob jectives.Complete:*Implemented Performance Planning and Monitoring requirements for Organizational Effectiveness Reviews; specifically addressing Staffing, Supervisor Effectiveness, Training and Qualifications, and Self-Evaluation Program Overview jAs a result of declining / poor standards, Leadership did not ensure organizational capacitywas sufficient to execute core Overview Complete:*Develop and implement a Safety Culture Improvement Plan to address behavioral shortfallsprocesses. RNP has exhibited behavioral shortfalls in SafetyCultureTheseshortfallshave Complete:*Complete Supervisor Leadership Assessments and make changes Complete: Safety Culture. These shortfalls have impacted organizational decisions and actions at all levels.*Initiateand begin execution of Procedure Upgrade ProjectDue 11/15/11:*Revise the annual budget process at RNP and incorporate into Fleet or Site procedures to develop the budget in a risk-informed manner incorporating identification of the gap between resources available and workload requirements and incorporate the revised process in to a site or fleet procedure(Continued on next page) | |||
RNPWhiteFindings | |||
-MitigatingSystems(95002) | |||
RNP White Findings Mitigating Systems (95002)FindingCause(s)Status of Corrective Action(s) | |||
White Finding Common Cause (Continued)Due 10/05/11:*Perform a comprehensive organizational capacity review Due 12/15/12:*Com plete a materialu pg rade p ro j ect t y in g a solid task list to ppgpjygobjectives in material ProcedureUpgradeProjectScope Procedure Upgrade Project ScopeTypeNumberOperations Single Column Procedures626Operations Emergency Operating Procedures43OperationsAbnormalOperatingProcedures 72 Operations Abnormal Operating Procedures 72Maintenance Procedures858 Chemistry Procedures133Radiation Protection Procedures60Total *1792 ProcedureUpgradeProjectMilestoneSchedule Procedure Upgrade Project Milestone Schedule Execution PhaseComplete all Path 1/2 EOPsSeptember 2011Clt llRiiEOPAil2012 Phase C omp l e t ea ll R ema i n i ng EOP s A pr il 2012Complete all Radiation Protection ProceduresOctober 2013Complete all Chemistry ProceduresJuly 2014Complete all Electrical Maintenance Procedures A ugust 2014Complete all Mechanical Maintenance ProceduresJuly 2015Completeall AOPsAugust 2016Complete all Operations Single Column ProceduresAugust 2016Complete all I&C Maintenance ProceduresNovember 2016 Closeout PhaseLessons Learned ReportSeptember 2016 Safety Culture Improvement Action Plan Inputs:95002RootCauses/CommonCause95002 Root Causes/Common CauseUSA Safety Culture Assessment Conducted March/AprilSafety Culture SurveysNRC95002InspectionFeedbackNRC 95002 Inspection FeedbackKey Focus Areas/Actions:SignificantlyEnhancedLeadershipandEmployer | |||
-Significantly Enhanced Leadership and Employer-Employee CommunicationsMonthly Organizational Effectiveness Challenge MeetingsCorrective Action Pro g ram Im p rovements in identification gpand quality of investigationWork Management EffectivenessNuclear Electric Institute 09-07 Implementation -on going SftCltt S a f e t y C u lt ure assessmen t | |||
StrategicImprovementPlanObjectives Strategic Improvement Plan Objectives*Address Performance and Historical Issues Issues*Address and Change Behaviors*Correct Pro g rammatic Deficiencies g*Establish a Continuous Learning OrganizationECltfStibilit | |||
*E nsure C u lt ure o f S us t a i na bilit y*Maintain Strong Nuclear Safety Culture*Serve as a Station Communications Alignment Tool KeyStrategicImprovements Key Strategic ImprovementsFocus on BehaviorsIncrease Permanent And Supplemental Staffing Accelerate Desi gn And Im plementation Of 17 Plant Modifications gp Backlog Reduction Work Management Procedure Upgrade ProjectTraining Material Upgrade Project FilitUd F ac ilit y U pgra d es RNPMission RNP MissionValue Continuous Improvement dBifthRihtAti an d a Bi as f or th e Ri g ht A c ti on to Achieve Safe, Predictable, dRliblPltOti an d R e li a bl e Pl an t O pera ti ons}} |
Revision as of 10:51, 3 August 2018
ML112360357 | |
Person / Time | |
---|---|
Site: | Robinson |
Issue date: | 08/24/2011 |
From: | NGG Holdings, Progress Energy Co |
To: | Office of Nuclear Reactor Regulation |
References | |
Download: ML112360357 (14) | |
Text
RbiNlPlt R o bi nson N uc l ear Pl an tAugust 25, 2011 RNPWhiteFinding
-InitiatingEvents(95001)
RNP White Finding Initiating Events (95001)EventCause(s)Status of Corrective Action(s)
Feedwater Regulating Valve Control Circuit Failure Vendor design errors with Haganpower suppliesresulted in premature part failure Complete:*Identified and located all RNPHagan modules with Rev. 3 Ensign power supplies installed ReplacedEnsignRe5PoerSppliesithEnsign5A
- Replaced Ensign Rev. 5 Po w er S u pplies w ith Ensign 5A power suppliesPlant Trip With 4KVFireInadequateimpactreviewofproblemresulted Complete:*Revisedworkmanagementprocesstoprovidespecific 4 KV Fire Inadequate impact review of problem resulted in wrong priorityBehaviors identified previously in training and crew assessment were not corrected and
followed-up
- Revised work management process to provide specific guidance for impact reviews of new Work Requests*Operator Fundamentalswere fully integrated into the RNP simulator evaluation grading, and students receive
imm ed i a t e f eedbac k f o r im p r o v e m e nt oppo rt u niti es. Th e During the installation of design change MOD
851 in 1986 the cable installed was different fthifitiiitfedaeeedbacopoeeoppoueseimprovement opportunities are included in the 'Crew Notebooks'*The Engineering Change process has been modified to include numerous sign-offs and reviews of plant designs f rom th e spec ifi ca tion, was i nappropr i a t e f or the application and was contrary to the manufacturer's data sheetto minimize the potential for a similar event to occur under the current process. (Historical)
RNPWhiteFinding
-InitiatingEvents(95001)
RNP White Finding Initiating Events (95001)EventCause(s)Status of Corrective Action(s)
Electro-hydraulic
Control Circuit Board PinsCircuit board (1A08H) connection in the Electro Hydraulic control cabinet was found to have a degraded connection with the backplane connectorThecauseofthepoorconnection Complete:*Replaced the 1A08H circuit board*Revised existing PM Model to require testing to validate Pins connector. The cause of the poor connection was due to bent pins on the circuit board, but the cause of the bent pins is unknown.proper circuit card seating of any EH System circuit cards that are replaced. This PM revision includes checking circuit boards for bent pins prior to installation as well as verifying all installed and surrounding circuit boards are seated properly Reactor Coolant The end-turn insulation in the stator windings Complete:*Implement a Preventive Maintenance task to rewind Pump Winding Shorteddegraded and ultimately failed, resulting in a turn to turn shorteach of the RCP motors, including the spare, on a 20 year frequency Due 10/01/12:
- Rewind the failed C RCP moto r and the motor currently installed on the C RCP using a design that provides for proper securing of all winding end -turns to reduce vibration and improvelong-term reliability RNPWhiteFindings
-MitigatingSystems(95002)
RNP White Findings Mitigating Systems (95002)FindingCause(s)Status of Corrective Action(s)
Conduct of OperationsSenior Managementdid notimplement a formal program or process to continually monitor, evaluate, andimproveOperationcrewperformance Complete:*Implemented Standards for Operations Shift/Training Crew Performance Improvementto driveconsistentoperatorperformance and improve Operation crew performance drive consistent operator performance*Implemented Organizational Effectiveness Review Committees to assure SeniorManagement oversight is maintainedTraining did not identifyand remediate operator performance deficienciesSite did not maintain an appropriate level of CAP initiation threshold*Revised appropriate training processes*Established appropriate Leadership engagement to initiate a culture shift in NCR initiation GP-004 did not contain an appropriate level of detail*Revised procedure references and connections to other procedures RNPWhiteFindings
-MitigatingSystems(95002)
RNP White Findings Mitigating Systems (95002)FindingCause(s)Status of Corrective Action(s)
Operations Complete: Operations Systematic
Approach to TrainingOperations, Training, Senior Site Managers, and the Training Advisory Board did not provide the leadership necessary to ensure the integrity of Operations training infrastructure was maintained
and monitored Complete:*Implemented requirements for Organizational Effectiveness Reviews; specifically addressing Staffing, Supervisor Effectiveness, Training and Qualifications, and Self-Evaluation Overview*Completed Management and Supervisory Leadership Assessments through panel process for all individuals new to positions since August 2010*Established and reinforcedmanagement standards within the training workforce RNPWhiteFindings
-MitigatingSystems(95002)
RNP White Findings Mitigating Systems (95002)FindingCause(s)Status of Corrective Action(s)Failureto Complete: Failure to Document EDG Output Breakerin
Corrective A ction Employees did notuse a systematic method for problem identification and resolution for a safety significant component failure Complete:*Training Maintenance personnel for work package
documentation Complete:*RevisedconductofMaintenancetoclearlyestablishProgramRNP personnel responded differently to a Diesel Generator breaker failure between outage and online conditions
- Revised conduct of Maintenance to clearly establish expectations for "Skill of the Craft" Due 06/20/12:*Establish and implement methods forSiteLeadership engagementtoinitiateacultureshiftinordertochange engagement to initiate a culture shift in order to change behavior to embrace CAP RNPWhiteFindings
-MitigatingSystems(95002)
RNP White Findings Mitigating Systems (95002)FindingCause(s)Status of Corrective Action(s)WhiteFinding Complete: White Finding Common CauseSite and Corporate Senior Leadership allowed behavioral standards of performance to deteriorate while focusing on the attainment of other business planning
ob jectives.Complete:*Implemented Performance Planning and Monitoring requirements for Organizational Effectiveness Reviews; specifically addressing Staffing, Supervisor Effectiveness, Training and Qualifications, and Self-Evaluation Program Overview jAs a result of declining / poor standards, Leadership did not ensure organizational capacitywas sufficient to execute core Overview Complete:*Develop and implement a Safety Culture Improvement Plan to address behavioral shortfallsprocesses. RNP has exhibited behavioral shortfalls in SafetyCultureTheseshortfallshave Complete:*Complete Supervisor Leadership Assessments and make changes Complete: Safety Culture. These shortfalls have impacted organizational decisions and actions at all levels.*Initiateand begin execution of Procedure Upgrade ProjectDue 11/15/11:*Revise the annual budget process at RNP and incorporate into Fleet or Site procedures to develop the budget in a risk-informed manner incorporating identification of the gap between resources available and workload requirements and incorporate the revised process in to a site or fleet procedure(Continued on next page)
RNPWhiteFindings
-MitigatingSystems(95002)
RNP White Findings Mitigating Systems (95002)FindingCause(s)Status of Corrective Action(s)
White Finding Common Cause (Continued)Due 10/05/11:*Perform a comprehensive organizational capacity review Due 12/15/12:*Com plete a materialu pg rade p ro j ect t y in g a solid task list to ppgpjygobjectives in material ProcedureUpgradeProjectScope Procedure Upgrade Project ScopeTypeNumberOperations Single Column Procedures626Operations Emergency Operating Procedures43OperationsAbnormalOperatingProcedures 72 Operations Abnormal Operating Procedures 72Maintenance Procedures858 Chemistry Procedures133Radiation Protection Procedures60Total *1792 ProcedureUpgradeProjectMilestoneSchedule Procedure Upgrade Project Milestone Schedule Execution PhaseComplete all Path 1/2 EOPsSeptember 2011Clt llRiiEOPAil2012 Phase C omp l e t ea ll R ema i n i ng EOP s A pr il 2012Complete all Radiation Protection ProceduresOctober 2013Complete all Chemistry ProceduresJuly 2014Complete all Electrical Maintenance Procedures A ugust 2014Complete all Mechanical Maintenance ProceduresJuly 2015Completeall AOPsAugust 2016Complete all Operations Single Column ProceduresAugust 2016Complete all I&C Maintenance ProceduresNovember 2016 Closeout PhaseLessons Learned ReportSeptember 2016 Safety Culture Improvement Action Plan Inputs:95002RootCauses/CommonCause95002 Root Causes/Common CauseUSA Safety Culture Assessment Conducted March/AprilSafety Culture SurveysNRC95002InspectionFeedbackNRC 95002 Inspection FeedbackKey Focus Areas/Actions:SignificantlyEnhancedLeadershipandEmployer
-Significantly Enhanced Leadership and Employer-Employee CommunicationsMonthly Organizational Effectiveness Challenge MeetingsCorrective Action Pro g ram Im p rovements in identification gpand quality of investigationWork Management EffectivenessNuclear Electric Institute 09-07 Implementation -on going SftCltt S a f e t y C u lt ure assessmen t
StrategicImprovementPlanObjectives Strategic Improvement Plan Objectives*Address Performance and Historical Issues Issues*Address and Change Behaviors*Correct Pro g rammatic Deficiencies g*Establish a Continuous Learning OrganizationECltfStibilit
- E nsure C u lt ure o f S us t a i na bilit y*Maintain Strong Nuclear Safety Culture*Serve as a Station Communications Alignment Tool KeyStrategicImprovements Key Strategic ImprovementsFocus on BehaviorsIncrease Permanent And Supplemental Staffing Accelerate Desi gn And Im plementation Of 17 Plant Modifications gp Backlog Reduction Work Management Procedure Upgrade ProjectTraining Material Upgrade Project FilitUd F ac ilit y U pgra d es RNPMission RNP MissionValue Continuous Improvement dBifthRihtAti an d a Bi as f or th e Ri g ht A c ti on to Achieve Safe, Predictable, dRliblPltOti an d R e li a bl e Pl an t O pera ti ons