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| {{#Wiki_filter:Independent Third-Party Second Nuclear Safety Culture Assessment of the NIST Center for Neutron Research (Task 12) | | {{#Wiki_filter:}} |
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| Revision 1
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| Conduct of Assessment: March 27 Through June 3, 2024
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| Report Approval: June 7, 2024
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| Page 1 of 170
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| Contents EXECUTIVE
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| ==SUMMARY==
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| ................................ ............................................................................ 4 Purpose .................................................................................................................................. 4 Scope and Approach ................................ .............................................................................. 4 Summary of Results ............................................................................................................... 4 Overall Conclusion ................................................................................................................10 REPORT ................................................................................................................................... 11 Methods of Analysis .................................................................................................................. 11 Analysis Results ........................................................................................................................13 Objective 1: Personal Accountability ......................................................................................13 Objective 2: Questioning Attitude ................................ ...........................................................14 Objective 3: Effective Safety Communications ................................................................ .......15 Objective 4: Leadership Safety Values and Actions ............................................................... 17 Objective 5: Decision Making ................................................................ ................................20 Objective 6: Respectful Work Environment ................................ ............................................22 Objective 7: Continuous Learning ................................ ..........................................................24 Objective 8: Problem Identification and Resolution ................................ ................................27 Objective 9: Environment for Raising Concerns .....................................................................29 Objective 10: Work Processes ...............................................................................................30 Safety Culture Performance Improvement .............................................................................33 Traits by OU Group ...............................................................................................................33 Review of Internal Events ......................................................................................................33 Review of External Information ..............................................................................................35 Matrix of Initiatives to Recommendations ................................ ..................................................37 Effectiveness Review ................................ ............................................................................39 Attachments ..............................................................................................................................40 Attachment 1: Survey Data Personal Accountability .............................................................. 41 Attachment 2: Survey Data Questioning Attitude ................................ ...................................44 Attachment 3: Survey Data Effective Safey Communications ................................ ................47 Attachment 4: Survey Data Leadership Safety Values and Actions ................................ ........50 Attachment 5: Survey Data Decision-Making ................................ .........................................53 Attachment 6: Survey Data Respectful Work Environment ....................................................56 Attachment 7: Survey Data Continuous Learning ................................ ..................................59 Attachment 8: Survey Data Problem Identification and Resolution ................................ ........62 Attachment 9: Survey Data Environment for Raising Concerns .............................................65
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| Page 2 of 170
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| Attachment 10: Survey Data Work Processes .......................................................................68 Attachment 11: Survey Data Status of NSC Improvement .....................................................71 Attachment 12: Survey Data for Operations ................................ ..........................................73 Attachment 13: Survey Data for Reactor Engineering ............................................................ 82 Attachment 14: Survey Data for Health Physics ................................ ....................................91 Attachment 15: Survey Data for Aging Reactor Management ................................ ................99 Attachment 16: Survey Data for Other Groups .................................................................... 109 Attachment 17: Survey Data Comparison 2023 to 2024 ................................ ...................... 117 Attachment 18: Survey Question List ................................................................................... 125 Attachment 19: Review of Internal Events ........................................................................... 130 Attachment 20: Review of External Information ................................................................... 132 Attachment 21: Status of 2023 INSCA Recommendations................................................... 135 Attachment 22: Status of 2023 INSCA Program Limiting Weaknesses ................................ 145 Attachment 23: Focus Group/Interviews Form ..................................................................... 151 Attachment 24: Meeting Observation Form ................................ ......................................... 156 Attachment 25: Behavioral Observation Form ..................................................................... 158 Attachment 26: INSCA Team Members, Assignments, and Bios .......................................... 161 Attachment 27: INSCA Background Detail ........................................................................... 164 Attachment 28: NRC Inspection Report - Confirmatory Order Excerpt ................................ 165 Attachment 29: Definitions ................................................................................................... 167 Attachment 30: References ................................ ................................................................. 170
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| Page 3 of 170
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| EXECUTIVE
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| ==SUMMARY==
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| Purpose
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| The Independent Nuclear Safety Culture Assessment (INSCA) Team conducted a second independent and comprehensive assessment of the existing Organizational Nuclear Safety Culture (NSC), including the Safety Conscious Work Environment (SCWE), at the NIST Center for Neutron Research. The assessment was performed in accordance with the requirements of the August 1, 2022, Confirmatory Order Modifying License No. TR-5 (Reference Attachment 27 and Attachment 28 for more detail). The Order required a second Nuclear Safety Culture Assessment, within 12 months of completing the initial assessment, to ensure sustainability and effectiveness of the identified recommended corrective actions within the identified areas.
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| Scope and Approach
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| A highly experienced INSCA team evaluated the current NCNR 10 Traits of a Healthy Safety Culture that included SCWE, using a survey, focus group/interviews, meeting observations, and other data collection methods. The survey data supported what personnel believe and the focus group/interviews and observations demonstrated what personnel do to support a healthy NSC. The results were analyzed to identify Integrated Safety Culture (ISC) strengths and weaknesses. The strengths and weaknesses were then compared to the status of the existing seven initiatives, and twelve recommendations out of the 2023 INSCA, and formulated into recommendations to support continuing improvement and close any substantive gaps.
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| Summary of Results
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| The overall results for each of the 10 Traits are provided below, with the supporting data and analyses being contained within the body of the report and attachments.
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| Trait 1: Personal Accountability (PA) - Individuals take personal responsibility for safety. The underlying Attributes include Standards (PA.1), Job Ownership (PA.2), and Teamwork (PA.3).
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| Positive Observation (PA.1): Understanding Standards and Responsibilities.
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| There is survey consensus on individuals understanding the importance of adherence to standards, encouraging teamwork, and responsibilities of raising safety concerns.
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| Recommendation:
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| : 1) Initiative - Safety Culture: Stay the course.
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| Trait 2: Questioning Attitude (QA) - Individuals avoid complacency and continuously challenge existing conditions and activities in order to identify discrepancies that might result in error or inappropriate action. The underlying Attributes include Nuclear is Recognized as Special and Unique (QA.1), Challenge the Unknown (QA.2), Challenge Assumptions (QA.3), and Avoid Complacency (QA.4).
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| Positive Observation (QA.2): Challenge the Unknown.
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| Personnel are questioning work practices, procedures, and equipment as evident in the increasing CAP inventory.
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| Page 4 of 170
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| Recommendation:
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| : 1) Initiative - Safety Culture: Stay the course.
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| Trait 3: Effective Safety Communication (CO) - Communications maintain a focus on safety.
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| The underlying Attributes include Work Process Communications (CO.1), Bases for Decisions (CO.2), Free Flow of Information (CO.3), and Expectations (CO.4).
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| Positive Observation (CO.4): Communication Methods.
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| NCNR has increased the forms and frequency of communications since the 2023 INSCA. Examples include K-Wing newsletter, Plan of the Day Meeting, All-Hands Meeting, and Integrated Plant Schedule and Meeting.
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| Area in Need of Attention (CO.4): Communication Strategy Plan and Execution.
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| The communications strategy lacks a full plan and implementation. Communications are not always timely and with enough context to support full understanding. There is limited confirmation that messages sent are being received and understood by those with a need to know.
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| Recommendations:
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| : 1) Initiative - Communications: Strengthen interim communication initiative and develop a strategy to support continuing communication improvement.
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| : 2) Initiative - Communications: As a part of the planned strategy, take action to improve engagement to obtain feedback/confirmation on the quality, dissemination, and understanding of communications.
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| Trait 4: Leadership Safety Values and Actions (LA) - Leaders demonstrate a commitment to safety in their decisions and behaviors. The underlying Attributes include Resources (LA.1);
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| Field Presence LA.2); Incentives, Sanctions, and Rewards (LA.3); Strategic Commitment to Safety (LA.4); Change Management (LA.5); Roles, Responsibilities, and Authorities (LA.6);
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| Constant Examination (LA.7); and Leader Behaviors (LA.8).
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| Positive Observation (LA.4): Leader Engagement.
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| Leaders are engaged in working towards improvement, accepting of understanding of performance shortfalls, and development of improvement plans.
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| Positive Observation (LA.7): Integrated Safety Culture Monitoring Panel (ISCMP).
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| ISCMP has been established for the monitoring of safety culture traits and the identification of performance issues and actions to achieve and then maintain a healthy safety culture. This is a leading initiative within the Research and Test Reactor (RTR) industry. This is not an Area of Strength at this time in that there have been only two meetings and effective implementation is pending.
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| Area for Improvement (LA.1): Resource Management.
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| The availability of personnel and funds is inadequate to support procedure quality, engineering drawing quality, training to close gaps in skills and knowledge, and necessary Corrective Action Program (CAP) improvements. The procedure and drawing elements are a part of configuration management that over the years has resulted in discrepancies between procedures, drawings, and equipment.
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| Page 5 of 170
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| Area in Need of Attention (LA.2): Observation Program.
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| The Observation Program is being used by leaders but is not fully leveraged to improve performance and specifically field presence to communicate, model, and reinforce the behaviors.
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| Area For Improvement (LA.8): Reinforcement of Standards and Expectations.
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| Leaders are not consistent in their coaching and are missing opportunities for reinforcement of standards and expectations that are important to the NSC.
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| Recommendations
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| : 1) Initiative - Resource Strategy: Conduct a review of the current levels of personnel and funds to identify critical underfunded area that comprise NSC and seek additional funding from NIST and Department of Commence (DOC).
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| Examples include procedure quality, drawing quality, training, and necessary CAP improvements.
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| : 2) Initiative - Communications: Communicate and reinforce to NCNR personnel the expectation to, and importance of, promptly identifying deltas in procedures and drawings in comparison to actual plant configuration into the CAP for collective review of priority and level of resolution.
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| : 3) Initiative - Safety Culture: Implement the following actions to improve the Behavioral Observation Program and Leader reinforcement of standards and expectations.
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| * Educate leaders on using the ABC Model (Aubrey Daniels - Antecedent, Behavior, and Consequence) to influence leader and worker behaviors.
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| * Develop and provide leaders observation forms/criteria that reflect desired behaviors.
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| * Mentor of leaders in observing and coaching behaviors in addition to the Observation Program expectations, to ensure expectations are met and deviations in expectations are promptly identified and corrected on the spot or within the CAP.
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| : 4) Initiative - Safety Culture: Roll out the ISC booklet and associated training for all workers.
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| Trait 5: Decision Making (DM) - Decisions that support or affect nuclear safety are systematic, rigorous, and thorough. The underlying Attributes include Consistent Process (DM.1),
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| Conservative Bias (DM.2), and Accountability for Decisions (DM.3).
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| Positive Observation (DM.2): Decision Making and Safety Margin.
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| NCNR staff are making informed, conservatively biased decisions with overt consideration of maintaining higher levels of safety margin.
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| Area in Need of Attention (DM.1): Stakeholder Participation in Decision Making.
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| Some safety decisions are made without engagement of some NCNR and NIST stakeholders. The communication of decisions by participants is not always timely and with adequate context/clarity as to why the decision was made, as to support personnel in the planning and scheduling of work functions.
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| Page 6 of 170
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| Recommendation
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| : 1) Initiative - Communications: Update the Communications Strategy Initiative to include the element of decision-making. Specifically, updates to include more timely and complete communications on important decisions to increase awareness, understanding, and ability of personnel to contribute and provide feedback.
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| Trait 6: Respectful Work Environment (WE) - Trust and respect permeate the organization.
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| The underlying Attributes include Respect is Evident (WE.1), Opinions are Valued (We.2), High Level of Trust (WE.3), and WE.4 (Conflict Resolution).
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| Positive Observation (WE.2): Willingness to Raise Concerns.
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| Personnel are confident in their ability to raise safety concerns and will raise safety concerns.
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| Positive Observation (WE.3): Teamwork.
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| People are open, engaged, and willing to ask for help due to a respectful work environment and the level of teamwork.
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| Area in Need of Attention (WE.2): Engagement of Stakeholders.
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| NCNR is not consistent in engaging key NCNR personnel in plans and decisions.
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| Area in Need of Attention (WE.3): Feedback when Raising Concerns.
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| The behavior of raising concerns is not always consistently reinforced in a positive manner.
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| Recommendations
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| : 1) Initiative - Safety Culture: Develop and incorporate actions within the Safety Culture Initiative with regard to providing positive reinforcement to individuals willing to raise concerns.
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| : 2) Initiative - Safety Culture: Consider incorporating a question regarding key NCNR stakeholder participation (O rganizational Groups (OU) and Integrated Safety) into NCNR decision-making guidance. Suggest placing in Integrated Management Model, Integrated Safety Culture Traits and Attributes Book, or procedure.
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| Trait 7: Continuous Learning (CL) - Opportunities to learn about ways to ensure safety are sought out and implemented. The underlying Attributes include Operating Experience (CL.1),
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| Self-Assessment (CL.2), Benchmarking (CL.3), and Training (CL.4).
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| Positive Observations (CL.4): Informal Training.
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| * Health Physics group has bi-weekly training on selected topics.
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| * Engineering group provides new hire indoctrination activities and monthly safety meetings.
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| Page 7 of 170
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| Area in Need of Attention (CL.1): Operating Experience.
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| NCNR is not consistently using internal and external Operating Experience (OE) and communicating the results, with recognition that external OE (other test reactors) is somewhat limited by the lack of industry communication methods. (Survey data driven ANA).
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| Area in Need of Attention (CL.4): Training Program Descriptions.
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| There is a lack of a consistent framework outside of Operations under which all groups in the OU can develop and implement consistent initial and continuing training programs.
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| Area for Improvement (CL.4): Training.
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| NCNR is not making progress fast enough, and in an integrated manner, to support OU groups and job performance across OU groups and job functions (i.e., Continuing Training, Supervisor Training, and General Employee Indoctrination).
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| Recommendations
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| : 1) Initiative - Resource Strategy: Provide augmented resources to allow a systematic approach to implementing the Operations Training Program.
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| : 2) Initiative - Training: Develop an overall strategy to improve training implementation across OU group functions and leader functions including the establishment of initial and continuing Training Program Descriptions.
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| : 3) Initiative - Communications: Communicate to NCNR personnel expectations for the use of internal and external operating experience, and successes in the use of OE in improving performance.
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| Trait 8: Problem Identification and Resolution (PI) - Issues potentially impacting safety are promptly identified, fully evaluated, and promptly addressed and corrected commensurate with their significance. The underlying Attributes include Identification (PI.1), Evaluation (PI.2),
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| Resolution (PI.3), and Trending (PI.4).
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| Area of Strength (PI.1): Non-Conformance Process A Non-Conformance process has been added to the CAP and personnel identify and enter material, part, and component non-conformances for disposition and resolution.
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| This is a leading initiative within the Research and Test Reactor (RTR) industry.
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| Area of Strength (PI.1, PI.2, & PI.3): Establishment of the CAP Dashboard.
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| CAP Management has developed a CAP dashboard where groups and individuals can quickly access the status of CAP, Equipment Deficiencies, Observation Program, Drawing Deficiencies, ECNs, and Procedure Deficiencies items. This strength is a leading initiative within the Research and Test Reactor (RTR) industry.
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| Positive Observation (PI.1): Use of CAP.
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| There has been an overall increase in the use of the CAP since the 2023 INSCA.
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| Page 8 of 170
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| Area for Improvement (PI.1, PI.2 & PI.3): Leveraging CAP to Improve Performance.
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| * Some personnel do not understand the scope and threshold for the entry of events, problems, and other issues in the CAP or which other programs should be used to identify and document issues.
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| * Cause Analysts lack knowledge and proficiency in analysis tools and techniques.
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| * There is limited use of the CAP dashboard due to a lack of reinforcement by management for personnel to use the dashboard.
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| * CAP successes are not being communicated to promote and reinforce the use of CAP.
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| Recommendations
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| : 1) Initiative - Performance Improvement - Finish building out the new CAP platforms (i.e., CAP dashboard, etc.) to improve the user interface, functionality, and visibility in problem identification, evaluation, and resolution.
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| : 2) Initiative - Performance Improvement - Identify OU groups not actively using CAP and the CAP Dashboard and provide some indoctrination into the mechanics of the system, the value added to performance improvement, and senior leader expectations for when and how to use.
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| : 3) Initiative - Communications - Develop and implement a communication strategy to educate NCNR personnel on 1) the threshold for CAP entry, 2) their accountability for using CAP, 3) the importance of, promptly identifying nonconformances in procedures and drawings in comparison to actual plant configuration, and 4) reinforcement of CAP successes.
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| : 4) Initiative - Training - Educate evaluators on the analytical tools and techniques necessary for successful conduct and documentation of causal analysis.
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| : 5) Initiative - Resources - Augment CAP resources and provide mentoring to support OU groups in problem identification, evaluation, and resolution.
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| Trait 9: Environment for Raising Concerns (RC) - A safety-conscious work environment (SCWE) is maintained where personnel feel free to raise safety concerns without fear of retaliation, intimidation, harassment, or discrimination. The underlying Attributes include SCWE Policy (RC.1) and Alternate Process for Raising Concerns (RC.2).
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| Positive Observation (RC.1): Raising Concerns.
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| Personnel, with a few exceptions, freely raise integrated safety concerns without fear of retribution and with confidence that their concerns will be addressed.
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| Area in Need of Attention (RC.2): Issue Employee Concerns Procedure.
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| The ECP has a designated office area and a program manager but lacks timeliness in issuance of the ECP procedure. The procedure has been developed and submitted to the NRC. Issuance has been delay ed awaiting NRC concurrence.
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| Recommendation
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| : 1) Initiative - Safety Culture: Develop and implement a change management plan to issue the ECP procedure.
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| Page 9 of 170
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| Trait 10: Work Processes (WP) - The process of planning and controlling work activities is implemented so that safety is maintained. The underlying Attributes include Work Management (WP.1), Design Margins (WP.2), Documentation (WP.3), and Procedure Adherence (WP.4).
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| Positive Observation (WP.1): Aligning Work and Priorities.
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| Use of the Plan of the Day (POD) and the 08:00 Meeting to align OU groups and personnel on work and priorities.
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| Positive Observation (WP.3): Finding and Fixing Procedures.
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| Personnel are finding and fixing procedure issues and the quality of procedures is generally improving.
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| Area in Need of Attention (WP.3): Procedure Quality.
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| Although there has been improvement, there are still issues with procedure quality involving errors and inconsistencies in content, and the process for changing procedures is slow.
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| Recommendations
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| : 1) Initiative - Resource Strategy: Conduct a review of the current levels of personnel supporting procedures, drawings, and configuration management, and acquire and allocate resources as necessary to support integrated safety.
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| : 2) Initiative - Procedures: Continue in the implementation of planned actions from the Procedure Initiative.
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| Overall Conclusion
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| There has been a positive change in the NSC with the establishment of some foundational elements and changes in behaviors. A questioning attitude, coupled with the startup of a Corrective Action Program, is supporting the identification and correction of non-conformances, procedure deficiencies, and behavioral issues. Leaders are also making progress toward more informed and prudent decisions, and there is a more collaborative effort in the planning and scheduling of activities.
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| Areas for increased attention and improvement include procedure quality, personnel training, and leaders communicating and reinforcing standards and expectations. Behavioral areas for focus include ensuring the receipt and understanding of communications, leader field presence in observing behaviors, reinforcing expectations, and responding to the concerns for the workforce. An underlying cross-cutting issue is challenges in the number of personnel and adequacy of funding to support the improvement initiatives. The level of resources is currently significantly impacting the rate of necessary positive change in achieving a healthy and sustained integrated safety culture.
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| Page 10 of 170
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| REPORT
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| Methods of Analysis
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| This INSCA was conducted by a team of independent consultants with over 235 years of aggregate experience in nuclear leadership, operations, maintenance, engineering, work management, licensing, training, safety culture and the safety conscious work environments, problem identification and resolution (equipment, human performance, process, organizational effectiveness), and recovery at power reactors following events of industry significance (Reference Attachment 26).
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| The Team evaluated the current NCNR Traits of a Healthy Safety Culture including SCWE, using a survey with 94 questions followed by 16 focus group/interviews, observations of meetings and training, and other data collection methods, and identified strengths and weaknesses. (Reference Attachment 18, 23, 24, 25). There was the intent to observe work activities but due to limited activities during the on-site week there were no substantive observations.
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| The survey data supported what personnel believe and the focus group/interviews and observations supported what personnel do to support a healthy NSC. The results were used to identify Areas of Strength (AOS), Positive Observations (PO), Areas in Need of Attention (ANA),
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| and Areas for Improvement (AFI).
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| The Areas of Strength, Positive Observations, Areas in Need of Attention, and Areas for Improvement were then compared to the status of the Twelve Recommendations out of the 2023 INSCA, and subsequently NCNR established Seven Initiatives to improve overall the NSC.
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| The overall conclusions are presented in the Executive Summary.
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| The scope of the NSC Traits, Data Collection Methods, Survey, NSC Recovery Initiatives, and Interviews and Observations are briefly summarized below as a primer to the Analysis Results section of this report.
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| The NSC Traits The Traits included Personal Accountability (PA), Questioning Attitude (QA), Effective Safety Communication (CO), Leadership Safety Values and Actions (LA) , Decision Making (DM), Respectful Work Environment (WE), Continuous Learning (CL), Problem Identification and Resolution (PI), Environment for Raising Concerns (RC), and Work Processes (WP).
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| The Data Collection Methods The methods included the Safety Culture Survey, Functional Analysis, Structured Focus Groups, Interviews, Observations of Meetings, Archived Data Review, Behavioral Anchored Rating Scales (BARS), and a Behavioral Checklist.
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| The Survey The survey consisted of 94 Questions across the NSC Traits, and was given across NCNR groups, with 65 respondents from Operations, Reactor Engineering, Health Physics, Aging Reactor Management, and Others. The data was broken down by All Respondents, Individual Contributors, Supervisors and Above, and OU groups.
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| Page 11 of 170
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| NSC Recovery Initiatives The Seven Initiatives included Communications, Safety Culture, Performance Improvement, Training, Procedures, Work Management, and Resource Strategy, as based on the previous 2023 INSCA Report Recommendations and Limiting Program Weaknesses (Reference Attachments 21 and 22 for status).
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| Interviews and Focus Groups There were multiple interviews and 16 focus groups comprised of personnel across OU groups at both the individual contributor and supervisor and above levels. The OU groups included Operations, Reactor Engineering, Health Physics, Aging Reactor Management, and Others. The NCNR Senior Leadership Team (SLT) was also interviewed as a part of data and insight collection, and there was a subsequent collegial review with the broader NCNR leadership team. The SLT and collegial reviews were only to gain additional insights and reduce the potential for any miss-characterization of performance. To clarify, the review with the leadership teams was not intended to, and did not, alter the independence of the NSC team or its conclusions.
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| Note: This report uses the term Nuclear Safety Culture (NSC) aligned with the Confirmatory Letter requirement to conduct a Nuclear Safety Culture Assessment. NCNR uses the term Integrated Safety Culture (ISC) that encompasses nuclear safety, occupational safety, radiological safety, security, and environmental safety, as defined in Attachment 29.
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| Page 12 of 170
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| Analysis Results Objective 1: Personal Accountability
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| Trait: Personal Accountability (PA) - individuals take personal responsibility for safety. The underlying Attributes include Standards (PA.1), Job Ownership (PA.2), and Teamwork (PA.3).
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| The survey included 6 questions related to PA to understand what people believe . The graph below is based on All Respondents . Individual Contributors and Supervisors and Above survey results are provided in Attachment 1, to provide additional insights for leaders and others with a need or desire to know.
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| Subsequently, the team used focus group/interviews, observations, and cognitive analysis to substantiate survey responses and gain further insights into what people believe and what people do. The analysis of data for the Trait PA identified the following:
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| The Assessment Category
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| Area of Strength: None
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| Area in Need of Attention: None
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| Area for Improvement: None
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| Positive Observation (PA.1): Understanding Standards and Responsibilities.
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| There is survey consensus on individuals understanding the importance of adherence to standards, encouraging teamwork, and responsibilities of raising safety concerns.
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| Page 13 of 170
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| Comparison of the Trait 2023 to 2024
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| Reference Attachment 17, Survey Data Comparison 2023 to 2024, and Trait PA for additional Areas of Interest that may need management attention to achieve full effectiveness and consistency.
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| Recommendations
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| : 1) Initiative - Safety Culture: Stay the course.
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| Objective 2: Questioning Attitude
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| Trait: Questioning Attitude (QA) - Individuals avoid complacency and continuously challenge existing conditions and activities in order to identify discrepancies that might result in error or inappropriate action. The underlying Attributes include Nuclear is Recognized as Special and Unique (QA.1), Challenge the Unknown (QA.2), Challenge Assumptions (QA.3), and Avoid Complacency (QA.4).
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| The survey included 9 questions related to QA to understand what people believe. The graph below is based on All Respondents. Individual Contributors and Supervisors and Above survey results are provided in Attachment 2, to provide additional insights for leaders and others with a need or desire to know.
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| Page 14 of 170
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| Subsequently, the team used focus group/interviews, observations, and cognitive analysis to substantiate survey responses and gain further insights into what people believe and what people do. The analysis of data for the Trait QA identified the following:
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| The Assessment Category
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| Area of Strength: None
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| Area in Need of Attention: None
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| Area for Improvement: None
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| Positive Observation (QA.2): Challenge the Unknown.
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| Personnel are questioning work practices, procedures, and equipment as evident in the increasing CAP inventory. The inventory was 58 at the time of the 2023 INSCA and is currently at 363. Status as follows:
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| * 344 CAPs
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| * 88 Fully Closed
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| * 254 CAP Items with actions being worked to closure.
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| * ~100 CAP Items less than 120 days old. 92 Level 0 and 1.
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| * 107 CAP Items greater than 120 days old.
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| Comparison of the Trait 2023 to 2024 Reference Attachment 17, Survey Data Comparison 2023 to 2024, and Trait LA for additional Areas of Interest that may need management attention to achieve full effectiveness and consistency.
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| Recommendations
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| : 1) Initiative - Communications: Stay the course
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| Objective 3: Effective Safety Communications
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| Trait: Effective Safety Communication (CO) - Communications maintain a focus on safety. The underlying Attributes include Work Process Communications (CO.1), Bases for Decisions (CO.2), Free Flow of Information (CO.3), and Expectations (CO.4).
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| The survey included 7 questions related to CO to understand what people believe. The graph below is based on All Respondents. Individual Contributors and Supervisors and Above survey results are provided in Attachment 3, to provide additional insights for leaders and others with a need or desire to know.
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| Page 15 of 170
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| Subsequently, the team used focus group/interviews, observations, and cognitive analysis to substantiate survey responses and gain further insights into what people believe and what people do. The analysis of data for the Trait CO identified the following:
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| The Assessment Category
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| Area of Strength: None
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| Area for Improvement : None
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| Positive Observation (CO.4) : Communication Methods.
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| NCNR has increased the forms and frequency of communications since the 2023 INSCA.
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| Examples include K-Wing newsletter, Plan of the Day Meeting , and Integrated Plant Schedule and Meeting.
| |
| | |
| Area in Need of Attention (CO.4): Communication Strategy Plan and Execution.
| |
| The communications strategy lacks a full plan and implementation . Communications are not always timely and with enough context to support full understanding. There is limited confirmation that messages sent are being received and understood by those with a need to know.
| |
| | |
| Supporting information includes:
| |
| * Emergent issues sometimes dont contain context - Confinement Entry Issues.
| |
| * Communications - there has been an effort to improve but there are still surprises with no consequence. i.e., I&C Flow and Level Calibrations - radios ineffective in basement -
| |
| moved to level calibrations and inadvertently tripped LOCA protection.
| |
| * Decisions about what we're doing next are often right before we do it. The "why" isn't always part of the explanation.
| |
| * Communications continues to be a weak area for the management team. Even when products have been requested that explain the basis of decisions, dissemination of these
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| Page 16 of 170
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| | |
| products to interested parties (the staff and non-management chain stakeholders) is non-existent.
| |
| * It doesn't matter how much we attempt to communicate, emails are ignored, or things are forgotten, to where an activity always surprises someone that should have known.
| |
| | |
| Comparison of the Trait 2023 to 2024 Reference Attachment 17, Survey Data Comparison 2023 to 2024, and Trait LA for additional Areas of Interest that may need management attention to achieve full effectiveness and consistency.
| |
| | |
| Recommendations
| |
| : 1) Initiative - Communications: Strengthen the follow up on the interim actions and develop strategy to support continuing improvement.
| |
| : 2) Initiative - Communications: As a part of the planned strategy, take action to improve engagement to obtain feedback/confirmation on the quality, dissemination, and understanding of communications.
| |
| Objective 4: Leadership Safety Values and Actions
| |
| | |
| Trait: Leadership Safety Values and Actions (LA) - Leaders demonstrate a commitment to safety in their decisions and behaviors. The underlying Attributes include Resources (LA.1); Field Presence LA.2); Incentives, Sanctions, and Rewards (LA.3); Strategic Commitment to Safety (LA.4); Change Management (LA.5); Roles, Responsibilities, and Authorities (LA.6); Constant Examination (LA.7); and Leader Behaviors (LA.8).
| |
| | |
| The survey included 16 questions related to LA to understand what people believe. The graph below is based on All Respondents. Individual Contributors, and Supervisors and Above, Survey results are provided in Attachment 4, to provide additional insights for leaders and others with a need or desire to know.
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| Page 17 of 170
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| Subsequently, the team used focus group/interviews, observations, and cognitive analysis to substantiate survey responses and gain further insights into what people believe and what people do. The analysis of data for the Trait LA identified the following:
| |
| | |
| The Assessment Category
| |
| | |
| Area of Strength: None
| |
| | |
| Positive Observation (LA.4): Leader Engagement.
| |
| Leaders are engaged in working towards improvement, accepting of understanding of performance shortfalls, and development of improvement plans.
| |
| | |
| Positive Observation (LA.7): Integrated Safety Culture Monitoring Panel (ISCMP).
| |
| The ISCMP has been established for the monthly monitoring of safety culture traits and the identification of performance issues and actions to achieve and then maintain a health safety culture. This is a leading initiative within the Research and Test Reactor (RTR) industry. This is not a strength at this time in that there have only been two meetings and effective implementation is pending.
| |
| | |
| Area for Improvement (LA.1): Resource Management.
| |
| The availability of personnel and funds is insufficient to support procedure, drawing, training, and Corrective Action Program (CAP) improvements. The procedure and drawing elements are a part of configuration management that over the years has resulted in discrepancies between procedures, drawings, and equipment.
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| Page 18 of 170
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| Supporting information includes:
| |
| * The procedure Change Process is not well defined or efficient in its present state.
| |
| * Changes to procedures are pushed and sometimes made only available just prior to the work activity.
| |
| * The backlog in the CAP is increasing as personnel are demonstrating a questioning attitude and using CAP. Resources to support the level of problem identification and resolution are not sufficient to manage day-to-day activities and the backlog.
| |
| * Self-Identified. (June 2023) NCNR does not have a documented approved process for issue, revision, and control of drawings. (Findings 2 & 16) CAP Item 102. Some drawings do not reflect as built configuration.
| |
| * Training support is a one-man show and focused on Operations Training. The CAP Program Owner is providing a level of training, but is resource limited.
| |
| | |
| Area in Need of Attention (LA.2): Observation Program.
| |
| The Observation Program is being used by leaders but is not fully leveraged to improve performance and specifically field presence to communicate, model, and reinforce the behaviors.
| |
| | |
| Supporting information includes:
| |
| * Surveys and interviews stated leader involvement and observations are less frequent than expected by the workforce.
| |
| * Schedule immaturity (predictability) has limited the accomplishment of observations.
| |
| | |
| Area For Improvement (LA.8): Reinforcement of Standards and Expectations.
| |
| Leaders are not consistent in their coaching and are missing opportunities for reinforcement of standards and expectations that are important to the NSC.
| |
| | |
| Supporting information includes:
| |
| * Both Survey and Interviews indicate that: Vertical and horizontal alignment at NCNR is not yet consistent. Sr. Leaders appear aligned. However, NCNR Supervisors were noted not to be aligned across the Organizational Unit (OU).
| |
| * NIST Leadership is sometimes perceived to not be aligned to NCNR needs and goals.
| |
| * There are pockets of siloed operations across the OU.
| |
| * There is a perception that there is still a level of rationalization at the Sr. Leadership Level.
| |
| o Not reinforcing present standards and expectations (PPE, use of CAP, follow through on commitments (procedure reviews), control room standards, and conduct of meeting standards)
| |
| * There is limited use of the CAP dashboard due to a lack of reinforcement by management for personnel to use the dashboard.
| |
| | |
| Comparison of the Trait 2023 to 2024 A comparison of the survey results for the LA Trait from 2023 to 2024 indicated a decline with respect to LA.1 Resources, as follows:
| |
| | |
| LA.1 Resources - Decline - NCNR provides training and ensures knowledge transfer to maintain a knowledgeable, technical competent workforce.
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| Page 19 of 170
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| | |
| Reference Attachment 17, Survey Data Comparison 2023 to 2024, and Trait LA for additional Areas of Interest that may need management attention to achieve full effectiveness and consistency.
| |
| | |
| Recommendations
| |
| : 1. Initiative - Resource Strategy: Conduct a review of the current levels of personnel and funds to identify critical underfunded area that comprise NSC and seek additional funding from NIST and Department of Commence (DOC). Examples include procedure quality, drawing quality, training, and necessary CAP improvements.
| |
| : 2. Initiative - Communications: Communicate and reinforce to NCNR personnel the expectation to, and importance of, promptly identifying deltas in procedures and drawings in comparison to actual plant configuration into the CAP for collective review of priority and level of resolution.
| |
| : 3. Initiative - Safety Culture: Implement the following actions (#4, 5, and 6) to improve the Behavioral Observation Program and Leader reinforcement of standards and expectations.
| |
| : 4. Initiative - Training: Educate leaders on using the ABC Model (Aubrey Daniels - Antecedent, Behavior, and Consequence) to influence leader and worker behaviors .
| |
| : 5. Initiative - Safety Culture: Develop and provide leaders observation forms/criteria that reflect desired behaviors.
| |
| * Mentor leaders in observing and coaching behaviors in addition to the Observation Program expectations, to ensure expectations are met and deviations in expectations are promptly identified and corrected on the spot or within the CAP.
| |
| : 6. Initiative - Safety Culture: Roll out the ISC booklet and associated training for all workers.
| |
| | |
| Objective 5: Decision Making
| |
| | |
| Trait: Decision Making (DM) - Decisions that support or affect nuclear safety are systematic, rigorous, and thorough. The underlying Attributes include Consistent Process (DM.1),
| |
| Conservative Bias (DM.2), and Accountability for Decisions (DM.3).
| |
| | |
| The survey included 5 questions related to DM to understand what people believe. The graph below is based on All Respondents. Individual Contributors and Supervisors and Above survey results are provided in Attachment 5, to provide additional insights for leaders and others with a need or desire to know.
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| Page 20 of 170
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| Subsequently, the team used focus group/interviews, observations, and cognitive analysis to substantiate survey responses and gain further insights into what people believe and what people do. The analysis of data for the Trait DM identified the following:
| |
| | |
| The Assessment Category
| |
| | |
| Area of Strength: None
| |
| | |
| Area for Improvement: None
| |
| | |
| Positive Observation (DM.2): Decision Making and Safety Margin.
| |
| NCNR staff are making informed, conservatively biased decisions with overt consideration of maintaining higher levels of safety margin.
| |
| | |
| Area in Need of Attention (DM.1): Stakeholder Participation in Decision Making.
| |
| Some safety decisions are made without engagement of some NCNR and NIST stakeholders.
| |
| The communication of decisions by participants is not always timely and with adequate context/clarity as to why the decision was made, as to support personnel in the planning and scheduling of work functions.
| |
| | |
| Supporting information includes:
| |
| | |
| The primary driver in this area is the timely communications of the whys behind decisions which appears to result in a perspective that either not all the inputs to a decision are being considered or just a lack of information necessary to support understanding of decisions.
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| Page 21 of 170
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| Decision Making o Indecision results in opportunity cost and impacts.
| |
| o We are not managing the risk of not running.
| |
| o Decisions being made outside of NCNR by NIST for appearances/political reasons with no technical basis.
| |
| * Is there a minimization of issues? Rationalizing based on actual technical facts and not recognizing the significance of the event.
| |
| * There is non-collective decision-making.
| |
| * Still working on getting the actual decisions made and communicated uniformly across all of management. Maybe then we can also bring in the basis for decisions.
| |
| * Rarely do we get into any detail for the basis of decisions.
| |
| * Decisions about what we're doing next is often right before we do it. The "why" isn't always part of the explanation.
| |
| * NCNR and NIST communications/coordination o External communication issues need to be resolved/formalized.
| |
| o Includes duties performed by outside organizations.
| |
| | |
| Comparison of the Trait 2023 to 2024 A comparison of the survey results for the DM Trait from 2023 to 2024 indicated improvement with respect to DM.3, as follows:
| |
| | |
| DM.3 - Improvement - Chiefs and Crew Chiefs maintain single-point accountability for important safety decisions.
| |
| | |
| Reference Attachment 17, Survey Data Comparison 2023 to 2024, and Trait LA for additional Areas of Interest that may need management attention to achieve full effectiveness and consistency.
| |
| | |
| Recommendation
| |
| : 1) Initiative - Communications: Update the Communications Strategy Initiative to include the element of decision-making. Specifically, include more timely and complete communications on important decisions to increase awareness, understanding, and ability of personnel to contribute and provide feedback.
| |
| | |
| Objective 6: Respectful Work Environment
| |
| | |
| Trait: Respectful Work Environment (WE) - Trust and respect permeate the organization. The underlying Attributes include Respect is Evident (WE.1), Opinions are Valued (We.2), High Level of Trust (WE.3), and WE.4 (Conflict Resolution).
| |
| | |
| The survey included 9 questions related to WE to understand what people believe. The graph below is based on All Respondents. Individual Contributors and Supervisors and Above survey results are provided in Attachment 6, to provide additional insights for leaders and others with a need or desire to know.
| |
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| Page 22 of 170
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| Subsequently, the team used focus group/interviews, observations, and cognitive analysis to substantiate survey responses and gain further insights into what people believe and what people do. The analysis of data for the Trait WE identified the following:
| |
| | |
| The Assessment Category
| |
| | |
| Area of Strength: None
| |
| | |
| Area for Improvement: None
| |
| | |
| Positive Observation (WE.2): Willingness to Raise Concerns.
| |
| Personnel are confident in their ability to raise safety concerns and will raise safety concerns.
| |
| | |
| Positive Observation (WE.3): Teamwork.
| |
| People are open, engaged, and willing to ask for help because of the respectful work environment and the level of teamwork.
| |
| | |
| Area in Need of Attention (WE.2): Engagement of Stakeholders.
| |
| NCNR is not consistent in engaging key NCNR personnel in plans and decisions.
| |
| | |
| Supporting information includes:
| |
| * This is a very emotional issue both in the survey and interviews.
| |
| o Not treated as a peer.
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| Page 23 of 170
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| o Frequently left out of discussions and meetings.
| |
| o Quoted gender influence.
| |
| o Management may not be equipped to deal with softer issues.
| |
| o What happens depends on who brings up the issue.
| |
| o Treating everyone as being on the team.
| |
| o Dismissing violations.
| |
| o Soft pedaling issues.
| |
| * NCNR personnel perceive that they are not included in decision-making which is leading to a limited perception of a lack of respect. (examples include junior but experienced personnel and supporting organizations outside Ops and engineering)
| |
| | |
| Area in Need of Attention (WE.3): Feedback when Raising Concerns.
| |
| The behavior of raising concerns is not always consistently reinforced in a positive manner.
| |
| | |
| Supporting Information Includes:
| |
| * People feel disrespect, when people are invited to a meeting and choose not to dont show up, and then result in delays in getting work done.
| |
| * Employees opinions and ideas are often not taken into serious consideration, especially from the junior employees, unless specifically asked for.
| |
| * Professional capability is often respected and acknowledged, however certain interactions between leadership and others can come across as condescending.
| |
| | |
| Comparison of the Trait 2023 to 2024 No change or areas of interest.
| |
| | |
| Recommendations
| |
| : 1) Initiative - Safety Culture: Strengthen actions within the Safety Culture Initiative with regard to providing positive reinforcement to individuals willing to raise concerns.
| |
| 2)
| |
| : 3) Initiative - Safety Culture: Consider incorporating a question regarding key NCNR stakeholder participation (OU Groups and Integrated Safety) into NCNR decision-making guidance. Suggest placing in Integrated Management Model, Integrated Safety Culture Traits and Attributes Book, or procedure.
| |
| Objective 7: Continuous Learning
| |
| | |
| Trait: Continuous Learning (CL) - Opportunities to learn about ways to ensure safety are sought out and implemented. The underlying Attributes include Operating Experience (CL.1), Self-Assessment (CL.2), Benchmarking (CL.3), and Training (CL.4).
| |
| | |
| The survey included 7 questions related to CL to understand what people believe. The graph below is based on All Respondents. Individual Contributors and Supervisors and Above survey results are provided in Attachment 7, to provide additional insights for leaders and others with a need or desire to know.
| |
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| Page 24 of 170
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| | |
| Subsequently, the team used focus group/interviews, observations, and cognitive analysis to substantiate survey responses and gain further insights into what people believe and what people do. The analysis of data for the Trait CL identified the following:
| |
| | |
| The Assessment Category
| |
| | |
| Area of Strength: None
| |
| | |
| Positive Observations (CL.4): Informal Training.
| |
| * Health Physics group has bi-weekly training on selected topics.
| |
| * Engineering group provides new hire indoctrination activities and monthly safety meetings.
| |
| | |
| Area in Need of Attention (CL.1): Operating Experience.
| |
| NCNR is not consistently using internal and external Operating Experience (OE) and communicating the results, with recognition that external OE (other test reactors) is somewhat limited by the lack of industry communication methods. (Survey data driven ANA).
| |
| | |
| Supporting information includes:
| |
| * Survey data indicates a desire for a more useful Operating Experience program using both within and outside NCNR information.
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| Page 25 of 170
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| Area in Need of Attention (CL.4): Training Program Descriptions.
| |
| There is a lack of a consistent framework outside of Operations under which all groups in the OU can develop and implement consistent initial and continuing training programs.
| |
| | |
| Supporting information includes:
| |
| * From both the survey and interviews there is a significant desire for more training and more effective training. Some of the elements and observations from the staff include:
| |
| * Only Ops has a strategy for improving training using the Systematic Approach to Training.
| |
| * Groups within NCNR have completely different approaches to training and no formal programs yet are distinctly different and therefore difficult to determine effectiveness.
| |
| | |
| Area for Improvement (CL.4): Training.
| |
| NCNR is not making progress fast enough, and in an integrated manner, to support NCNR job performance across OU groups and job functions (i.e., Continuing Training, Supervisor Training, and General Employee Indoctrination).
| |
| | |
| Supporting information includes:
| |
| * Training is in flux and the current state has a negative impact on the Operators and staffing the Operations organization. Concerned about training being a one man show.
| |
| * Todays training program is not adequate. Framework is not there.
| |
| * We are getting better at this, but the training and knowledge transfer infrastructure.
| |
| (particularly within Engineering) is still in its infancy, and it is still being developed.
| |
| * Training programs are still under development and need to be formalized. Much of the training is informal at this time. Work is in progress to improve though.
| |
| * This area had a significant decline since 2023 based on survey statistical data.
| |
| | |
| Comparison of the Trait 2023 to 2024 A comparison of the survey results for the CL Trait from 2023 to 2024 indicated decline in CL.1 and CL.4, as follows:
| |
| | |
| CL.1 Operating Experience - Decline - Operating experience is effectively implemented and institutionalized through changes to NCNR processes, procedures, equipment, and training programs.
| |
| | |
| CL.4 Training - Decline - NCNR provides training and ensures knowledge transfer to maintain a knowledgeable, technical competent workforce.
| |
| | |
| Reference Attachment 17, Survey Data Comparison 2023 to 2024, and Trait LA for additional Areas of Interest that may need management attention to achieve full effectiveness and consistency.
| |
| | |
| Recommendations
| |
| : 1) Initiatives - Resource Strategy: Provide augmented resources to allow a systematic approach to implementing the Operations Training Program.
| |
| : 2) Initiative - Training: Develop an overall strategy to improve training implementation across OU group functions and leader functions including the establishment of initial and continuing Training Program Descriptions.
| |
| | |
| Page 26 of 170
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| : 3) Initiative - Communications: Communicate to NCNR personnel expectations for the use of internal and external operating experience, and successes in the use of OE in improving performance.
| |
| | |
| Objective 8: Problem Identification and Resolution
| |
| | |
| Trait: Problem Identification and Resolution (PI) - Issues potentially impacting safety are promptly identified, fully evaluated, and promptly addressed and corrected commensurate with their significance. The underlying Attributes include Identification (PI.1), Evaluation (PI.2),
| |
| Resolution (PI.3), and Trending (PI.4).
| |
| | |
| The survey included 6 questions related to PI to understand what people believe . The graph below is based on All Respondents. Individual Contributors and Supervisors and Above survey results are provided in Attachment 8, to provide additional insights for leaders and others with a need or desire to know.
| |
| | |
| Subsequently, the team used focus group/interviews, observations, and cognitive analysis to substantiate survey responses and gain further insights into what people believe and what people do. The analysis of data for the Trait PI identified the following:
| |
| | |
| The Assessment Category
| |
| | |
| Area of Strength (PI.1): Non-Conformance Process A Non-Conformance process has been added to the CAP and personnel identify and enter material, part, and component non -conformances for disposition and resolution. This is a leading initiative within the Research and Test Reactor (RTR) industry.
| |
| | |
| Area of Strength (PI.1, PI.2, & PI.3): Establishment of the CAP Dashboard CAP Management has developed a CAP dashboard where groups and individuals can quickly access the status of CAP items. This strength is a leading initiative within the Research and Test Reactor (RTR) industry.
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| Page 27 of 170
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| Positive Observation (PI.1): Use of CAP.
| |
| There has been an overall increase in the use of the CAP since the 2023 INSCA. The inventory was 58 at the time of the 2023 INSCA and is currently at 363. Status as follows:
| |
| * 344 CAPs
| |
| * 88 Fully Closed
| |
| * 254 CAP Items with actions being worked to closure.
| |
| * ~100 CAP Items less than 120 days old. 92 Level 0 and 1.
| |
| * 107 CAP Items greater than 120 days old.
| |
| | |
| Area for Improvement (PI.1, PI.2 & PI.3): Leveraging CAP to Improve Performance.
| |
| * Some personnel do not understand the scope and threshold for the entry of events, problems, and other issues in the CAP or which other programs should be used to identify and document issues.
| |
| * Cause Analysts lack knowledge and proficiency in analysis tools and techniques.
| |
| * There is limited use of the CAP dashboard due to a lack of reinforcement by management for personnel to use the dashboard.
| |
| * CAP successes are not being communicated to promote and reinforce the use of CAP.
| |
| | |
| Supporting information includes:
| |
| * There are pockets across the organization that are perceived to not value the CAP Process and therefore are not using it to its best advantage.
| |
| * There is a wide perception that a feedback loop to support understanding of CAP successes and dispositions would be helpful.
| |
| * Survey results and interviews indicate there is not a consistent standard or understanding of what goes into CAP and what goes into other systems.
| |
| * Resource limitations were stated as a barrier to timeliness of disposition and corrective actions.
| |
| | |
| Comparison of the Trait 2023 to 2024 A comparison of the survey results for PI Trait from 2023 to 2024 indicated improvement with respect to PI.2, as follows:
| |
| | |
| PI.2 Evaluation - Improvement - NCNR thoroughly evaluates problems underlying organizational and safety culture contributors.
| |
| | |
| Reference Attachment 17, Survey Data Comparison 2023 to 2024, and Trait LA for additional Areas of Interest that may need management attention to achieve full effectiveness and consistency.
| |
| | |
| Recommendations Initiative - Performance Improvement
| |
| : 1) Initiative - Performance Improvement - Finish building out the new CAP platforms (i.e.,
| |
| CAP dashboard, etc.) to improve the user interface, functionality, and visibility in problem identification, evaluation, and resolution.
| |
| | |
| Page 28 of 170
| |
| : 2) Initiative - Performance Improvement - Identify OU groups not actively using CAP and the CAP Dashboard and provide some indoctrination into the mechanics of the system, the value added to performance improvement, and senior leader expectations for when and how to use.
| |
| : 3) Initiative - Communications - Develop and implement a communication strategy to educate NCNR personnel on 1) the threshold for CAP entry, 2) their accountability for using CAP, 3) the importance of, promptly identifying nonconformances in procedures and drawings in comparison to actual plant configuration, and 4) reinforcement of CAP successes.
| |
| : 4) Initiative - Training - Educate evaluators on the analytical tools and techniques necessary for successful conduct and documentation of causal analysis.
| |
| : 5) Initiative - Resources - Augment CAP resources and provide mentoring to support OU groups in problem identification, evaluation, and resolution.
| |
| | |
| Objective 9: Environment for Raising Concerns
| |
| | |
| Trait: Environment for Raising Concerns (RC) - A safety-conscious work environment (SCWE) is maintained where personnel feel free to raise safety concerns without fear of retaliation, intimidation, harassment, or discrimination. The underlying Attributes include SCWE Policy (RC.1) and Alternate Process for Raising Concerns (RC.2).
| |
| | |
| The survey included 4 questions related to RC to understand what people believe. The graph below is based on All Respondents. Individual Contributors and Supervisors and Above survey results are provided in Attachment 9, to provide additional insights for leaders and others with a need or desire to know.
| |
| | |
| Subsequently, the team used focus group/interviews, observations, and cognitive analysis to substantiate survey responses and gain further insights into what people believe and what people do. The analysis of data for the Trait RC identified the following:
| |
| | |
| Page 29 of 170
| |
| | |
| The Assessment Category
| |
| | |
| Area of Strength: None
| |
| | |
| Area for Improvement: None
| |
| | |
| Positive Observation (RC.1): Raising Concerns.
| |
| The survey and interviews indicated that personnel, with a few exceptions, freely raise integrated safety concerns without fear of retribution and with confidence that their concerns will be addressed.
| |
| | |
| Area in Need of Attention (RC.2): Issue Employee Concerns Procedure.
| |
| The ECP has a designated office area and a program manager but lacks timeliness in issuance of the ECP procedure. The procedure has been developed and submitted to the NRC. Issuance has been delayed awaiting NRC concurrence.
| |
| | |
| Supporting information includes:
| |
| | |
| Both in Interviews and the survey comments:
| |
| * There is no ECP Procedure/Program (at least that personnel are aware of)
| |
| * Generally, issues and concerns are received well, however positive reinforcement of reporting concerns is not consistent.
| |
| | |
| Comparison of the Trait 2023 to 2024 A comparison of the survey results for the RC Trait from 2023 to 2024 indicated improvement in RC.1, as follows:
| |
| | |
| RC.1 SCWE Policy - Improvement - Leaders take ownership when receiving and responding to concerns, recognizing confidentiality if appropriate and ensuring the concerns are adequately addressed in a timely manner.
| |
| | |
| Reference Attachment 17, Survey Data Comparison 2023 to 2024, and Trait LA for additional Areas of Interest that may need management attention to achieve full effectiveness and consistency.
| |
| | |
| Recommendations
| |
| : 1) Initiative - Safety Culture: Develop and implement a change management plan to issue the ECP procedure.
| |
| | |
| Objective 10: Work Processes
| |
| | |
| Trait: Work Processes (WP) - The process of planning and controlling work activities is implemented so that safety is maintained. The underlying Attributes include Work Management (WP.1), Design Margins (WP.2), Documentation (WP.3), and Procedure Adherence (WP.4).
| |
| | |
| The survey included 8 questions related to WP to understand what people believe. The graph below is based on All Respondents. Individual Contributors and Supervisors and Above survey results are provided in Attachment 10, to provide additional insights for leaders and others with a need or desire to know.
| |
| | |
| Page 30 of 170
| |
| | |
| Subsequently, the team used focus group/interviews, observations, and cognitive analysis to substantiate survey responses and gain further insights into what people believe and what people do. The analysis of data for the Trait WP identified the following:
| |
| | |
| The Assessment Category
| |
| | |
| Area of Strength: None
| |
| | |
| Area for Improvement: None
| |
| | |
| Positive Observation (WP.1): Aligning Work and Priorities.
| |
| Use of the Plan of the Day (POD) and the 08:00 Meeting to align OU groups and personnel on work and priorities.
| |
| | |
| Positive Observation (WP.3): Finding and Fixing Procedures.
| |
| Personnel are finding and fixing procedure issues and the quality of procedures is generally improving.
| |
| | |
| Area in Need of Attention (WP.3): Procedure Quality.
| |
| | |
| Page 31 of 170
| |
| | |
| Although there has been improvement, there are still issues with procedure quality involving errors and inconsistencies in content, and the process for changing procedures is slow.
| |
| | |
| Supporting information includes:
| |
| o Procedure/Drawing issues identified in both survey comments and interviews:
| |
| o Some are still on the R Drive.
| |
| o Physical Versions arent always available.
| |
| o Not all versions are on SharePoint.
| |
| o Revisions arent always sequential.
| |
| o Drawings and Diagram availability.
| |
| o Too many hands write procedures to varying levels of details and conflicts between procedures exist (quality) o The routing process can get things stuck and newer changes may be made without benefit of changes in process.
| |
| o The review process is not effectively used as a quality check.
| |
| | |
| Comparison of the Trait 2023 to 2024 Reference Attachment 17, Survey Data Comparison 2023 to 2024, and Trait LA for additional Areas of Interest that may need management attention to achieve full effectiveness and consistency.
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| Recommendations
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| : 1) Initiative - Resource Strategy: Conduct a review of the current levels of personnel supporting procedures, drawings, and configuration management, and acquire and allocate resources as necessary to support integrated safety.
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| : 2) Initiative - Procedures: Continue in the implementation of planned actions under the Procedure Initiative.
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| Page 32 of 170
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| Safety Culture Performance Improvement
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| The survey results for all respondents revealed that personnel believe the NSC is improving based on the below chart. The question The NCNRs Nuclear Safety Culture has improved since the last survey in 2023 was not asked in the 2023 survey so there is no comparison data.
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| A more detailed comparison of the 10 traits from the 2023 survey to the 2024 survey is available in Attachment 11. Some of the more noteworthy changes were factored into the overall analyses within the report.
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| Traits by OU Group
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| The survey results for each of the 10 Traits are presented in Attachments by the Operations, Reactor Engineering, Health Physics, Aging Reactor Management, and Others are in Attachments 12, 13, 14, 15, and 16, for those with a need or desire to know. While this INSCA Report identifies Areas in Need of Attention (ANA) and Areas for Improvement (AFIs) with recommendations for improvement, the survey results by OU group provide leaders with additional more subtle information for group leaders to review and act as they deemed appropriate.
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| Review of Internal Events
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| The Team reviewed two significant events since the last INSCA and identified the following Positive and Negative Observations. The results of the review are further discussed in 9.
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| Event: August 9, 2023, a loss of ventilation event occurred, resulting in minor contamination of fifteen NCNR staff members.
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| Positive Observations:
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| Page 33 of 170
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| : 1) The timeliness of the NCNR internal technical evaluation.
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| : 2) Developing a comprehensive timeline of the events leading up to the event.
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| : 3) Very detailed examination of the factors that drove the event with corrective actions to address each of the factors.
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| Negative Observations:
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| : 1) The IRIS evaluation has been drafted but is not yet approved. The organization is not currently aligned on the drivers for the event or the actions to prevent recurrence.
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| : 2) The CAP 172 analysis has structural issues, including:
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| : i. Clear identification of a Problem Statement ii. Systematic evaluation of the extent of condition.
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| iii. Use of diverse and sufficient tools to determine causal factors.
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| iv. A systematic examination of organizational factors that allowed this event to occur and drove NIST response.
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| : 3) The root cause statement is a renaming of the effect (i.e., escape of FP inventory into confinement resulting in low-level contamination) and lacks sufficient depth to drive effective actions to prevent recurrence.
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| : 4) The evaluation does not adequately aggregate the contributing causes to understand if there is a deeper underlying causal factor that may be caused by deeper organizational drivers.
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| Event: On November 30, 2023, during installation of a shim shaft seal on a Shim Arm, the team misidentified their current work step causing a worker to apply 40 ft-lbs. to the incorrect bolt. The incorrect amount of torque caused the bolt to fail.
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| Positive Observations:
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| : 1) The decision by management to upgrade to a higher level of effort (root cause) to understand the underlying causes of the event.
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| : 2) Developing a comprehensive timeline of the events leading up to the event.
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| : 3) Tying each identified root cause to a safety culture attribute shows an organizational effort to tie significant events into gaps in Integrated Safety Culture.
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| Negative Observations:
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| : 1) The analysis has structural issues, including:
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| : a. Clear identification of a Problem Statement
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| : b. Systematic evaluation of the extent of condition.
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| : c. Use of diverse and sufficient tools to determine causal factors.
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| : d. Identification of the inappropriate action(s) or condition(s) that directly led to the event.
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| : e. A systematic examination of organizational factors that allowed this event to occur at NCNR.
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| : 2) The root cause does not adequately aggregate the 18 root causes to understand organizational drivers. For example, examining the multiple issues related to procedures to determine if there are underlying organizational drivers.
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| Page 34 of 170
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| Review of External Information
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| NRC Inspection Activities and Reports:
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| On January 25, 2024, the NRC issued the 1st and 2nd Quarter 2023 Supplemental Inspection Report for NIST. No violations were identified in this report. The report provided a status of the Supplemental Inspection Objectives. The following objectives remain open:
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| Emergency Plan and Event Response o Observe implementation of emergency plan procedures Operator Licensing o Evaluate adequacy of licensed operator proficiency training o Observe implementation of licensed operator proficiency training Corrective Actions o Evaluate program to ensure expectations, processes, and procedures are in place to identify and implement safety improvements.
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| o Evaluate the adequacy of corrective actions for re-evaluated root cause analysis performed with emphasis on nuclear safety culture.
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| o Confirm consideration of CO2 build up potential in safety documentation and emergency plan.
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| Safety Committee Oversight o Review disposition of SAC recommendations Procedures o Evaluate program and processes in place to ensure quality of written procedures, to ensure procedures can be effectively executed, and to ensure procedures are periodically evaluated to implement improvements.
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| Design Change Process o Review change process program and procedures for compliance with Title 10 of the Code of Federal Regulations (10 CFR) 50.59 o Evaluate effectiveness of Engineering Change Management Program for ensuring changes are made consistent with 10 CFR 50.59 Safety Culture o Follow-up Safety Culture Inspections
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| The NRC documented the following observations and findings:
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| : 1. The inspectors observed several fuel operations and based on their observations determined that the appropriate corrective actions have been implemented to prevent recurrence and the associated IFI is now closed.
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| : 2. The inspectors observed several shifts and sessions of fuel handling training and noted adherence to procedure use and adherence guidance and concluded that all workers were trained on fuel movement operations.
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| : 3. The inspectors observed operations staff performing pre-evolution briefs and operations and observed consistent referring to procedures and place keeping. During training of operators at the console good coaching methods and challenges were observed.
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| : 4. The inspectors observed that NCNR staff conservatively limited power and staff working as a team to work through issues associated with power ascent.
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| : 5. The inspectors noted that operations personnel were not sure which process to use when they encountered problems; however, after discussions did enter the issue into CAP.
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| Page 35 of 170
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| : 6. The inspectors observed several evolutions and identified that while the licensee made numerous procedure changes, they still need to update procedures as they return to operations and use them.
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| NCNR Staff is aware of and has reviewed the NRC OIG Report Special Inquiry onto the US Nuclear Regulatory Commissions Oversight of Research and Test Reactors findings and the NRC Staff response. Discussions with senior NCNR staff show that they are aware of the concerns raised in the report and responses and are engaged with potential regulatory issues that may arise concerning the operation and inspection of RTRs.
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| Research and Test Reactor Interfaces
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| The staff at NCNR has been actively involved with other RTRs as part of a group working to define the appropriate program controls and activities related to Problem Identification and Resolution at RTRs.
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| The senior staff at NCNR are engaged with their counterparts at similar facilities and are using that engagement to benchmark and interface on important external issues facing the RTR community.
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| ==
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| Conclusion:==
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| : 1. NRC Inspection activities show an improvement in the behaviors observed by the NRC Inspectors in the areas of safety committee oversight, procedure quality and adherence behaviors, corrective action program use, and conduct of operations.
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| : 2. The NCNR staff is aware of regulatory challenges, and are interacting with counterparts in the RTR community, to understand and address challenges.
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| Page 36 of 170
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| Matrix of Initiatives to Recommendations
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| Initiative Trait Recommendation Communications Effective Safety Strengthen the follow up on the interim actions and develop strategy to support continuing Communications improvement.
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| (CO)
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| Effective Safety As a part of the pending strategy, take action to improve engagement to obtain Communications feedback/confirmation on the quality, dissemination, and understanding of communications to (CO) support implementation of tactical check/adjust actions.
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| Leadership Communicate and reinforce to NCNR personnel the expectation to, and importance of, promptly Safety Values identifying deltas in procedures and drawings in comparison to actual plant configuration into the and Actions (LA) CAP for collective review of priority and level of resolution.
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| Decision-Making Update the Communications Strategy Initiative to include the element of decision-making in the (DM) Communications Strategy Initiative. Specifically, updates to include more timely and complete communications on important decisions to increase awareness, under standing, and ability of personnel to contribute and provide feedback.
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| Continuous Communicate to NCNR personnel expectations for the use of internal and external operating Learning (CL) experience, and successes in the use of OE in improving performance.
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| PI&R (PI) Develop and implement a communication strategy to educate NCNR personnel on 1) the threshold for CAP entry, 2) their accountability for using CAP, 3) the importance of, promptly identifying nonconformances in procedures and drawings in comparison to actua l plant configuration, and 4) reinforcement of CAP successes.
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| Safety Culture Personal Stay the course.
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| Accountability (PA)
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| Questioning Stay the course.
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| Attitude (QA)
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| Leadership Implement the following actions to improve the Behavioral Observation Program and Leader Safety Values reinforcement of standards and expectations.
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| and Actions (LA)
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| Page 37 of 170
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| Initiative Trait Recommendation Leadership Implement the following actions to improve the Behavioral Observation Program and Leader Safety Values reinforcement of standards and expectations.
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| and Actions (LA)
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| * Educate leaders on using the ABC Model (Aubrey Daniels - Antecedent, Behavior, and Consequence) to influence leader and worker behaviors.
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| * Develop and provide leaders observation forms/criteria that reflect desired behaviors.
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| * Mentor of leaders in observing and coaching behaviors in addition to the Observation Program expectations, to ensure expectations are met and deviations in expectations are promptly identified and corrected on the spot or within the CAP.
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| Leadership Roll out the ISC booklet and associated training for all workers.
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| Safety Values and Actions (LA)
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| Work Develop and incorporate actions within the Safety Culture Initiative with regard to providing Environment positive reinforcement to individuals willing to raise concerns.
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| (WE)
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| Work Consider incorporating a question regarding key NCNR stakeholder participation (OU Groups Environment and Integrated Safety) into NCNR decision-making guidance. Suggest placing in Integrated (WE) Management Model, Integrated Safety Culture Traits and Attributes Book, or procedure.
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| Environment for Develop and implement a change management plan to issue the ECP procedure in a timelier Raising manner - prior to NRC approval if necessary.
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| Concerns (RC)
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| Performance PI&R (PI) Finish building out the new CAP platforms (i.e., CAP dashboard, etc.) to improve the user Improvement interface, functionality, and visibility in problem identification, evaluation, and resolution.
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| PI&R (PI) Identify OU groups not actively using CAP and the CAP Dashboard and provide some indoctrination into the mechanics of the system, the value added to performance improvement, and senior leader expectations for when and how to use.
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| Training Continuous Develop an overall strategy to improve training implementation across OU group functions and Learning (CL) leader functions including the establishment of initial and continuing Training Program Descriptions.
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| PI&R (PI) Educate evaluators on the analytical tools and techniques necessary for successful conduct and documentation of causal analysis.
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| Resource Leadership Conduct a review of the current levels of personnel and funds to identify critical underfunded Safety Values area that comprise NSC and seek additional funding from NIST and Department of Commence and Actions (LA)
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| Page 38 of 170
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| Initiative Trait Recommendation (DOC). Examples include procedure quality, drawing quality, training, and necessary CAP improvements.
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| Continuous Provide augmented resources to allow a systematic approach to implementing the Operations Learning (CL) Training Program PI&R (PI) Augment CAP resources and provide mentoring to support OU groups in problem identification, evaluation, and resolution.
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| Work Processes Conduct a review of the current levels of personnel supporting procedures, drawings, and (WP) configuration management, and acquire and allocate resources as necessary to support integrated safety.
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| Performance PI&R (PI) Finish building out the new CAP platforms (i.e., CAP dashboard, etc.) to improve the user Improvement interface, functionality, and visibility in problem identification, evaluation, and resolution.
| |
| PI&R (PI) Identify OU groups not actively using CAP and the CAP Dashboard and provide some indoctrination into the mechanics of the system, the value added to performance improvement, and senior leader expectations for when and how to use.
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| Training Continuous Develop an overall strategy to improve training implementation across OU group functions and Learning (CL) leader functions including the establishment of initial and continuing Training Program Descriptions.
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| PI&R (PI) Educate evaluators on the analytical tools and techniques necessary for successful conduct and documentation of causal analysis.
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| Procedures Work Processes Continue in the implementation of planned actions for procedure initiative.
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| (WP)
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| Effectiveness Review
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| The effectiveness of the recommendations will be measured by the Quarterly ISCMP, and the 2025 INSCA as defined in the Confirmatory Order.
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| Page 39 of 170
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| Attachments
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| : Survey Data Personal Accountability : Survey Data Questioning Attitude : Survey Data Effective Safey Communications : Survey Data Leadership Safety Values and Actions : Survey Data Decision-Making : Survey Data Respectful Work Environment : Survey Data Continuous Learning : Survey Data Problem Identification and Resolution : Survey Data Environment for Raising Concerns 0: Survey Data Work Processes 1: Survey Data Status of NSC Improvement 2: Survey Data for Operations 3: Survey Data for Reactor Engineering 4: Survey Data for Health Physics 5: Survey Data for Aging Reactor Management 6: Survey Data for Other Groups 7: Survey Data Comparison 2023 to 2024 8: Survey Question List 9: Review of Internal Events 0: Review of External Events and Guidance 1: Status of 2023 INSCA Recommendations 2: Status of 2023 INSCA Program Limiting Weaknesses 3: Focus Group/Interviews Form 4: Meeting Observation Form 5: Behavioral Observation Form 6: INSCA Team Members, Assignments, and Bios 7: INSCA Background Detail 8: NRC Inspection Report - Confirmatory Order Excerpt 9: Definitions
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| Page 40 of 170
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| : Survey Data Personal Accountability
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| Trait: Personal Accountability (PA) - individuals take personal responsibility for safety. The underlying Attributes include Standards (PA.1), Job Ownership (PA.2), and Teamwork (PA.3).
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| The survey included 6 questions related to PA to understand what people believe about NCNR ROE NSC. The graph s below represent survey results based on All Respondents , Individual Contributors, and Supervisors and Above. The survey results were reviewed to understand what people believe and focus group/interviews were then held to obtain insights into their beliefs and then followed by observations to gain insights into what people do with key insights provided in the below tables. The results are provided in the Analysis Results section of this Report.
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| Graph of All Respondents
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| Page 41 of 170
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| Graph of Individual Contributors
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| Page 42 of 170
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| Graph of Supervisors and Above
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| Page 43 of 170
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| : Survey Data Questioning Attitude
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| Trait: Questioning Attitude (QA) - Individuals avoid complacency and continuously challenge existing conditions and activities in order to identify discrepancies that might result in error or inappropriate action. The underlying Attributes include Nuclear is Recognized as Special and Unique (QA.1), Challenge the Unknown (QA.2), Challenge Assumptions (QA.9), and Avoid Complacency (QA.4).
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| The survey included 8 questions related to QA to understand what people believe about NCNR ROE NSC. The graphs below represent survey results based on All Respondents, Individual Contributors, and Supervisors and Above. The survey results were reviewed to understand what people believe and focus group/interviews were then held to obtain insights into their beliefs and then followed by observations to gain insights into what people do with key insights provided in the below tables. The results are provided in the Analysis Results section of this Report.
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| Graph of All Respondents
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| Page 44 of 170
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| Graph of Individual Contributors
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| Page 45 of 170
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| Graph of Supervisors and Above
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| Page 46 of 170
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| : Survey Data Effective Safey Communications
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| Trait: Effective Safety Communication (CO) - Communications maintain a focus on safety. The underlying Attributes include Work Process Communications (CO.1), Bases for Decisions (CO.2), Free Flow of Information (CO.3), and Expectations (CO.4).
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| The survey included 7 questions related to CO to understand what people believe about NCNR ROE NSC. The graph s below represent survey results based on All Respondents , Individual Contributors, and Supervisors and Above. The survey results were reviewed to understand what people believe and focus group/interviews were then held to obtain insights into their beliefs and then followed by observations to gain insights into what people do with key insights provided in the below tables. The results are provided in the Analysis Results section of this Report.
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| Graph of All Respondents
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| Page 47 of 170
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| Graph of Individual Contributors
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| Page 48 of 170
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| Graph of Supervisors and Above
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| Page 49 of 170
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| : Survey Data Leadership Safety Values and Actions
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| Trait: Leaders demonstrate a commitment to safety in their decisions and behaviors. The underlying Attributes include Resources (LA.1); Field Presence LA.2); Incentives, Sanctions, and Rewards (LA.3); Strategic Commitment to Safety (LA.4); Change Management (LA.5);
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| Roles, Responsibilities, and Authorities (LA.6); Constant Examination (LA.7); and Leader Behaviors (LA.8).
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| The survey included 16 questions related to LA to understand what people believe about NCNR ROE NSC. The graphs below represent survey results based on All Respondents, Individual Contributors, and Supervisors and Above. The survey results were reviewed to understand what people believe and focus group/interviews were then held to obtain insights into their beliefs and then followed by observations to gain insights into what people do with key insights provided in the below tables. The results are provided in the Analysis Results section of this Report.
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| Graph of All Respondents
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| Page 50 of 170
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| Graph of Individual Contributors
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| Page 51 of 170
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| Graph of Supervisors and Above
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| Page 52 of 170
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| : Survey Data Decision-Making
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| Trait: Decision Making (DM) - Decisions that support or affect nuclear safety are systematic, rigorous, and thorough. The underlying Attributes include Consistent Process (DM.1),
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| Conservative Bias (DM.2), and Accountability for Decisions (DM.3).
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| The survey included 5 questions related to DM to understand what people believe about NCNR ROE NSC. The graph s below represent survey results based on All Respondents , Individual Contributors, and Supervisors and Above. The survey results were reviewed to understand what people believe and focus group/interviews were then held to obtain insights into their beliefs and then followed by observations to gain insights into what people do with key insights provided in the below tables. The results are provided in the Analysis Results section of this Report.
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| Graph of All Respondents
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| Page 53 of 170
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| Graph of Individual Contributors
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| Page 54 of 170
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| Graph of Supervisors and Above
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| Page 55 of 170
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| : Survey Data Respectful Work Environment
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| Trait: Respectful Work Environment (WE) - Trust and respect permeate the organization. The underlying Attributes include Respect is Evident (WE.1), Opinions are Valued (We.2), High Level of Trust (WE.3), and WE.4 (Conflict Resolution).
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| The survey included 9 questions related to WE to understand what people believe about NCNR ROE NSC. The graphs below represent survey results based on All Respondents, Individual Contributors, and Supervisors and Above. The survey results were reviewed to understand what people believe and focus group/interviews were then held to obtain insights into their beliefs and then followed by observations to gain insights into what people do with key insights provided in the below tables. The results are provided in the Analysis Results section of this Report.
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| Graph of All Respondents
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| Page 56 of 170
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| Graph of Individual Contributors
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| Page 57 of 170
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| Graph of Supervisors and Above
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| Page 58 of 170
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| : Survey Data Continuous Learning
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| Trait: Continuous Learning (CL) - Opportunities to learn about ways to ensure safety are sought out and implemented. The underlying Attributes include Operating Experience (CL.1), Self-Assessment (CL.2), Benchmarking (CL.3), and Training (CL.4).
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| The survey included 7 questions related to CL to understand what people believe about NCNR ROE NSC. The graph s below represent survey results based on All Respondents , Individual Contributors, and Supervisors and Above. The survey results were reviewed to understand what people believe and focus group/interviews were then held to obtain insights into their beliefs and then followed by observations to gain insights into what people do with key insights provided in the below tables. The results are provided in the Analysis Results section of this Report.
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| Graph of All Respondents
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| Page 59 of 170
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| Graph of Individual Contributors
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| Page 60 of 170
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| Graph of Supervisors and Above
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| Page 61 of 170
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| : Survey Data Problem Identification and Resolution
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| Trait: Problem Identification and Resolution (PI) - Issues potentially impacting safety are promptly identified, fully evaluated, and promptly addressed and corrected commensurate with their significance. The underlying Attributes include Identification (PI.1), Evaluation (PI.2),
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| Resolution (PI.3), and Trending (PI.4).
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| The survey included 6 questions related to PI to understand what people believe about NCNR ROE NSC. The graph s below represent survey results based on All Respondents , Individual Contributors, and Supervisors and Above. The survey results were reviewed to understand what people believe and focus group/interviews were then held to obtain insights into their beliefs and then followed by observations to gain insights into what people do with key insights provided in the below tables. The results are provided in the Analysis Results section of this Report.
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| Graph of All Respondents
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| Page 62 of 170
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| Graph of Individual Contributors
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| Page 63 of 170
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| Graph of Supervisors and Above
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| Page 64 of 170
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| : Survey Data Environment for Raising Concerns
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| Trait: Environment for Raising Concerns (RC) - A safety-conscious work environment (SCWE) is maintained where personnel feel free to raise safety concerns without fear of retaliation, intimidation, harassment, or discrimination. The underlying Attributes include SCWE Policy (RC.1) and Alternate Process for Raising Concerns (RC.2).
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| The survey included 4 questions related to RC to understand what people believe about NCNR ROE NSC. The graphs below represent survey results based on All Respondents, Individual Contributors, and Supervisors and Above. The survey results were reviewed to understand what people believe and focus group/interviews were then held to obtain insights into their beliefs and then followed by observations to gain insights into what people do with key insights provided in the below tables. The results are provided in the Analysis Results section of this Report.
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| Graph of All Respondents
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| Page 65 of 170
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| Graph of Individual Contributors
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| Page 66 of 170
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| Graph of Supervisors and Above
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| Page 67 of 170 0: Survey Data Work Processes
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| Trait: Work Processes (WP) - The process of planning and controlling work activities is implemented so that safety is maintained. The underlying Attributes include Work Management (WP.1), Design Margins (WP.2), Documentation (WP.3), and Procedure Adherence (WP.4).
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| The survey included 8 questions related to WP to understand what people believe about NCNR ROE NSC. The graphs below represent survey results based on All Respondents, Individual Contributors, and Supervisors and Above. The survey results were reviewed to understand what people believe and focus group/interviews were then held to obtain insights into their beliefs and then followed by observations to gain insights into what people do with key insights provided in the below tables. The results are provided in the Analysis Results section of this Report.
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| Graph of All Respondents
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| Page 68 of 170
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| Graph of Individual Contributors
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| Page 69 of 170
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| Graph of Supervisors and Above
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| Page 70 of 170 1: Survey Data Status of NSC Improvement
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| The survey included one question related to has NSC improved since the last survey in 2023 to understand what people believe about NCNR ROE NSC. The graphs below represent survey results based on All Respondents, Individual Contributors, and Supervisors and Above.
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| Graph of All Respondents
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| Graph of Individual Contributors
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| Page 71 of 170
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| Graph of Supervisor and Above
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| Page 72 of 170 2: Survey Data for Operations
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| The survey results for what Operations personnel believe about performance for each of the 10 NSC traits are provided in the below charts. The charts are broken-down by All Respondents, Individual Contributors, and Supervisors and Above. While this INSCA Report identifies Areas in Need of Attention (ANA) and Areas for Improvement (AFIs) with recommendations for improvement, the survey results by OU group provide leaders with additional more subtle information for group leaders to review and act as they deemed appropriate.
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| Personal Accountability (PA)
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| Page 73 of 170
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| Questioning Attitude (QA)
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| Page 74 of 170
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| Effective Safety Communications (CO)
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| Page 75 of 170
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| Leadership Safety Value and Actions (LA)
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| Page 76 of 170
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| Decision-Making (DM)
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| Page 77 of 170
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| Respectful Work Environment (WE)
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| Page 78 of 170
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| Continuous Learning (CL)
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| Problem Identification and Resolution (PI)
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| Page 79 of 170
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| Environment for Raising Concerns (RC)
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| Work Processes (WP)
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| Page 80 of 170
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| Page 81 of 170 3: Survey Data for Reactor Engineering
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| The survey results for what Reactor Engineering personnel believe about performance for each of the 10 NSC traits are provided in the below charts. The charts are broken-down by All Respondents, Individual Contributors, and Supervisors and Above. While this INSCA Report identifies Areas in Need of Attention (ANA) and Areas for Improvement (AFIs) with recommendations for improvement, the survey results by OU group provide leaders with additional more subtle information for group leaders to review and act as they deemed appropriate.
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| Personal Accountability (PA)
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| Page 82 of 170
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| Questioning Attitude (QA)
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| Effective Safety Communications (CO)
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| Page 83 of 170
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| Leadership Safety Value and Actions (LA)
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| Page 84 of 170
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| Decision-Making (DM)
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| Page 85 of 170
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| Respectful Work Environment (WE)
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| Page 86 of 170
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| Continuous Learning (CL)
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| Page 87 of 170
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| Problem Identification and Resolution (PI)
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| Page 88 of 170
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| Environment for Raising Concerns (RC)
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| Page 89 of 170
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| Work Processes (WP)
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| Page 90 of 170 4: Survey Data for Health Physics
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| The survey results for what Health Physics personnel believe about performance for each of the 10 NSC traits are provided in the below charts. The charts are broken-down by All Respondents, Individual Contributors, and Supervisors and Above. While this INSCA Report identifies Areas in Need of Attention (ANA) and Areas for Improvement (AFIs) with recommendations for improvement, the survey results by OU group provide leaders with additional more subtle information for group leaders to review and act as they deemed appropriate.
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| Personal Accountability (PA)
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| Page 91 of 170
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| Questioning Attitude (QA)
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| Page 92 of 170
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| Effective Safety Communications (CO)
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| Page 93 of 170
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| Leadership Safety Value and Actions (LA)
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| Page 94 of 170
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| Decision-Making (DM)
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| Respectful Work Environment (WE)
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| Page 95 of 170
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| Continuous Learning (CL)
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| Problem Identification and Resolution (PI)
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| Page 96 of 170
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| Environment for Raising Concerns (RC)
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| Work Processes (WP)
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| Page 97 of 170
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| Page 98 of 170 5: Survey Data for Aging Reactor Management
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| The survey results for what Aging Reactor Management personnel believe about performance for each of the 10 NSC traits are provided in the below charts. The charts are broken-down by All Respondents, Individual Contributors, and Supervisors and Above. While this INSCA Report identifies Areas in Need of Attention (ANA) and Areas for Improvement (AFIs) with recommendations for improvement, the survey results by OU group provide leaders with additional more subtle information for group leaders to review and act as they deemed appropriate.
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| Personal Accountability (PA)
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| Page 99 of 170
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| Questioning Attitude (QA)
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| Page 100 of 170
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| Effective Safety Communications (CO)
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| Page 101 of 170
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| Leadership Safety Value and Actions (LA)
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| Page 102 of 170
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| Decision-Making (DM)
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| Decision-Making ARM
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| (DM.1) 43. I use a consistent, systematic approach to 4 6 4.60 making decisions.
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| (DM.1) 47. When previous operational decisions are called into question by new facts, leaders re-evaluate 3 7 4.70 these decisions to ensure they remain appropriate and adjust as needed.
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| (DM.2) 3. Leaders apply a conservative approach to decision making, particularly when information is 1 3 6 4.50 incomplete or conditions are unusual.
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| (DM.2) 46. I use decision-making practices that emphasize prudent choices over those that are simply 1 1 4 4 4.10 allowable.
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| (DM.3) 44. Chiefs and Crew Chiefs maintain single-point 1 1 5 3 4.00 accountability for important safety decisions.
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| Strongly Disagree Disagree Neither Agree or Disagree Agree Strongly Agree Average
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| Page 103 of 170
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| Respectful Work Environment (WE)
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| Page 104 of 170
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| Continuous Learning (CL)
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| Page 105 of 170
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| Problem Identification and Resolution (PI)
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| Environment for Raising Concerns (RC)
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| Page 106 of 170
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| Work Processes (WP)
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| Page 107 of 170
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| Page 108 of 170 6: Survey Data for Other Groups
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| The survey results for what Other Groups personnel believe about performance for each of the 10 NSC traits are provided in the below charts. The charts are broken-down by All Respondents, Individual Contributors, and Supervisors and Above. While this INSCA Report identifies Areas in Need of Attention (ANA) and Areas for Improvement (AFIs) with recommendations for improvement, the survey results by OU group provide leaders with additional more subtle information for group leaders to review and act as they deemed appropriate.
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| Personal Accountability (PA)
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| Questioning Attitude (QA)
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| Page 109 of 170
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| Effective Safety Communications (CO)
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| Page 110 of 170
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| Leadership Safety Value and Actions (LA)
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| Page 111 of 170
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| Decision-Making (DM)
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| Page 112 of 170
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| Respectful Work Environment (WE)
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| Continuous Learning (CL)
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| Page 113 of 170
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| Problem Identification and Resolution (PI)
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| Environment for Raising Concerns (RC)
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| Page 114 of 170
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| Work Processes (WP)
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| Page 115 of 170
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| Page 116 of 170 7: Survey Data Comparison 2023 to 2024
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| The survey questions and changes in All Respondents responses from 2023 to 2024 are provided in the below table. While this INSCA Report identifies Areas in Need of Attention (ANA) and Areas for Improvement (AFIs) with recommendations for improvemen t, the survey results from 2023 to 2024 are provided to leaders with additional more subtle information for review and act as they deemed appropriate.
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| Leadership Safety Value and Actions ATTRIBUTE 2023 QUESTIONS SCORE 2024 QUESTIONS SCORE 2023 2024 LA.6 Q44 Leaders assign single-point accountability for nuclear safety 3.25 44. Chiefs and Crew Chiefs maintain single-point 3.80 decisions. accountability for important safety decisions.
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| Q23 Team Leaders are selected based upon fostering a strong 3.38 Not Used Not nuclear safety environment that promotes accountability. Used LA.3 Q12 Leaders provide incentives and rewards that are aligned with 3.44 Q12. Leaders provide incentives, sanctions, and 3.40 nuclear safety policies. rewards that are aligned with NCNR integrated safety policies and reinforce behaviors and outcomes that reflect safety as the overriding priority.
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| LA.5 Q33. Leaders implement change in a way that builds 3.56 Q33. Leaders use a systematic process for evaluating 3.66 organizational trust. and implement change so that integrated safety remains the overriding priority.
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| LA.8 Q21. Leaders at all levels ensure that the basis for operational 3.58 Q21. Leaders ensure that the basis for operational 3.62 and organizational decisions is communicated to staff in a timely and organizational decisions is communicated in a manner. timely manner.
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| Q59. Leaders develop contingencies to deal with the possibility of 3.70 Not Used Not emergent problems. Used LA.1 Q41. Leaders provide training and knowledge transfer to establish 3.71 Q41. NCNR provides training and ensures knowledge 3.29 and maintain technical competence. transfer to maintain a knowledgeable, technical competent workforce.
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| LA.1 Q71. Leaders foster an environment in which individuals value 3.71 71. Leaders foster an environment in which 3.97 and seek continuous learning opportunities. individuals value and seek continuous learning opportunities.
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| LA.2 Q17. Leaders from all levels in the organization are involved in 3.83 17. Leaders from all levels in the organization are 3.95 oversight of work activities. involved in oversight of work activities.
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| LA.8 Q24. Leaders 'walk the talk modeling behaviors when resolving 3.8 Q24. Leaders walk the talk, modeling correct 3.97 conflicts between nuclear safety and production. behaviors when resolving apparent conflicts between Integrated safety and facility availability.
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| LA.2 Q8. Leaders reinforce the focus on nuclear safety through site 3.90 Q8. Leaders exhibit behaviors that set the standard 3.92 visits. for integrated safety.
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| Page 117 of 170
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| LA.4 Q20. Leaders provide goals for production of neutrons that are 3.92 Q20. Chiefs and Crew Chiefs develop and implement 3.62 aligned to reflect nuclear safety as the overriding priority. cost and schedule goals in a manner that reinforces the importance of integrated safety.
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| Q16. Team Leaders are visible in the plant reinforcing Nuclear 3.92 Not Used Not Safety Culture behaviors. Used LA.7 Q63. Leaders apply conservative decision making to mitigate 3.94 Q63. Leaders apply a conservative approach to 4.35 unpredicted failures. decision making, particularly when information is incomplete or conditions are unusual.
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| LA.6 Q6. Leaders clearly define roles, responsibilities, authorities, and 4.00 Q6. Leaders ensure roles, responsibilities, and 3.87 accountabilities to ensure nuclear safety. authorities are clearly defined, understood and documented to promote integrated safety.
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| Q26. Our Team Leaders are frequently present in the field. 4.00 Not Used Not Used Q14. Leaders exhibit behaviors that set the standard for nuclear 4.02 Not Used Not safety. Used LA.8 Q45. Leaders ask for input when evaluating nuclear safety issues. 4.02 Q45. Leaders solicit challenges to assumptions when 4.02 evaluating integrated safety issues.
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| LA.4 Q36. Leaders enhance trust and nuclear safety through 4.08 Q36. Leaders share important information in an open, 4.22 communications. honest and timely manner such that trust is maintained.
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| Q72. Leadership enforces management standards and 4.08 Not Used Not expectations that reflect nuclear safety values. Used
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| LA.8 Q47. When previous operational decisions are called into 4.08 Q47. When previous operational decisions are called 4.39 question by emerging facts, leaders re-evaluate and adjust as into question by new facts, leaders re-evaluate these needed. decisions to ensure they remain appropriate and adjust as needed.
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| Environment for Raising Concerns ATTRIBUTE 2023 QUESTIONS SCORE 2024 QUESTIONS SCORE 2023 2024 RC2 Q16. Team Leaders are visible in the plant reinforcing nuclear 3.93 Q16. NCNR has a process for raising and resolving 3.86 safety culture behaviors. concerns that is independent of line-management influence.
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| RC1 Q29. I freely raise nuclear safety concerns without fear of 4.64 Q 29. I freely raise integrated safety concerns without 4.43 retribution. fear of retribution and with confidence that their concerns will be addressed.
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| RC1 Q23. Team Leaders are selected based upon fostering a strong 3.45 Q 23. Leaders take ownership when receiving and 4.08 nuclear safety environment that promotes accountability. responding to concerns, recognizing confidentiality if appropriate and ensuring the concerns are adequately addressed in a timely manner.
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| Page 118 of 170
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| Q15. My First-level Supervisor has personally recognized me for 3.91 Not Used in 2024 supporting nuclear safety.
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| RC.1 Not Used Q 15. Claims of harassment, intimidation, retaliation, 4.09 and discrimination are investigated.
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| Work Processes ATTRIBUTE 2023 QUESTIONS SCORE 2024 Question SCORE 2023 2024 WP.4 Q38. I follow processes, procedures, and work instructions. 4.67 Q 38. I follow processes, procedures, and work 4.65 instructions.
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| Q25. My supervisor periodically observes me working and 4.02 Not Used gives me useful feedback.
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| WP.3 Q55. Plant activities are governed by comprehensive high- 3.51 Q 55. NCNR creates and maintains complete, 3.25 quality programs, processes, and procedures. accurate and up-to-date documentation.
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| WP.3 Q49. Plant activities are governed by comprehensive high- 3.46 49. NCNR facility activities are governed by 3.26 quality programs, processes, and procedures. comprehensive high-quality programs, processes, and procedures.
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| WP.2 Q53. Safety-related equipment is operated and maintained 4.28 Q 53. Safety-related equipment is operated and 4.37 within design requirements. maintained within design requirements.
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| WP.2 Q52. Design and operating margins are carefully guarded and 4.21 Q 52. Design and operating margins are carefully 4.39 changed as defined by procedures. guarded and changed only with great thought and care.
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| Q72. Leadership enforces management standards and 4.11 Not Used expectations that reflect nuclear safety values.
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| WP.1 Q54. Work is effectively planned and executed by 3.69 Q 54. Work is effectively planned and executed by 3.65 incorporating risk-informed insights. incorporating risk-informed insights.
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| WP.4 Not Used Q 25. I understand and use human error reduction 4.34 techniques, such as self-check, STAR, and pre-job briefs.
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| WP.2 Not Used Q 72. NCNR implements the work management 3.98 process (planning, controlling and executing work activities) such that integrated safety is the overriding priority.
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| Personal Accountability ATTRIBUTE 2023 QUESTIONS SCORE 2024 QUESTIONS SCORE 2023 2024 PA.3 Not Used Q73. I communicate and coordinate my activities 4.41 within and across organizational boundaries to ensure integrated safety is maintained.
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| Page 119 of 170
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| PA.2 Q39. My supervisor discusses nuclear safety with me regarding 4.25 Q 39. I actively participate in pre-job briefings, 4.51 my job responsibilities. understanding my responsibilities to raise integrated safety concerns before work begins.
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| PA.2 Q14. Leaders exhibit behaviors that set the standard for nuclear 4.05 Not Used safety.
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| PA.2 Q11. The line of responsibility for nuclear safety is clear and not 4.04 Not Used confused by research-related priorities.
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| PA.1 Q10. Employees adhere to nuclear safety culture behaviors. 4.04 Q 10. I am accountable for shortfalls in meeting 4.17 integrated safety standards/behaviors.
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| PA.1 Q5. I am personally accountable for my nuclear safety culture 4.68 Q 5. I clearly understand the importance of 4.79 behaviors. adherence to integrated safety standards.
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| PA.2 Not Used Q 14. I ensure that I am trained and qualified to 4.39 perform assigned work.
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| PA.2 Not Used Q 11. I understand my personal responsibility to 4.61 foster a professional environment, encourage teamwork and identify challenges to integrated safety.
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| Questioning Attitude ATTRIBUTE 2023 QUESTIONS SCORE 2024 QUESTIONS SCORE 2023 2024 QA.4 Not Used Q65. I avoid complacency and plan for the possibility 4.38 of mistakes.
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| QA.4 Not Used Q 37. I perform a thorough review of the work site and 4.16 planned activity every time work is performed.
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| QA.3 Q45. Leaders ask for input when evaluating nuclear safety issues. 4.05 Q 45. Leaders solicit challenges to assumptions when 4.02 evaluating integrated safety issues.
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| QA.3 Q64. I challenge assumptions/offer opposing views when I think 4.54 Q 64. I challenge assumptions/offer opposing views 4.48 something is not correct. when I think something is not correct.
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| QA.2 Not Used Q 81.I stop work activities when confronted with an 4.63 unexpected condition.
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| QA.2 Q60. I promptly challenge unanticipated test results or 4.44 Q 60. I promptly challenge unanticipated test results 4.41 unexpected system response. or unexpected system response rather than rationalize them.
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| QA.2 Q58. I maintain a questioning attitude during pre-job briefs/job- 4.61 Q 58. I maintain a questioning attitude during pre-job 4.48 site reviews to address changed conditions. briefs/job-site reviews to Identify and resolve unexpected conditions.
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| QA.1 Q57. I recognize the unique hazards of nuclear technology. 4.64 Q 57. I recognize the special characteristics and 4.80 unique hazards of nuclear technology.
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| Page 120 of 170
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| QA.1 Q51. The organization conducts activities that could affect 4.36 Q 51. Leaders ensures that activities that could affect 4.57 reactivity with caution, in accordance with procedures. reactivity are conducted with particular care, caution, oversight, and in accordance with procedures.
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| Problem Identification and Resolution ATTRIBUTE 2023 QUESTIONS SCORE 2024 QUESTIONS SCORE 2023 2024 PI.4 Q77. A broad set of performance indicators is utilized with a focus 3.49 Q 77. NCNR uses performance indicators to monitor 3.47 on early detection of problems. both equipment and organizational performance, including integrated safety culture.
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| Q18. Employees have input into resolving issues. 4.25 Not Used PI.2 Q70. We have processes to identify and resolve existing 3.50 Q 70. NCNR thoroughly evaluates problems for 3.98 organizational weaknesses. underlying organizational and safety culture contributors.
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| PI.2 Q69. Root cause analysis is rigorously applied to identify and 3.80 Q 69. NCNR thoroughly evaluates problems to ensure 3.89 correct the fundamental causes of significant events. that resolutions address causes and extent of conditions.
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| PI.1 Q62. I recognize and act upon deviations from standards. 4.42 Q 62. I recognize deviations from standards. 4.22
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| Q50. I understand the importance of processes designed to 4.45 Not Used maintain critical nuclear safety functions.
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| PI.1 Q 50. I ensure issues, problems, degraded conditions 4.27 and near misses are promptly reported and documented in the corrective action program.
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| PI.3 Q18. NCNR takes effective corrective actions to 3.71 address issues in a timely manner, commensurate with their safety significance.
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| Respectful Work Environment ATTRIBUTE 2023 QUESTIONS SCORE 2024 QUESTIONS SCORE 2023 2024 WE.3 Q36. Leaders enhance trust and nuclear safety through 4.05 Q 36. Leaders share important information in an 4.22 communications. open, honest and timely manner such that trust is maintained.
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| Page 121 of 170
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| WE.3 Q32. Supervisors respond to questions and concerns. 4.27 Q 32. Chiefs, Crew Chiefs, Leads and Supervisors 4.20 respond to questions and concerns in an open and honest manner.
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| Q27. My supervisor responds to questions and concerns in an 4.52 Not Used open and honest manner.
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| WE.2 Q78. We value insights provided by operational support or 4.08 Q 78. I value the insights and perspectives provided 4.23 oversight groups. by quality assurance, the employee concerns programs and independent oversight organizations.
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| WE.2 Q31. Differing opinions are welcomed and respected. 3.98 Q 31. Differing opinions are welcomed and respected. 4.09 WE.2 Q30. Leadership encourages individuals to seek ways to improve 4.31 Q 30. I am encouraged to offer ideas, concerns, 4.26 nuclear safety processes. suggestions, differing opinions and questions to help identify and solve problems.
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| WE.1 Q42. I treat decision-makers with respect, even when I disagree 4.55 Q 42. I treat decision-makers with respect, even when 4.72 with a decision. I disagree with a decision.
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| WE.1 Q28. I treat other employees with dignity and respect. 4.68 Q 28. I treat other employees with dignity and respect. 4.77 WE.1 Q7. Management regards individuals as its most valuable asset. 3.87 Q 7. Leaders regard individuals and their professional 3.89 capabilities and experiences as its most valuable asset.
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| WE.3 Not Used Q 27. Leaders promote collaboration among work 3.88 groups.
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| Effective Safety Communications ATTRIBUTE 2023 QUESTIONS SCORE 2024 QUESTIONS SCORE 2023 2024 CO.4 Q61. I stop when I identify unexpected or uncertain conditions. 4.60 Not Used CO.4 Not Used Q 40. Leaders frequently communicate and reinforce 4.27 the expectation that integrated safety is the organizations overriding priority.
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| CO.3 Q74. I believe the Center for Neutron Research (NCNR) Director, 4.45 Not Used and Deputy Director are regularly informed about Reactor Safety Performance.
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| CO.3 Q35. I communicate candidly with oversight, audit, and 4.63 Q 35. I communicate openly and candidly with 4.48 regulatory organizations. oversight, audit, and regulatory organizations.
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| CO.2 Q59. Leaders develop contingencies to deal with the possibility of 3.72 Not Used emergent problems.
| |
| CO.2 Q21. Leaders at all levels ensure that the basis for operational 3.64 Q 21. Leaders ensure that the basis for operational 3.62 and organizational decisions is communicated to staff in a timely and organizational decisions is communicated in a manner. timely manner.
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| CO.1 Q4. Safety is discussed at every meeting where plant work 4.43 Q4. Integrated safety is discussed at every meeting 4.11 activities are planned and reviewed. where plant work activities are planned and reviewed.
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| Page 122 of 170
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| CO.2 Not Used Q59. Leaders encourage individuals to ask questions 4.40 if they do not understand the basis of operational and management decisions.
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| CO.4 Not Used Q 61. Leaders ensure supplemental personnel 4.16 understand expected behaviors and actions necessary to maintain integrated safety.
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| CO.3 Not Used Q 74. Leaders respond to me in an open, honest and 4.34 non-defensive manner.
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| Continuous Learning ATTRIBUTE 2023 QUESTIONS SCORE 2024 QUESTIONS SCORE 2023 2024 CL.4 Q71. Leaders foster an environment in which individuals value 3.75 Q 71. Leaders foster an environment in which 3.97 and seek continuous learning opportunities. individuals value and seek continuous learning opportunities.
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| CL.4 Q56. ROE employees master reactor operations to establish a 3.97 Q 56. I understand reactor operations to establish a 3.97 solid foundation for decisions and behaviors. solid foundation for decisions and behaviors.
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| CL.4 Q41. Leaders provide training and knowledge transfer to establish 3.77 Q 41. NCNR provides training and ensures knowledge 3.29 and maintain technical competence. transfer to maintain a knowledgeable, technical competent workforce.
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| CL.3 Q76. Periodic nuclear safety culture assessments are used as a 3.91 basis for improvement.
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| CL.2 Q75. The organization uses both self-assessments and 4.30 Q 75. Leaders value the insight and perspective 4.21 independent oversight. provided through assessments.
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| CL.2 Q68. Employees are well informed of lessons learned from 4.14 Q 68. I use operating experience to understand 4.17 industry events. equipment, operational and industry challenges and adopt new ideas.
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| CL.1 Q67. Leaders evaluate serious events and implement actions to 4.18 Q 67. Operating experience is effectively 3.50 learn from the experience. implemented and institutionalized through changes to facility processes, procedures, equipment, and training programs.
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| CL.3 Not Used Q 76. NCNR uses benchmarking as an avenue to 3.61 acquire innovative ideas to improve integrated safety.
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| Decision-Making ATTRIBUTE 2023 QUESTIONS SCORE 2024 QUESTIONS SCORE 2023 2024
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| Page 123 of 170
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| DM.3 Q44. Leaders assign single-point accountability for nuclear safety 3.35 Q 44. Chiefs and Crew Chiefs maintain single-point 3.80 decisions. accountability for important safety decisions.
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| DM.2 Q63. Leaders apply conservative decision making to mitigate 4 Q63. Leaders apply a conservative approach to 4.35 unpredicted failures. decision making, particularly when information is incomplete or conditions are unusual.
| |
| DM.2 Q46. I use a conservative approach to nuclear safety when 4.47 Q 46. I use decision-making practices that emphasize 4.35 making decisions. prudent choices over those that are simply allowable.
| |
| DM.1 Q47. When previous operational decisions are called into 4.07 Q 47. When previous operational decisions are called 4.39 question by emerging facts, leaders re-evaluate and adjust as into question by new facts, leaders re-evaluate these needed. decisions to ensure they remain appropriate and adjust as needed.
| |
| DM.1 Q43. I apply a rigorous approach to problem solving in 4.24 Q 43. I use a consistent, systematic approach to 4.37 accordance with procedures. making decisions.
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| Page 124 of 170 8: Survey Question List
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| Page 125 of 170
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| Trait Question
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| : 1. How long have you worked at the NCNR?
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| : 2. What is your level in the organization (i.e., individual contributor, lead, supervisor, crew chief, chief, director)?
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| : 3. Within the NCNR, where do you work?
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| CO1 4. Integrated safety is discussed at every meeting where plant work activities are planned and reviewed.
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| PA1 5. I clearly understand the importance of adherence to integrated safety standards.
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| LA6 6. Leaders ensure roles, responsibilities, and authorities are clearly defined, understood and documented to promote integrated safety.
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| WE1 7. Leaders regard individuals and their professional capabilities and experiences as its most valuable asset.
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| LA8 8. Leaders exhibit behaviors that set the standard for integrated safety.
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| LA4 9. Leaders ensure NCNR facility priorities are aligned to reflect integrated safety as the overriding priority.
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| PA1 10. I am accountable for shortfalls in meeting integrated safety standards/behaviors.
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| PA2 11. I understand my personal responsibility to foster a professional environment, encourage teamwork and identify challenges to integrated safety.
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| LA3 12. Leaders provide incentives, sanctions, and rewards that are aligned with NCNR integrated safety policies and reinforce behaviors and outcomes that reflect safety as the overriding priority.
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| LA1 13. Leaders ensure that personnel, tools, equipment, procedures and other resource materials are available and adequate to support integrated safety.
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| PA2 14. I ensure that I am trained and qualified to perform assigned work.
| |
| RC1 15. Claims of harassment, intimidation, retaliation, and discrimination are investigated.
| |
| RC2 16. NCNR has a process for raising and resolving concerns that is independent of line-management influence.
| |
| LA2 17. Leaders from all levels in the organization are involved in oversight of work activities.
| |
| PI3 18. NCNR takes effective corrective actions to address issues in a timely manner, commensurate with their safety significance.
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| LA2 19. Chiefs, Crew Chiefs, Leads and Supervisors ensure supervisory and management oversight of contractors and supplemental personnel work activities, such that integrated safety is supported.
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| LA4 20. Chiefs and Crew Chiefs develop and implement cost and schedule goals in a manner that reinforces the importance of integrated safety.
| |
| CO2 21. Leaders ensure that the basis for operational and organizational decisions is communicated in a timely manner.
| |
| LA2 22. Chiefs and Crew Chiefs encourage informal leaders (non-supervisors) to model safe behaviors and high standards of accountability.
| |
| RC1 23. Leaders take ownership when receiving and responding to concerns, recognizing confidentiality if appropriate and ensuring the concerns are adequately addressed in a timely manner.
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| Page 126 of 170
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| Trait Question LA8 24. Leaders walk the talk, modeling correct behaviors when resolving apparent conflicts between Integrated safety and facility availability.
| |
| WP4 25. I understand and use human error reduction techniques, such as self-check, STAR, and pre-job briefs.
| |
| LA5 26. Chiefs and Crew Chiefs anticipate, manage and communicate the effects of impending changes.
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| WE3 27. Leaders promote collaboration among work groups.
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| WE1 28. I treat other employees with dignity and respect.
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| RC1 29. I freely raise integrated safety concerns without fear of retribution and with confidence that their concerns will be addressed.
| |
| WE2 30. I am encouraged to offer ideas, concerns, suggestions, differing opinions and questions to help identify and solve problems.
| |
| WE2 31. Differing opinions are welcomed and respected.
| |
| WE3 32. Chiefs, Crew Chiefs, Leads and Supervisors respond to questions and concerns in an open and honest manner.
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| LA5 33. Leaders use a systematic process for evaluating and implement change so that integrated safety remains the overriding priority.
| |
| LA3 34. Chiefs and Crew Chiefs reward individuals who identify and raise issues affecting the integrated safety policy.
| |
| CO3 35. I communicate openly and candidly with oversight, audit, and regulatory organizations.
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| WE3 36. Leaders share important information in an open, honest and timely manner such that trust is maintained.
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| QA4 37. I perform a thorough review of the work site and planned activity every time work is performed.
| |
| WP4 38. I follow processes, procedures, and work instructions.
| |
| PA2 39. I actively participate in pre-job briefings, understanding my responsibilities to raise integrated safety concerns before work begins.
| |
| CO4 40. Leaders frequently communicate and reinforce the expectation that integrated safety is the organizations overriding priority.
| |
| CL4 41. NCNR provides training and ensures knowledge transfer to maintain a knowledgeable, technical competent workforce.
| |
| WE1 42. I treat decision-makers with respect, even when I disagree with a decision.
| |
| DM1 43. I use a consistent, systematic approach to making decisions.
| |
| DM3 44. Chiefs and Crew Chiefs maintain single-point accountability for important safety decisions.
| |
| QA3 45. Leaders solicit challenges to assumptions when evaluating integrated safety issues.
| |
| DM2 46. I use decision-making practices that emphasize prudent choices over those that are simply allowable.
| |
| DM1 47. When previous operational decisions are called into question by new facts, leaders re-evaluate these decisions to ensure they remain appropriate and adjust as needed.
| |
| LA6 48. Corporate governance, review boards, and independent oversight organizations support the Director's ultimate responsibili ty for decisions affecting nuclear safety.
| |
| WP3 49. NCNR facility activities are governed by comprehensive high-quality programs, processes, and procedures.
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| Page 127 of 170
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| Trait Question PI1 50. I ensure issues, problems, degraded conditions and near misses are promptly reported and documented in the corrective action program.
| |
| QA1 51. Leaders ensures that activities that could affect reactivity are conducted with particular care, caution, oversight, and in accordance with procedures.
| |
| WP2 52. Design and operating margins are carefully guarded and changed only with great thought and care.
| |
| WP2 53. Safety-related equipment is operated and maintained within design requirements.
| |
| WP1 54. Work is effectively planned and executed by incorporating risk-informed insights.
| |
| WP3 55. NCNR creates and maintains complete, accurate and up-to-date documentation.
| |
| CL4 56. I understand reactor operations to establish a solid foundation for decisions and behaviors.
| |
| QA1 57. I recognize the special characteristics and unique hazards of nuclear technology.
| |
| QA2 58. I maintain a questioning attitude during pre-job briefs/job-site reviews to Identify and resolve unexpected conditions.
| |
| CO2 59. Leaders encourage individuals to ask questions if they do not understand the basis of operational and management decision s.
| |
| QA2 60. I promptly challenge unanticipated test results or unexpected system response rather than rationalize them.
| |
| CO4 61. Leaders ensure supplemental personnel understand expected behaviors and actions necessary to maintain integrated safety.
| |
| PI1 62. I recognize deviations from standards.
| |
| DM2 63. Leaders apply a conservative approach to decision making, particularly when information is incomplete or conditions are unusual.
| |
| QA3 64. I challenge assumptions/offer opposing views when I think something is not correct.
| |
| QA4 65. I avoid complacency and plan for the possibility of mistakes.
| |
| LA1 66. Chiefs and Crew Chiefs ensure staffing levels are consistent with the demands related to maintaining safety and reliability.
| |
| CL1 67. Operating experience is effectively implemented and institutionalized through changes to facility processes, procedures, equipment, and training programs.
| |
| CL1 68. I use operating experience to understand equipment, operational and industry challenges and adopt new ideas.
| |
| PI2 69. NCNR thoroughly evaluates problems to ensure that resolutions address causes and extent of conditions.
| |
| PI2 70. NCNR thoroughly evaluates problems for underlying organizational and safety culture contributors.
| |
| CL4 71. Leaders foster an environment in which individuals value and seek continuous learning opportunities.
| |
| WP1 72. NCNR implements the work management process (planning, controlling and executing work activities) such that integrated safety is the overriding priority.
| |
| PA3 73. I communicate and coordinate my activities within and across organizational boundaries to ensure integrated safety is maintained.
| |
| CO3 74. Leaders respond to me in an open, honest and non-defensive manner.
| |
| CL2 75. Leaders value the insight and perspective provided through assessments.
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| | |
| Page 128 of 170
| |
| | |
| Trait Question CL3 76. NCNR uses benchmarking as an avenue to acquire innovative ideas to improve integrated safety.
| |
| | |
| PI4 77. NCNR uses performance indicators to monitor both equipment and organizational performance, including integrated safety culture.
| |
| WE2 78. I value the insights and perspectives provided by quality assurance, the employee concerns programs and independent oversight organizations.
| |
| 79 79. The NCNRs Nuclear Safety Culture has improved since the last survey in 2023.
| |
| LA7 80. Leaders constantly scrutinize nuclear safety through a variety of monitoring techniques, including assessments of nuclear safety culture.
| |
| QA2 81.I stop work activities when confronted with an unexpected condition.
| |
| ml 82. When you know that your immediate supervisor is responsible, do you put any extra efforts into his/her initiatives?
| |
| ml 83. Do you respond quickly when your immediate supervisor ask you to do something?
| |
| ml 84. Are you working now on his/her top priority issues?
| |
| ml 85. Do you see the connection between your daily efforts and the organization's vision?
| |
| ml 86. Can you cite an example of someone living the organization's values?
| |
| ml 87. Do you invest as much energy and enthusiasm as the leader invests into his/her initiatives?
| |
| ml 88. Can you give a recent example where a peer has helped you with your work?
| |
| ml 89. Do other departments and work units cooperate and assist your unit?
| |
| ml 90. Have you made any suggestions for improvement in the past 3 months?
| |
| ml 91. Is it safe to admit that you have made a mistake or failed at something?
| |
| ml 92. Is your immediate supervisor someone you feel you would respect for counsel and advice?
| |
| ml 93. Are you actively encouraged to improve your skills and personal growth here?
| |
| : 94. If there is any additional information you would like us to know, please add here.
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| | |
| Page 129 of 170 9: Review of Internal Events
| |
| | |
| The assessment team reviewed the Corrective Action Program (CAP) database from June 2023 to present for events that would rise to a significance requiring an upper-level causal evaluation. The following two events were viewed as significant:
| |
| : 1. On August 9, 2023, a loss of ventilation event occurred, resulting in minor contamination of fifteen NCNR staff members. On the following day, CAP 172 in the NCNR Corrective Action Program was initiated to investigate the event and root causes. In accordance with Administrative Rule 7.2, this CAP was classified as a level 2 CAP which requires review by the NCNR Chief of Operations and Engineering. A narrative of the details of this event, including root causes and corrective actions was presented to the SEC and discussed during SEC meeting 413, held on August 24, 2023. Significant effort has been undertaken by the organization to understand the drivers of the scram and take corrective actions to prevent of minimize recurrence.
| |
| | |
| The Team reviewed CAP 172, which concluded the following root and contributing causes:
| |
| | |
| Root Cause: High fission-product inventory in the reactor primary system, originating from residual fuel debris, escaped into reactor confinement that resulted in low-level personal contamination upon reactor scram.
| |
| Contributing Cause 1: The reactor refueling plug and other penetrations around the reactor vessel leak helium (and therefore fission products) from the helium sweep system.
| |
| Contributing Cause 2: Loss of facility power resulting from maintenance being performed on building main electrical feeder lines at time of start-up without coordination between the maintenance component and NCNR.
| |
| Contributing Cause 3: Loss or reduction of reactor ventilation is lost or reduced upon loss of power to the confinement building.
| |
| Contributing Cause 4: Loss of helium sweep flow due to loss of power.
| |
| Contributing Cause 5: Messaging regarding the event was passed to the Department was not properly controlled and coordinated.
| |
| Contributing Causes 6 and 7: Relevant operating procedures were not written to cover the prevailing conditions resulting in somewhat slower operator response, and previously unanticipated conditions.
| |
| | |
| Page 130 of 170
| |
| | |
| Contributing Cause 8: The consequences of ventilation failure on effluent detectors (i.e., the effect of conservative setpoints) were not fully understood.
| |
| The assessment team determined the following observations:
| |
| Positive Observations:
| |
| : 1) The timeliness of the NCNR internal technical evaluation.
| |
| : 2) Developing a comprehensive timeline of the events leading up to the event.
| |
| : 3) Very detailed examination of the factors that drove the event with corrective actions to address each of the factors.
| |
| | |
| Negative Observations:
| |
| : 1) The IRIS evaluation has been drafted but is not yet approved. The organization is not currently aligned on the drivers for the event or the actions to prevent recurrence.
| |
| : 2) The analysis has structural issues, including:
| |
| : i. Clear identification of a Problem Statement ii. Systematic evaluation of the extent of condition.
| |
| iii. Use of diverse and sufficient tools to determine causal factors.
| |
| iv. A systematic examination of organizational factors that allowed this event to occur and drove NIST response.
| |
| : 3) The root cause statement is a renaming of the effect (i.e., escape of FP inventory into confinement resulting in low-level contamination) and lacks sufficient depth to drive effective actions to prevent recurrence.
| |
| : 4) The evaluation does not adequately aggregate the contributing causes to understand if there is a deeper underlying causal factor that may be caused by deeper organizational drivers.
| |
| : 2. On November 30, 2023, during installation of the shim shaft seal on #4 Shim Arm, the team misidentified their current work step causing a worker to apply 40 ft-lbs. to the incorrect bolt. The incorrect amount of torque caused the bolt to fail. Work was halted, the area was placed in a safe condition, and a team investigation utilizing both operations and engineering commenced. The event was input into the Corrective Action Program and upgraded to a Level 3 by management decision.
| |
| After some fact-finding meetings the root cause team was assembled. The consequences of the event were Increased regulatory scrutiny, damage to trust in the organization, concern over the technical basis for several torque related items across multiple procedures, and rework and extent of condition review resulting in a schedule delay of a minimum three months.
| |
| | |
| The Assessment Team reviewed the final report dated January 31. 2024. NCNR conducted the root cause analysis using the TapRoot methodology and determined 18 root causes that they categorized into seven (7) categories:
| |
| | |
| Page 131 of 170
| |
| * The procedure was not fully Administrative Rule (AR) 5.1 compliant which created several possible error precursors.
| |
| * The review process outlined in Administrative Rule (AR) 5.2 did not catch the non-compliance with AR 5.1 or address the error precursors.
| |
| * Communication needs improvement as the turnover process allowed misunderstandings to persist.
| |
| * Procedure adherence standards, and policies were confusing and not strict enough notably when marking steps not applicable (N/A) within a procedure when not directed to do so by that procedure.
| |
| * Procedure adherence standards and policies were not known or adequately enforced for step tracking across multiple copies and across multiple shifts.
| |
| * Continuous Training needs improvement regarding both technical skills as well and policy understanding and adherence.
| |
| * Work planning, general oversight, and job support need improvement when planning and performing high impact / risk work.
| |
| | |
| The assessment team was not able to determine a timeline for when the root cause analysis will be completed.
| |
| | |
| Positive Observations:
| |
| : 1) The decision by management to upgrade to a higher level of effort (root cause) to understand the underlying causes of the event.
| |
| : 2) Developing a comprehensive timeline of the events leading up to the event.
| |
| : 3) Tying each identified root cause to a safety culture attribute shows an organizational effort to tie significant events into gaps in Integrated Safety Culture.
| |
| | |
| Negative Observations:
| |
| : 1) The analysis has structural issues, including:
| |
| : a. Clear identification of a Problem Statement
| |
| : b. Systematic evaluation of the extent of condition.
| |
| : c. Use of diverse and sufficient tools to determine causal factors.
| |
| : d. Identification of the inappropriate action(s) or condition(s) that directly led to the event.
| |
| : e. A systematic examination of organizational factors that allowed this event to occur at NCNR.
| |
| : 2) The root cause does not adequately aggregate the 18 root causes to understand organizational drivers. For example, examining the multiple issues related to procedures to determine if there are underlying organizational drivers.
| |
| Attachment 20: Review of External Information
| |
| | |
| Page 132 of 170 0: Review of External Information NRC Inspection Activities and Reports:
| |
| | |
| On January 25, 2024, the NRC issued the 1st and 2nd Quarter 2023 Supplemental Inspection Report for NIST. No violations were identified in this report. The report provided a status of the Supplemental Inspection Objectives. The following objective remain open:
| |
| | |
| Emergency Plan and Event Response
| |
| * Observe implementation of emergency plan procedures Operator Licensing
| |
| * Evaluate adequacy of licensed operator proficiency training
| |
| * Observe implementation of licensed operator proficiency training Corrective Actions
| |
| * Evaluate program to ensure expectations, processes, and procedures are in place to identify and implement safety improvements.
| |
| * Evaluate the adequacy of corrective actions for re-evaluated root cause analysis performed with emphasis on nuclear safety culture.
| |
| * Confirm consideration of CO2 build up potential in safety documentation and emergency plan.
| |
| Safety Committee Oversight
| |
| * Review disposition of SAC recommendations Procedures
| |
| * Evaluate program and processes in place to ensure quality of written procedures, to ensure procedures can be effectively executed, and to ensure procedures are periodically evaluated to implement improvements.
| |
| Design Change Process
| |
| * Review change process program and procedures for compliance with Title 10 of the Code of Federal Regulations (10 CFR) 50.59
| |
| * Evaluate effectiveness of Engineering Change Management Program for ensuring changes are made consistent with 10 CFR 50.59 Safety Culture
| |
| * Follow-up Safety Culture Inspections
| |
| | |
| The NRC documented the following observations and findings:
| |
| : 1. The inspectors observed several fuel operations and based on their observations determined that the appropriate corrective actions have been implemented to prevent recurrence and the associated IFI is now closed.
| |
| | |
| Page 133 of 170
| |
| : 2. The inspectors observed several shifts and sessions of fuel handling training and noted adherence to procedure use and adherence guidance and concluded that all workers were trained on fuel movement operations.
| |
| : 3. The inspectors observed operations staff performing pre-evolution briefs and operations and observed consistent referring to procedures and place keeping. During training of operators at the console good coaching methods and challenges were observed.
| |
| : 4. The inspectors observed that NCNR staff conservatively limited power and staff working as a team to work through issues associated with power ascent.
| |
| : 5. The inspectors noted that operations personnel were not sure which process to use when they encountered problems; however, after discussions did enter the issue into CAP.
| |
| : 6. The inspectors observed several evolutions and identified that while the licensee made numerous procedure changes, they still need to update procedures as they return to operations and use them.
| |
| | |
| NCNR Staff is aware of and has reviewed the NRC OIG Report Special Inquiry onto the US Nuclear Regulatory Commissions Oversight of Research and Test Reactors findings and the NRC Staff response. Discussions with senior NCNR staff show that they are aware of the concerns raised in the report and responses and are engaged with potential regulatory issues that may arise concerning the operation and inspection of RTRs.
| |
| | |
| Research and Test Reactor Interfaces
| |
| | |
| The staff at NCNR has been actively involved with other RTRs as part of a group working to define the appropriate program controls and activities related to Problem Identification and Resolution at RTRs.
| |
| | |
| The senior staff at NCNR are engaged with their counterparts at similar facilities and are using that engagement to benchmark and interface on important external issues facing the RTR community.
| |
| | |
| ==
| |
| Conclusion:==
| |
| : 1) NRC Inspection activities show an improvement in the behaviors observed by the NRC Inspectors in the areas of safety committee oversight, procedure quality and adherence behaviors, corrective action program use, and conduct of operations.
| |
| : 2) The NCNR staff is aware of regulatory challenges, and are interacting with counterparts in the RTR community, to understand and address challenges.
| |
| | |
| Page 134 of 170 1: Status of 2023 INSCA Recommendations
| |
| | |
| # Source Recommendation May 2024 Status Update 1 INSCA#1 RECOMMENDATION 1: Designate Operations and the I & C Engaged the NIST OmBuds, and HR to aid in Jun 2023 portion of the Aging Reactor Management section as development of corrective actions.
| |
| priority groups and develop communications and team Developed and implemented coaching and building strategies to better clarify and address the quality addition to performance evaluation for of the safety culture environment and implement corrective discrete individuals. Follow-ups. Behavior actions. observations validate behavior change and o Develop Communication and Team Building Plan to anecdotal information from other portions address toxic work environment between Operations and of ARM and Ops reflect improvement. Code I&C groups of ethics refreshed from NIST. Code of
| |
| | |
| conduct for interpersonal behaviors is in development.
| |
| | |
| Page 135 of 170
| |
| | |
| # Source Recommendation May 2024 Status Update 2 INSCA#1 RECOMMENDATION 2: Develop and deliver a Based on Budget Limitations and timing this Jun 2023 competence-based understanding of Nuclear Safety recommendation was broken up into three Culture. pieces (not from the 2023 report). 1. To Develop and implement a formal NCNR-ROE Nuclear answer the CO, SC Training in this area, for Safety Culture Program based upon INPO 12-012 Traits the ROE Leadership, was developed and of a Healthy Nuclear Safety Culture / NUREG 2165 to implemented. (Nov 2023). 2. As an outcome understand Nuclear Safety Culture (including SCWE), of that training the Safety Culture Industrial Safety Culture, and the difference. Monitoring Panel Guidance was tested with Develop and implement the vision, values, principles, accomplishment of the initial SCMP was and objectives that define the expected behaviors and completed and continuing on a regular attitudes needed to achieve and sustain a high-reliability basis. 3. Modification of the INPO 12-012 Nuclear Safety Culture. SC Traits to match the NCNR Organization Enabling objectives need to focus on all NCNR-ROE and Verbiage was completed published leadership and staff owning and living nuclear safety electronically and is in printing. 4.
| |
| culture attributes and role-modeling behaviors to: Build Conducted a Baldrige Organizational Profile trust, Breakdown silos, and Improve daily Exercise to define baseline Mission, Vision, communication behaviors. Values and Culture for integration into a Develop and implement NSC Training, and socialize master reference for Behaviors, teamwork, expected NSC behaviors, teamwork and interactions and interactions as 5 Develop an Integrated amongst departments and between people. Management Model as a frequently Engage external resources to assist in developing, referenced tool for indoctrination, delivering, implementing, and coaching sustainable alignment and improvement.
| |
| actions.
| |
| Interim: Re-implement daily use of the Gray Book INPO 12-012, Traits of a Healthy Nuclear Safety Culture.
| |
| | |
| Page 136 of 170
| |
| | |
| # Source Recommendation May 2024 Status Update 3 INSCA#1 RECOMMENDATION 3: Mitigate the staffing and resource New entry level hires have been added to Jun 2023 shortage in the Operations Department. Operations. Due to reactor conditions and Obtain and prioritize external resources (including primarily shutdown operations, the funding) who can take on the Operations Department application of resources has somewhat administrative workload (see LA.1, Section 7.4.1.2.2, last been mitigated in the area of administrative table entry). workload. Fed Government Continuing Prioritize the engagement of external resources to Resolutions and delay of 2024 funding coach Operations Crew Chiefs, SROs, and non-licensed made the application of coaching in a operators regarding shift Operational Focus. shutdown environment a lower priority for Complete the planned selection and appointment of a the time being. Applications for Deputy Deputy Chief Reactor Operations. Chief of Operations has yet to be posted.
| |
| | |
| 4 INSCA#1 RECOMMENDATION 4: Develop, with Human Resources: New entry level hires have been added to Jun 2023 An effective and timely policy to attract and retain ARM. Due to reactor conditions and Operations staff. primarily shutdown operations, the Build Operator ranks with full support to stand up a fifth application of resources has somewhat shift with a prescribed minimum reserve bench metric. been mitigated in the area of administrative Aggressively pursue increasing the number of licensed workload. The CAP, Observation Program, individuals. etc. have been reassigned outside ARM to Mitigate the resource shortage in the Aging Reactor strengthen focus of ARM on Maintenance, Management (ARM) Group Surveillances and Trouble shooting.
| |
| with external resources to:
| |
| o Take on the administrative tasks.
| |
| o Develop and implement organization-wide programs (e.g., CAP, Observation Program, et.al.).
| |
| o Coach and mentor ARM staff with regards to programmatic responsibilities.
| |
| | |
| Page 137 of 170
| |
| | |
| # Source Recommendation May 2024 Status Update 5 INSCA#1 RECOMMENDATION 5: Corrective Action Program: The PI&R Assessment was completed with Jun 2023 Complete the PI&R Assessment as soon as practicable. 12 recommendations. In parallel to Continue with plans to implement a right-sized PI&R development of follow-on scopes of work, process. In the interim, prioritize the following immediate strengthening of reporting, prioritization, actions: application of CAP Screening, and Establish and enforce an expectation for a reporting disposition reviews (CARB/MRG) has been threshold across NCNR-ROE. effective at identification and proper Select external resources to assist with program classification of issues, correction and implementation, administration, and coaching. closure of issues lag initiations are slowly Develop and implement an easy and personal input method for CAP. being address. Additional resources have Establish a Corrective Action Review Board (CARB) / been delayed due to Government Funding Management Operations Review Group utilizing external Issues. Changes in input screens, metrics, resources to assist with development, charter, startup, etc. are in progress. Reverse benchmarking administration, and member coaching. CAP was conducted in February with MURR.
| |
| The RTR high powered reactors have entered into a collaborative agreement to share and optimize RTR CAP and a consortium.
| |
| | |
| Page 138 of 170
| |
| | |
| # Source Recommendation May 2024 Status Update 6 INSCA#1 RECOMMENDATION 6: Conduct behavioral assessments A minor level of personality and behavior Jun 2023 of the Operations Crew Chiefs to assess attitudes, assessments have been performed by NIST alignment, leadership capabilities, and provide targeted and others to provide input into changes in development feedback. performance evaluations. Based on plant Behavioral assessments, feedback and coaching have condition the facility decided that additional been shown to be critical to aligning leadership behavior assessment would be more appropriate to obtain consistent performance improvements. once the base programs and processes Consider extending these assessments to other key were fledged out and near normal leaders as priorities allow. operations are achieved.
| |
| | |
| The priority was also adjusted based on Fed Government Continuing Resolutions and delay of 2024 funding and make the application of coaching in a shutdown environment a lower priority for the time being. Applications for Deputy Chief of Operations have been non-existent.
| |
| | |
| Page 139 of 170
| |
| | |
| # Source Recommendation May 2024 Status Update 7 INSCA#1 RECOMMENDATION 7: Develop a behavior-based Part of this action is a repeat of the above.
| |
| Jun 2023 mentoring/coaching program focused on safety culture (Conducting Behavioral Assessments) attributes, leadership, and process improvements.
| |
| Provide the top leadership team with a team coach at Identifying Key Leaders is a work in process the Director/Chief level to promote organizational as the staffing of the team is gelling. With alignment and teamwork. changes in alignment (Safety, SEC, Identify key leaders in ROE and establish individual QA/Programs, Engineering) some stability is mentors to develop manager behaviors and their needed to determine assessment needs interface to the organizational recovery processes. and define the strategy (Resources Conduct behavioral assessments of current Strategy) organizational leadership starting at Crew Chiefs level and going to top level management (Director/Chiefs). Task 10 is providing the services of team coach for the top team leadership. The areas of present engagement are alignment, teamwork and R2A2, Baldrige, Aubrey Daniels basis for reinforcement of behaviors and communication interim actions
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| | |
| Page 140 of 170
| |
| | |
| # Source Recommendation May 2024 Status Update 8 INSCA#1 RECOMMENDATION 8: Training and Procedures Programs: Training and Procedures assessments are Jun 2023 Complete the Training and Procedures Assessments as soon complete with a total of 25 as practical. recommendations. Each of these Implement the Systematic Approach to Training (SAT). assessments were deemed to be separate Fully implement the PPA / INPO 11-003 requirements for Improvement initiatives.
| |
| procedures.
| |
| | |
| Page 141 of 170
| |
| | |
| # Source Recommendation May 2024 Status Update 9 INSCA#1 RECOMMENDATION 9: Establish and maintain Recommendation has been being Jun 2023 housekeeping/combustibles and gas cylinder loading that addressed Level of Effort by the facility.
| |
| reflect OSHA standards in: Guide Hall, Confinement Building, Recently $80K has been allotted to continue Laboratories, and other spaces. improvement. A significant reduction in fire loading in C100 and the Guide Hall has been achieved even in parallel to Instrument installation work. Much work to do in B1. Two labs have been emptied of equipment and risk.
| |
| | |
| 10 INSCA#1 RECOMMENDATION 10: Complete the planned The ECP Coordinator was named and Jun 2023 development and implementation of an Employee assigned at the beginning of 2024. The ECP Concerns Program (ECP). Procedure is in NRC Review. There is an Strongly recommend for the foreseeable future, ECP SharePoint site. The Facility is highly establish and maintain a regular and consistent onsite considering activating that procedure and presence. program without NRC Approval. A decision Include within the scope of follow-on Nuclear Safety is expected in June.
| |
| Culture Assessments.
| |
| | |
| Page 142 of 170
| |
| | |
| # Source Recommendation May 2024 Status Update 11 INSCA#1 RECOMMENDATION 11:Develop and implement a The methodology has been piloted and Jun 2023 problem-solving approach for emergent issues to applied in several circumstances. In include: concert with the development of the Define the Problem Statement. Integrated Project Schedule across NCNR Conduct significance assessment. this is maturing.
| |
| Identify known consequences.
| |
| Perform extent of condition evaluation.
| |
| Pre-establish a Command-and-Control NCNR-ROE response structure.
| |
| Establish response teams with issue-specific roles &
| |
| responsibilities.
| |
| Develop a written response plan.
| |
| Implement and revise response plan as necessary.
| |
| | |
| Page 143 of 170
| |
| | |
| # Source Recommendation May 2024 Status Update 12 INSCA#1 RECOMMENDATION 12: As a function of development of Collective Eval 1 was completed, 61 Jun 2023 the comprehensive improvement plan that results from recommendations from the assessments planned assessments and the collective evaluation process, and 11 recommendations from the first consider the following elements to address Cross-Cutting, SCMP (All from both data sets) were risk Distributed Function Programs. ranked and prioritized for implementation.
| |
| Every line manager owns a piece of distributed functions; The IMM is intended to address, in some examples of distributed functions include, but are not fashion, the list in this recommendation.
| |
| limited to:
| |
| o Nuclear Safety Culture and Roles, Responsibilities, Authorities, and Accountabilities o Emergent Issue Management Process o Conduct of Operations o Operational Focus o PI&R/Corrective Action Program o Employee Concerns Program o Training o Management Observation Program o Work Planning, Management and Control o Management of Change o QA and Oversight Function o Risk Management Obtain and prioritize external resources (including funding) to support development and implementation of the programs listed above.
| |
| Interim: Establish a daily framework: Morning meetings, daily schedule reviews, CAP Screening, Management Reviews, Plan of the Day, Break-out groups as needed.
| |
| | |
| Page 144 of 170
| |
| | |
| Attachment 22: Status of 2023 INSCA Program Limiting Weaknesses
| |
| | |
| Program 2023 Rating Trend Limiting Weaknesses Program Status 2024 Rating and Trend Management Marginally Flat The existing management From the Observation Based on Observation Observation Program Effective AFI observation program is limited to Dashboard - 5/13/24 data review the procedural observations. Observation goals are process is being Many observations, including some being met or exceeded. implemented as from senior management, are not In the 1st Quarter 24, 23 designed. Interviews consistently documented in a timely observations were indicate some leaders manner by NCNR observers; some conducted for a goal of are using the process managers meet minimum 18. This performance for teaching moments.
| |
| requirements for 2 per quarter. was improved based on actions taken in Oct 23 Rating: Marginally CAPs are not consistently being per CAP 199. Effective ANA.
| |
| written by observers when observations document problems. While the observation Trend: Improving form hasnt been revised, approximately 25% of the observations were beyond procedure based. All observations had at least one element of behavioral observation beyond the procedure quality aspects.
| |
| | |
| Procedure issues found during observations are being entered into CAP Corrective Action Not Effective Flat Less than adequate staffing to CAP is being utilized to Rating: Marginally Program AFI develop CAP. address deficiencies Effective AFI and events. P.1, P.2, P.3
| |
| | |
| Page 145 of 170
| |
| | |
| Program 2023 Rating Trend Limiting Weaknesses Program Status 2024 Rating and Trend Less than adequate training re: The CAP volume was Trend: Improving CAP. 363, up from 58 at the time of the last Program exists, recently revised. assessment.
| |
| Threshold not well understood by staff. CAP Screening is Lack of management engagement. mature. The backlog of unscreened items is at a minimum.
| |
| | |
| The AR 7.0 series needs to be updated to reflect the details being currently implemented.
| |
| | |
| The CAP process is being transitioned to a new platform with much more mature functionality.
| |
| | |
| There is still some misunderstanding of what goes into CAP or other systems that need to be addressed.
| |
| | |
| Documentation of actions taken are entered into CAP Cause Analysis is not consistently attached to the CAP Item.
| |
| | |
| Page 146 of 170
| |
| | |
| Program 2023 Rating Trend Limiting Weaknesses Program Status 2024 Rating and Trend Audit/Surveillance/QA Not Effective Flat QA Program applies to only 21 Audits and Self Rating: Marginally Program AFI Engineering. Assessments have Effective Program does not identify important been conducted in the programs needed for safe and last year. The findings Trend: Improving effective nuclear plant facility of audits are entered operation. and resolved in CAP.
| |
| | |
| Of those programs that are Development of a full identified, most have short runtimes QA program based on and are in very early stages. ANSI 15.8/ISO 9000 is Program definition is fragmented planned as a part of the among several documents, causing Procedures and PI&R confusion and lack of Initiative Strategies use/compliance.
| |
| Document Control Not Effective Flat No Records/Document Control A Document Librarian Rating: Marginally Program AFI Manager has been hired and is Effective No plan to meet Federal Document actively resurrecting the Control requirements (36 CFR 1200 Document Control Trend: Improving Att. B). Process.
| |
| | |
| Lack of a Records Management Program that meets federal government requirements (36 CFR 1200 Att B)
| |
| | |
| Page 147 of 170
| |
| | |
| Program 2023 Rating Trend Limiting Weaknesses Program Status 2024 Rating and Trend Conduct of Operations Marginally Positive Critical elements of CONOPs AR 5.0, Procedure Use Rating: Marginally Program Effective are insufficiently addressed in and Adherence and AR Effective AFI NBSR Conduct of Operations 1.1 Human guidance. (See Section 7.3.5) Performance Tools Trend: Improving Operations staffing shortages, address the majority of weaknesses in limited currently to two shifts. CONOPs as listed in Ops Training weaknesses (see section 7.3.5 of the 23 Training program) INSCA Report.
| |
| Lack of Ops staff understanding of NSC and how it applies to Three Shift Coverage is CONOPs in effect.
| |
| | |
| Staffing levels continue to be a significant weakness.
| |
| Training Program Marginally Positive Current training program does not The facility has named Rating: Marginally Effective AFI support a continuing Operator Training as an Initiative Effective AFI Training program. for improvement. CL.4 Training that has been developed was not done using the Systematic The training Supervisor Trend: Improving Approach to Training. has been names, Postings for 2 additional Operator training is limited in scope resources are posted.
| |
| and does not address full spectrum of Operations Department needs. Resources have been applied to SAT Application of the Ops Training Program
| |
| | |
| Page 148 of 170
| |
| | |
| Program 2023 Rating Trend Limiting Weaknesses Program Status 2024 Rating and Trend Procedures Marginally Positive Procedures are inadequate for rule- Procedures was Rating: Marginally Effective AFI based operations required by named as an Initiative Effective ANA operators with less experience. for Improvement. AR Some revised procedures are overly 5.0 was revised to meet Trend: Improving complex and cumbersome. industry guidance. Pen and Ink changes are Pen and ink changes to important now categorized as procedures (i.e., reactor startup) did Major and Minor and not receive 10CFR50.59 review. receive the appropriate Inexperienced (rather than 50.59 screening and experienced) operators are writing reviews.
| |
| procedures.
| |
| The facility is applying outside resources to revising AR 5.1 Procedures Writers Guide and plans to revise the ~300 procedures that were revised earlier in 2021/2022 to be more user friendly, at the correct level of detail of consistent structure and format.
| |
| Causal Analysis Not Effective Flat Program has not been implemented There are 3 trained Rating: Marginally AFI & is under development with no cause analysts (Tap Effective ANA written plans. Root and other Few trained causal analysts. techniques). Trend: Improving Experience is widely The few trained causal analysts varied.
| |
| have limited experience.
| |
| The facility would benefit greatly with a
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| Page 149 of 170
| |
| | |
| Program 2023 Rating Trend Limiting Weaknesses Program Status 2024 Rating and Trend Cause Analysis Manual and training. This is planned as a part of the PI&R Initiative Employee Concerns Not Effective Flat Program has not been implemented. The ECP Coordinator Rating: Not Effective AFI ECP Coordinator has not yet has been hired, The been trained or started in the ECP Website position. Developed. The ECP Program has been written and has been in NRC review for over a year. The facility has recently decided to implement the program in advance of NRC Review and approval.
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| Page 150 of 170 3: Focus Group/Interviews Form
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| | |
| Note: The below form is a facsimile. While the content remains the same, there have been minor format changes to reduce the overall size of the form - removal of the number of spaces for written comments.
| |
| | |
| Focus Group Record: 2024 Independent Integrated Safety Culture Assessment:
| |
| ASSESSMENT CONFIDENTIAL: Do NOT Share beyond Assessment Team
| |
| | |
| Focus Group FG- Template CONTAINS PRE-DECISIONAL INFORMATION: NOT TO BE DISTRIBUTED BEYOND THE INDEPENDENT ASSESSMENT TEAM WITHOUT THE EXPRESS AUTHORIZATION OF TASK LEADER
| |
| | |
| FOCUS GROUP NUMBER:
| |
| GROUP MEMBERS/POSITIONS:
| |
| GROUP FACILITATORS:
| |
| DATE:
| |
| START: END:
| |
| DISCUSSION FOCUS:
| |
| | |
| NOTES:
| |
| This document summarizes a Focus Group conducted in support of an Independent Integrated Safety Culture Assessment of the NCNR.
| |
| | |
| This Focus Group was conducted for the sole purpose of evaluating the Integrated Safety Culture and is but one of a large number of data inputs. Readers are STRONGLY CAUTIONED against drawing conclusions or making decisions on the basis of this Focus Group alone.
| |
| | |
| Focus Group content is summarized below. This is not a verbatim transcript. Except where indicated by quotation marks; statements without quotation marks are either paraphrased or summarized. The order in which aspects of the Focus Group are documented may differ from the order in which they were discussed.
| |
| | |
| The Group Facilitators explained:
| |
| * We are part of an independent team that was requested to conduct a comprehensive Integrated Safety Culture assessment of the NCNR.
| |
| The assessment will include: The Integrated Safety Culture survey administered in April 2024.
| |
| Individual interviews of approximately half of the NCNR staff and management.
| |
| Facilitated Focus Groups of NCNR staff.
| |
| Workplace and work observations.
| |
| Meeting observations; and Facility inspections.
| |
| | |
| No one at NCNR, and no one beyond the independent team itself will see the Focus Group summary, and we will protect your anonymity by not linking any
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| Page 151 of 170
| |
| | |
| comments or responses to any results report. Your name will appear on a list of People Contacted in the final report, along with other individuals who may or may not have participated in Focus Groups or have been interviewed.
| |
| At the end of this assessment, we will publish a report that includes our observations, conclusions, findings, and recommendations for specific actions to be taken, and details and elaboration the team believes to be vital to NCNRs understanding of the conclusions.
| |
| | |
| Focus Group Record: 2024 Independent Integrated Safety Culture Assessment:
| |
| | |
| ASSESSMENT CONFIDENTIAL: Do NOT Share beyond Assessment Team
| |
| | |
| Focus Group FG- Template CONTAINS PRE-DECISIONAL INFORMATION: NOT TO BE DISTRIBUTED BEYOND THE INDEPENDENT ASSESSMENT TEAM WITHOUT THE EXPRESS AUTHORIZATION OF TASK LEADER
| |
| * Please do not share the content of, or questions from this Focus Group until the final report has been published.
| |
| | |
| Q: IF ANYONE WOULD LIKE TO TALK WITH US PRIVATELY FOLLOWING THIS FOCUS GROUP, WE WILL MAKE THE TIME AVAILABLE TO DO SO. PLEASE LET US KNOW BY CALLING OR EMAILING WITH A WAY TO CONTACT YOU. WE WILL RESPECT YOUR PRIVACY AND CONFIDENTIALITY.
| |
| | |
| Q: FGQ1: What does the term Integrated Safety Culture mean?
| |
| A:
| |
| | |
| SC Trait(s):
| |
| What examples of overall Integrated Safety Culture changes can you provide?
| |
| Prompts: Communications [CO]
| |
| Conduct of Operations [WP]
| |
| Employee Concerns [RC]
| |
| | |
| Performance Improvement [PI] Corrective Action Program Causal Analysis Benchmarking Management Observations Audit Surveillance
| |
| | |
| Training Program [CL]
| |
| Procedures [WP]
| |
| Document Control Procedures in general
| |
| | |
| Work Management [WP]
| |
| Resources [LA]
| |
| | |
| Q: FGQ2: How has the Integrated Safety Culture changed at NCNR overall since the 2023 Assessment?
| |
| A:
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| Page 152 of 170
| |
| | |
| SC Trait(s):
| |
| | |
| Q: FGQ3: Where would you rate the NCNR Integrated Safety Culture on a scale of 1 to 10, with 10 being outstanding and 1 being poor?
| |
| A:
| |
| | |
| SC Trait(s):
| |
| | |
| Q: FGQ4: What are the top three issues at NCNR that impact the Integrated Safety Culture?
| |
| A:
| |
| | |
| SC Trait (s):
| |
| | |
| Q: FGQ5: What are some examples of you stopping work when you identified unexpected or uncertain conditions? [DM, QA]
| |
| A:
| |
| | |
| SC Trait(s):
| |
| | |
| Q: FGQ6: What examples can you provide of managers/supervisors encouraging identification and reporting of nuclear safety issues or concerns? [RC, LA]
| |
| A:
| |
| | |
| SC Trait(s):
| |
| : a. Can you give an example where the Corrective Action Program was effectively used to resolve an issue. [PI]
| |
| : b. Have you entered an issue into the NCNR Corrective Action Program? If so, what issue(s) did you identify? [PI, PA]
| |
| | |
| Q: FGQ7: Corrective Action Program (CAP) Effectiveness:
| |
| : a. Who owns the Corrective Action Program? [PI] How are you using the CAP? [PA]
| |
| A:
| |
| | |
| SC Trait(s):
| |
| | |
| Q: FGQ8: What is NCNRs greatest risk of failure to complete a successful restart and return to 127 full power operations?
| |
| A:
| |
| | |
| SC Trait(s):
| |
| | |
| Q: FGQ9: To what extent is reinforcement of standards and expectations (personal accountability) consistently carried out throughout the organization? [WE, LA] Examples?
| |
| A:
| |
| | |
| SC Trait(s):
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| | |
| Page 153 of 170
| |
| | |
| Q: FGQ10: To what extent do your peers question assumptions, decisions, or justifications that do not appear to sufficiently consider impacts to integrated safety? [QA]
| |
| A:
| |
| | |
| SC Trait(s):
| |
| | |
| Leaders 153 Walk the talk? [LA]
| |
| Communicate effectively? (NIST vs. NCNR? For Director and Chiefs) [CO]
| |
| Respect and respond effectively to differing opinions? [WE]
| |
| Respond to employees and the concerns they raise without defensiveness to questions, problems, issues, and concerns? [RC]
| |
| | |
| Workers Stop when unexpected or uncertain conditions exist? [DM]
| |
| | |
| Challenge assumptions and/or offer opposing views? [QA]
| |
| | |
| Are actively engaged in changes to processes and procedures? [WP]
| |
| | |
| Organization You receive feedback? [CL]
| |
| | |
| You give feedback? [LA]
| |
| | |
| Effective organizational communications? [CO]
| |
| | |
| Individuals taking ownership of issues, problems, and processes? [PA]
| |
| | |
| Clearly and unambiguously defined roles and responsibilities? [LA]
| |
| | |
| Processes Effective use of the problem reporting and resolution process? ID vs. Resolution?
| |
| [PI]
| |
| | |
| Effective resolution of employee concerns? [RC]
| |
| | |
| Q: FGQ11: On a scale of 1 to 10, with 10 being always and 1 being never, how frequently do you see:
| |
| A:
| |
| | |
| Page 154 of 170
| |
| | |
| SC Trait(s):
| |
| | |
| Q: FGQ12: To what extent is respect demonstrated for each other and others in the organization? Can you provide examples? [WE]
| |
| A:
| |
| | |
| Q: FGQ13: What else should we have asked to get a better feel for the current Integrated Safety Culture at NCNR? [Alternatively, What else can you tell us that you think we need to know?]
| |
| A:
| |
| | |
| SC Trait(s):
| |
| | |
| END OF FOCUS GROUP
| |
| | |
| Page 155 of 170 4: Meeting Observation Form
| |
| | |
| NIST/NCNR INSCA Meeting - NSC Behavioral Observation Checklist
| |
| | |
| Title of Meeting: _______________________________________________
| |
| Date and Time: _______________________________________________
| |
| Location: _______________________________________________
| |
| Observer: _______________________________________________
| |
| Point of
| |
| | |
| ==Contact:==
| |
| * Prior to an Observation, Observers are expected to clearly communicate their presence to the Point of Contact and the purpose of the observation - learning and performance improvement - mitigating the potential of future events.
| |
| * During Observations, Observers are expected to coach on the spot if during an Observation there is a significant gap in NSC behaviors or other performance issue with likely unacceptable consequences.
| |
| * After the Observation, Observers are expected to verbally communicate observed positive behaviors and areas for improvement to affected stakeholders to gain additional insights - the underlying drivers for performance.
| |
| * For each noteworthy weakness, the Observer should provide a brief comment on the weaknesses including if known the stated underlying driver for the behavior or performance weakness.
| |
| | |
| Item Observable Behaviors Score Scoring is 1 for Strength, 2 for Satisfactory, 3 for Weakness, or N/A for Not Applicable).
| |
| 1.0 Start of Meeting 1.1 Attendance (quorum is met and stakeholders are present) 1.2 Start Time (meeting starts on time with materials and audio/visual aids in place) 1.3 Stakeholders Preparations (materials have been reviewed and ready to comment)
| |
| | |
| 2.0 Conduct of Meeting 2.1 Agenda (clearly stated purpose, objectives, and expected outcomes) 2.2 NSC Topic (review of a Trait and/or Behaviors related to an agenda item) 2.3 In-Process (adherence to protocols, work d processes, and corrective action program) 2.4 Pacing (length of discussions are commensurate with complexity and risk) 2.5 Risk Awareness (decisions factor risk/mitigation using probability/consequences)
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| Page 156 of 170
| |
| | |
| Item Observable Behaviors Score 2.6 Leadership (solicits stakeholders for input, concurrence, and/or concerns) 2.7 Respect is Evident (Opinions are valued and support fully informed decisions) 2.8 Supportive (no tolerance for elitism or bullying via words, expressions, or body language)
| |
| | |
| 3.0 Conclusion 3.1 Objectives Met (Leader summarizes objectives and conclusions) 3.2 Clear Follow-up Actions (Actions to be taken, owners, timing, and resolution) 3.3 NSC Critique (Discuss positives and areas for improvement for awareness and learning) 3.4 End Time (Meeting finishes on time so stakeholder can make it to their next commitment)
| |
| | |
| 4.0 Other NSC Behaviors 4.1 Leadership Safety Values and Actions (LA) 4.2 Problem Identification and Resolution (PI) 4.3 Personal Accountability (PA) 4.4 Work Processes (WP) 4.5 Continuous Learning (CL) 4.6 Environment for Raising Concerns (RC) 4.7 Effective Safety Communication (CO) 4.8 Respectful Work Environment (WE) 4.9 Questioning Attitude (QA) 4.10 Decision making (DM)
| |
| | |
| Comments:
| |
| | |
| Page 157 of 170 5: Behavioral Observation Form
| |
| | |
| NIST/NCNR INSCA Work Activity - NSC Behavioral Observation Checklist
| |
| | |
| Scope of Work: _______________________________________________
| |
| Date and Time: _______________________________________________
| |
| Location: _______________________________________________
| |
| Observer: _______________________________________________
| |
| Point of
| |
| | |
| ==Contact:==
| |
| * Prior to an Observation, Observers are expected to clearly communicate their presence to the Point of Contact and the purpose of the observation - learning and performance improvement - mitigating the potential of future events.
| |
| * During Observations, Observers are expected to coach on the spot if during an Observation there is a significant gap in NSC behaviors or other performance issue with likely unacceptable consequences.
| |
| * After the Observation, Observers are expected to verbally communicate observed positive behaviors and areas for improvement to affected stakeholders to gain additional insights - the underlying drivers for performance.
| |
| * For each noteworthy weakness, the Observer should provide a brief comment on the weaknesses including if known the stated underlying driver for the behavior or performance weakness.
| |
| | |
| Item Observable Behaviors Score Scoring is 1 for Strength, 2 for Satisfactory, 3 for Weakness, or N/A for Not Applicable 1.0 Preparation for Work 1.1 Work Package (complete and accurate) 1.2 Stakeholder Awareness/Involvement (Operations, Engineering, Health Physics, etc., as applicable) 1.3 Pre-Job Brief (supervisor present, job scope/details, risk awareness/mitigation, and backout criteria) 1.4 Supervisor (solicits stakeholders/workers for input, concurrence, and/or concerns) 1.5 Qualifications (supervisors/workers are trained, qualified, experienced, and comfortable with the job) 1.6 Radiological Controls (RWP in place and workers aware, and surveys complete with postings in place) 1.7 Job Walkdown (clearance ready, Lockout/Tagout, and tags hung and verified) 1.8 Tools, Equipment, and Materials (staged, ready to go, and in good condition) 2.0 Conduct of Work
| |
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| Page 158 of 170
| |
| | |
| Item Observable Behaviors Score 2.1 Take Two for Safety (verify system configuration and condition matches the work and in a safe manner) 2.2 Positive Component Verification (Independent Verification, Concurrent Verification, Peer Checking, etc.)
| |
| 2.3 Self-Check STAR (Stop, Think, Act, and Review for critical and other important steps) 2.4 Stop When Unsure (use a questing attitude to stop, put job in safe condition, and notify supervision) 2.5 Procedure/Plan Quality (complete and accurate with detail commensurate with the job and risk) 2.6 Procedure Use (continuous use, reference use, information use, or multiple use) 2.7 Procedure Adherence (steps followed in sequence with up-to-date documentation and signoffs/initials 2.8 RWP Adherence (adherence to radiological safety protocols, procedures, and behaviors) 2.9 Industrial Safety Adherence (adherence to IS work practices with satisfactory IS equip/tool inspections) 2.10 Conservative Bias (a focus on prudent behaviors over simply allowable and no cutting of corners) 2.11 Safety Bias (safety takes priority when competing priorities exist, such as schedule and production) 2.12 Verbal Communications (3-part communication, phonetic alphabet, and clarifying questions) 2.13 Respect is Evident (Opinions are valued and support fully informed decisions) 2.14 Supportive (no tolerance for elitism or bullying via words, expressions, or body language)
| |
| | |
| 3.0 Post-Job Review/Critique 3.1 Job Performance (what went right, what went wrong, and what can be done better) 3.2 Obstacles to Performance (any substantive barriers to doing work safely, correctly, and efficiently) 3.3 NSC Behaviors (what behaviors prevented a problem/event or removed a latent or active error precursor) 3.4 Determine approach to address successes and barriers/problems (Good Catches, CAP, etc.)
| |
| | |
| 4.0 NSC Behaviors 4.1 Leadership Safety Values and Actions (LA) 4.2 Problem Identification and Resolution (PI) 4.3 Personal Accountability (PA) 4.4 Work Processes (WP)
| |
| | |
| Page 159 of 170
| |
| | |
| Item Observable Behaviors Score 4.5 Continuous Learning (CL) 4.6 Environment for Raising Concerns (RC) 4.7 Effective Safety Communication (CO) 4.8 Respectful Work Environment (WE) 4.9 Questioning Attitude (QA) 4.10 Decision making (DM)
| |
| | |
| Comments:
| |
| | |
| Page 160 of 170 6: INSCA Team Members, Assignments, and Bios
| |
| | |
| Independent TPNSCA Team Membership
| |
| * Frederic Lake, Task Leader, and Analyst
| |
| * Karen Hutchings, Analyst and Assessment Report Leader
| |
| * John Osborne, Analyst and Assessment Report Author
| |
| * Dr. Mary Jo Rogers, Behavioral Scientist, Analyst**
| |
| * Steven K. Crowe, CAPT, USNR (ret.), Analyst**
| |
| * Bruce OBrien, Analyst**
| |
| * John Ettien, TFE Oversight**
| |
| | |
| **Team members that are designated with stars were involved in the 2023 INSCA as either team members or oversight activities. These members will provide continuity and insights from the previous INSCA.
| |
| | |
| Frederic Lake (President WD Associates, Inc.)
| |
| | |
| Over 40 years of experience root cause analysis and leadership experience covering operations, maintenance, engineering, licensing, and performance improvement. NRC recovery experience at numerous nuclear plants; Senior organizational leader guiding implementation of 95003 recovery at the Palo Verde Nuclear Station. Developed and implemented training activities to improve worker and leader behaviors, and to improve safety culture at several nuclear power plants as part of regulatory recovery efforts.
| |
| | |
| Karen Hutchings (Consultant/Contractor WD Associates, Inc.)
| |
| | |
| Over 35 years of experience in commercial nuclear power plants. Development and implementation of safety culture and leadership training for nuclear power plants; Conduct of cause analyses for Chilled Work Environment, SCWE, and safety culture issues; Leadership for assessments, problem identification, and investigation, and resolution. Workforce and staffing planning, succession planning, knowledge transfer and retention process; Implementation of NSC assessments and surveys; Champion of Human Performance (HU) initiatives and mentoring to change behaviors.
| |
| | |
| John Osborne (Consultant/Contractor WD Associates, Inc.)
| |
| | |
| Over 40 years of experience in commercial nuclear power plants. Corrective action program management, implementation, and oversight; evaluating programmatic, organizational, and cultural performance issues; analysis and resolution of NRC 95001/95002/95003 Issues including Safety Culture (Organizational Weaknesses), Safety Conscious Work Environment, Human Performance/Decision Making, Significant Equipment/Human Events (Plant Trips, EDGs, Refueling Activities, etc.), Organizational Performance / Leadership Fundamentals (Culture/Behaviors), Willful Events (Confirmatory Action Order), and Problem Identification &
| |
| Resolution (Cross-Cutting Issues).
| |
| | |
| Dr. Mary Jo Rogers (President of Rogers Leadership Group)
| |
| | |
| Authored the book Nuclear Energy Leadership: Lessons Learned from U.S. Operators (PennWell) and several published articles in HazardEx and Power Engineering magazines. Dr.
| |
| | |
| Page 161 of 170
| |
| | |
| Rogers has 25 years of experience consulting to commercial nuclear power, electric and gas utility companies, the U.S. Department of Energy, DOE contractors, and the National Institute of Standards and Technology (NCNR), among others. She has conducted board-requested effectiveness assessments of risk reduction programs and multiple safety culture assessments.
| |
| Her extensive background and education enable her to apply psychological and behavioral science principles, combined with real-world utility and business experience, to help individuals and organizations uncover the values, beliefs, and behaviors that may be limiting their performance.
| |
| | |
| Steven K. Crowe (Consultant)
| |
| | |
| Mr. Crowe has 45 years of experience in the operation and licensing of nuclear facilities, safe management of nuclear materials, decommissioning and demolition of nuclear facilities, and disposal of hazardous chemicals. He is a recognized subject matter expert (SME) in operational readiness and Conduct of Operations (CONOPS) and has mentored the recovery of troubled facilities prior to Operational Readiness Review (ORR) resumption. His relevant experience includes leading multiple root cause investigations and serving as a qualified team leader/advisor for numerous U.S. Department of Energy (DOE) ORRs and other assessments, including the Waste Isolation Pilot Plant (WIPP) restart. He is trained in MORT, Kepner-Tragoe, PII, and INPO Human Performance Evaluation/Root Cause Methodology. He provided specialty nuclear engineering, operations support, and consulting for the Depleted Uranium Hexafluoride (DUF6) facilities startup at the Portsmouth Gaseous Diffusion Plant (PORTS) and the Paducah Gaseous Diffusion Plant (PGDP). He served as a member of the Nuclear Safety Basis Review Board that reviewed and approved for submittal over 20 Documented Safety Analysis (DSA) documents for Bechtel Jacobs Company LLC (BJC). At the Rocky Flats Environmental Technology Site (RFETS), he managed all safety, health, and quality aspects for nuclear material-handling and rule and order compliance for the quality assurance (QA), nuclear safety, fire protection, waste management, and construction programs. He also managed the Westinghouse Government Services Quality Assurance Manual (QAM) Review and Gap Analysis. Mr. Crowe retired from TVA in 1995. While at TVA he served in a variety of positions including being a charter member of the nuclear oversight group, a shift outage manager, Human Performance Enhancement System coordinator, and the coordinator of the off -site (Nuclear Safety Review Board) activities. Mr. Crowe graduated from the United States Naval Academy in 1977 with Bachelor of Science (with merit) in Operations Analysis.
| |
| | |
| Bruce OBrien (ATL International Director of Reactor Safety and Performance Improvement )
| |
| | |
| Over 50 years of experience in commercial nuclear power production, naval submarine operations and shipyard work. Engagements include direct Management and Consulting assignments at an array of stations across North America and Africa. Bruce has had Senior Manager assignments in Operations, Maintenance, Training, Work Management/Outage Management, in addition to having held and exercised an SRO License. Bruce joined Marathon Consulting Group in 2000 and has held positions of increasing responsibility. His assumption of duties as President and CEO became effective in January 2016. Bruce has been a principal participant and driver in the support of several stations exiting the Degraded Cornerstone and Multiple/Repetitive Degraded Cornerstone columns of the NRC s ROP Action Matrix, including the writing and implementation of the procedures supporting those efforts, overall project management, and Senior Manager review of NRC Inspection preparation activities. Activities in this area include development or oversight of recovery project governance, project controls, subcontractor control and staffing, leadership indoctrination, conduct and oversight of assessment activities, cause analysis oversight, action plan development, implementation
| |
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| Page 162 of 170
| |
| | |
| oversight, regulatory interface, and senior leadership mentoring through the process. Note:
| |
| Multiple/Repetitive Degraded Cornerstone (Column 4) recoveries involve deep diagnostic assessments to determine if the station operations are acceptable and if additional actions are required to arrest declining performance. These assessments include but are not limited to:
| |
| Program/Process (Governance) for all management processes, engineering programs, and cross organizational processes such as Problem Identification and Resolution, Work Management, etc., Equipment Reliability, Human Performance, Nuclear Safety Culture (including independent or third-party Safety Culture Assessments), Training, and Leadership. In earlier Marathon engagements, Bruce served as: Project Team Lead, to implement a system team for the Emergency Diesel Systems, including framework, performance metrics and industry wide benchmarking to identify vulnerabilities and provide mitigating strategies improving diesel system reliability. Project Manager of a CANDU Outage benchmark and improvement plan at Pickering Nuclear Generating Station. Also, implemented a standard Outage Control Center process and design. Liaison for the Chief Information Officer of Ontario Power Generation for Work Management Integration across all OPG sites. Project Manager for the Maintenance Improvement Project, Nine Mile Point. Maintenance Director, (seconded assignment) responsible for management of all maintenance activities during power operations, refueling, and several short outages. Nine Mile Point Unit 1; Work Control and Outage Manager (second assignment). Nine Mile Point Unit 2; Developed and lead human performance improvement program for the Operations Department, Nine Mile Point Unit 2. Acting General Manager, Operations Support, (second assignment) Nine Mile Point Unit 2. Lead the plant team in the NEI/EUCG management effectiveness review of overall station performance, responsible for assessment in areas of Operations, Maintenance, Work Planning, and Work Management, Outage, Radiation Protection, Chemistry, and Corrective Action and Self- Assessment, Koeberg Station in South Africa.
| |
| | |
| John Ettien (TFE Inc. Director of Operations & Technical Services)
| |
| | |
| More than 43 years of experience in program/project/facility management, procedure development and implementation, training, and qualification, conduct of operations (CONOPS),
| |
| and regulatory compliance to include over 21 years of experience directly supporting the U.S.
| |
| Department of Energy (DOE) and its prime contractors. His relevant experience includes Waste Disposition Operations Manager; Oak Ridge Reservation Landfill (ORRLF) Operations Manager; Operations Manager for the K-25 Decontamination and Decommissioning (D&D)
| |
| Project; and Deputy Project Manager (DPM) for the Molten Salt Reactor Experiment (MSRE) chemical defueling project. He served as the Program Manager for URS l CH2M Oak Ridge LLC (UCOR) Facility Management, training all UCOR Facility Managers (FMs) and implementing CONOPS organization wide for UCOR. Mr. Ettien also served as the Lockout/Tagout Subject Matter Expert (SME) and the Hazardous Energy Program Manager for UCOR. He was also the DPM for the U.S. Spent Fuel Team in the DPRK and mentor to the Operations Managers at the Comanche Peak, Point Beach, and Sizewell B Nuclear Plants. Mr.
| |
| Ettien is trained in Tap Root Cause Analysis and has participated in performing Root Cause Analysis utilizing other methodologies. Mr. Ettien has an active DOE "Q" clearance.
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| Page 163 of 170 7: INSCA Background Detail
| |
| | |
| The National Institute of Standards and Technology (NIST) Center for Neutron Research (NCNR) owns and operates a heavy water-moderated nuclear test reactor and associated neutron beam research facility. The NCNRs reactor is licensed by the Nuclear Regulatory Commission (NRC) under the name National Bureau of Standards Reactor (NBSR).
| |
| | |
| On February 3, 2021, the chief of NCNR Reactor Operations and Engineering notified the NRC (event notification EN 55094) of an alert concerning elevated radiation levels at the NIST Reactor. Pursuant to the event notification received from NCNR staff on February 3, 2021, the NRC initiated a special inspection at the NCNR. On April 14, 2021, the NRC staff issued an interim special inspection report to provide an initial assessment of their understanding of the event sequence, consequences, and the NCNRs response to the event (ADAMS Accession No. ML21077A094).
| |
| | |
| On March 16, 2022, the NRC released a final report of its initial conclusion from its special inspection report. The NRCs final report confirms and expands on many aspects of NISTs analysis of the incident, pointing to deficiencies in policies, procedures, training, and safety culture as contributing to the incident.
| |
| | |
| On August 1, 2022, a Confirmatory Order Modifying License No. TR-5 was issued by the NRC.
| |
| The issued Confirmatory Order documents the NIST NCNR completed and planned actions, as well as the commitments made by NIST to enable the safe operation of the research reactor in the NCNR.
| |
| | |
| On June 2, 2023, the Final Report for the baseline Independent Third-Party Nuclear Safety Culture Assessment of the NIST Center For Neutron Research was issued. This report was an independent and critical assessment of NCNR-ROEs performance compared to INPO 12-012 /
| |
| NUREG 2165 Nuclear Safety Culture Traits. This assessment established the state of NCNR-ROEs Nuclear Safety Culture and described it by NSC traits and attributes. This report identified gaps and made recommendations for improvement in several organizational areas.
| |
| | |
| This task (Task 12) provides a second independent and comprehensive assessment of the existing Organizational Nuclear Safety Culture, including the Safety Conscious Work Environment (SCWE) at the NIST Center for Neutron Research. The assessment will be performed in accordance with the requirements of the August 1, 2022, Confirmatory Order Modifying License No. TR-5, which required a second Nuclear Safety Culture Assessment, within 12 months of completing the initial assessment, to ensure sustainability and effectiveness of the identified recommendation corrective actions within the identified areas.
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| Page 164 of 170 8: NRC Inspection Report - Confirmatory Order Excerpt
| |
| | |
| ==Reference:==
| |
| NRC Inspection Report,
| |
| | |
| ==Subject:==
| |
| National Institute of Standards and Technology, Center for Neutron Research - Confirmatory Order, Dated August 1, 2022
| |
| : 2. Nuclear safety program assessments
| |
| : a. Nuclear safety culture assessment
| |
| : i. Within 6 months of issuance of the CO, NCNR will hire a third-party, independent nuclear consultant (consultant) to conduct an independent third-party nuclear safety culture assessment. The contract will specify that the consultant will assist NCNR in the implementation of the recommendations and corrective actions identified in the assessment to prevent recurrence of the February 3, 2021, event or similar events at the NBSR.
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| ii. Prior to issuance of the Request for Quotations, NCNR will include criteria equivalent to the those described in Section 03.02.c.1, c.2, and c.3 of Inspection Procedure 95003, Supplemental Inspection for Repetitive Degraded Cornerstones, Multiple Degraded Cornerstones, Multiple Yellow Inputs or One Red Input, dated June 7, 2022, to ensure a consultant with the appropriate qualifications is identified.
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| iii. Within 6 months of contract award to the consultant, NCNR will submit a copy of the safety assessment report and NCNRs written response to the assessment report to the NRC. NCNRs written response will either address how it will implement the recommendations and corrective actions of the assessment report, including a proposed timeline; or provide an explanation and justification for why the recommendation(s) and corrective action(s) will not be implemented.
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| iv. Within 2 months of submitting the assessment report to the NRC, the NCNR Director shall issue written and verbal communications providing the results of the assessment, recommendations, and corrective actions to the NCNR staff. At least 30 days prior to issuing the written communication, NCNR will provide the statement for NRC staff review. Within 15 days of receiving the statement, the NRC staff will provide feedback to NCNR staff. NCNR will notify the NRC when the statement is issued.
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| : v. The assessment will include employee surveys, the review of anonymous reports, and contractor-conducted interviews and focus groups to assess the effectiveness of the programs.
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| vi. NCNR will ensure this consultant is provided with all necessary materials, reports, and access to personnel to complete its assessment. The reports shall include the NRC special inspection report dated March 16, 2022, future NRC inspections reports regarding the February 3, 2021, event, and NCNR safety evaluation committee and safety assessment committee (SEC/SAC) reports.
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| vii. Within 12 months of completing the initial assessment, the consultant will perform a second assessment to ensure the sustainability and effectiveness of the corrective actions within the identified areas. Within 30 days of receiving the report, NCNR will submit a copy of the second assessment report to the NRC.
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| viii. Within 12 months of completing the second assessment, the consultant will conduct a third assessment to ensure long term sustainability and effectiveness of the identified
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| Page 165 of 170
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| recommendations and corrective actions. Within 30 days of receiving the report, NCNR will submit a copy of the third assessment report to the NRC.
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| Excerpt from NRC Inspection Manual, Inspection Procedure IP 95003: Supplemental Inspection Response to Action Matrix Column 4 (Multiple/Repetitive Degraded Cornerstone) Inputs, Effective Date: June 7, 2022
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| : c. Qualification Requirements for SCAs
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| : 1. The team leader should coordinate with the program office to select the lead SCA.
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| The lead SCA will determine the size of the SCA team and members.
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| : 2. The lead SCA, in coordination with the team leader, should verify that the SCAs collectively possess the needed education and experience in the following areas:
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| * Knowledge of methods for gathering safety culture data through: (1) individual and group interviews, (2) structured and unstructured interviews, (3) surveys, (4) behavioral observations and checklists, and (5) case studies;
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| * Ability to determine the applicability and likely usefulness of various data-gathering methods under different circumstances;
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| * Ability to implement the different methods correctly, including, but not limited to (1) conducting focus groups and interviews in a manner that elicits the desired Issue Date:
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| 06/07/22 22 95003 information while reducing potential biases in the responses, (2) conducting reliable (i.e., repeatable) structured behavioral observations, and (3) collecting insights from written documentation and verbal communications;
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| * Knowledge of the requirements for developing, administering, and analyzing the results of surveys and questionnaires, including knowledge of: (1) the strengths and weaknesses of different item types (Likert, BARS, forced-choice, etc.); (2) the requirements for administering a survey to reduce potential biases in the responses; (3) behavioral statistics and the appropriate methods, and their constraints, for analyzing survey data; and (4) statistical requirements for the different types of validity and reliability, and appropriate techniques to assess, measure, and establish them;
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| * Knowledge of the rationale for a multiple-measures approach and an ability to assess the limitations of a single-method safety culture assessment;
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| * Knowledge of statistical and conceptual constraints on determining appropriate sample sizes for each method;
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| * Knowledge of the alternatives for selecting samples for the assessment and the biases introduced by different sample selection strategies;
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| * Knowledge of theories and research in organizational and human behavior;
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| * Ability to integrate results from applying the different methods to arrive at defensible conclusions;
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| * Knowledge of the ROP and applicable inspection requirements and techniques; and
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| * Knowledge of theory and research in safety culture.
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| : 3. The knowledge and experience of the selected SCAs should be evaluated promptly by the lead SCA to identify any training needs. The selected SCAs should complete the identified training before participating in IP 95003 inspection activities.
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| Page 166 of 170 9: Definitions
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| Safety Culture: The set of core values and behaviors resulting from a collective commitment by leaders and individuals to emphasize safety over competing goals to ensure protection of people and the environment. (NUREG 2165, Safety Culture Common Language, INPO 12-012, Traits of a healthy Nuclear Safety Culture.
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| Safety Conscious Work Environment (SCWE) : A working environment where personnel feel free to raise safety concerns without fear of retaliation, intimidation, harassment, or discrimination because they raised the issue.
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| Integrated Safety Culture: The term integrated safety culture includes the values and beliefs associated with nuclear safety, occupational safety, radiological safety, security, and environmental safety.
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| Nuclear Safety: The achievement of proper operating conditions and the prevention or mitigation of accident consequences, resulting in the protection of workers, the public, and the environment from undue radiation hazards.
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| Radiation Safety: The protection of people from the harmful effects of exposure to ionizing radiation, and the means for achieving this.
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| Occupational Safety: The reduction of the risk of injury, loss, and danger to persons, property, or the environment in any facility or place involving the manufacturing, producing, and processing of goods or merchandise.
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| Nuclear Security: The prevention, or detection and response, to intentional malicious acts involving radioactive substances or directed against facilities or activities where such substances are used.
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| Environmental Safety: The guidance, policies, and practices enforced to ensure that the surrounding environment is free from hazards that will warrant the safety and well-being of workers, employees, and residents near industrial operations, as well as the prevention of accidental environmental damage.
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| Organization Structure: The collective group of all individuals, the reporting structure, and the procedures, policies, and practices that individuals use to set goals and make decisions, to accomplish tasks, and to implement and maintain a healthy integrated safety culture.
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| NIST Senior Leadership: NIST decision makers who are responsible for setting the long-term strategic goals for the NCNR organization; in addition, develop and implement NIST policies.
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| Director / Deputy Director: Individuals who are responsible for the execution of business activities, including setting priorities for and monitoring the performance of the organization.
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| Page 167 of 170
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| Leaders: Individuals who influence, coach, or lead others within the organization and determine the vision, goals, or objectives of their teams; leaders include NIST Senior Leadership, Directors, Chiefs, Supervisors, and others who influence individuals in the organization.
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| Chiefs and Leads: Individuals assigned to managerial positions who control, direct, guide, and advise.
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| Supervisors: Individuals who provide direction of the day-to-day activities of individual contributors; supervisors may include reactor supervisors, engineering supervisors, team leaders or work leaders.
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| Individual Contributors: Individuals who operate individually or as members of work groups to accomplish tasks; individual contributors may include leaders when leaders are acting in a nonsupervisory capacity or are accomplishing tasks as members of a work group.
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| Individuals: All people at all levels of the organization; individuals include all leaders, individual contributors, and supplemental personnel.
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| Supplemental Personnel: Individuals who accomplish work for but are not employees of the NCNR organization. Supplemental personnel include short- and long-term contractors, vendors, OFPM Office of Facilities and Property Management, research and science personnel and any other individuals who are not employed by the organization but occasionally perform work at NCNR.
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| Work Groups: Groups of individuals who work collaboratively to accomplish tasks; work groups may exist at any level of the organization.
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| Independent Oversight Organizations : Groups that independently review the performance and direction of the NCNR organization. This includes the NCNR Safety Evaluation Committee (SEC) and the NCNR Safety Assessment Committee (SAC), as well as independent reviews from groups outside of the NC NR organization.
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| Assessment Categories for Traits and Initiatives
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| Area of Strength (AOS): Performance that is exceptionally effective in achieving its desired results; a program, process, or activity of such high quality that it could serve as an example for other similar elements.
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| Positive Observation (PO) - A performance, program, or element that is sufficient to meet its basic intent and does not require additional management attention to achieve full effectiveness and consistency.
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| Area in Need of Attention (ANA): A performance, program, or process element that is sufficient to meet its basic intent, but that requires management attention to achieve full effectiveness and consistency.
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| Area for Improvement (AFI): A performance, program, or process element that requires significant improvement to obtain the desired results in a consistent and effective manner.
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| Page 168 of 170
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| Area of Interest (AOI): A performance, program, or process element that is sufficient to meet its basic intent but would benefit from management attention to achieve full effectiveness and consistency.
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| Page 169 of 170 0: References
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| * US DOE G 414.1-1C, Management and Independent Assessments Guide
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| * US NRC Inspection Procedure 95003
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| * US NRC Inspection Procedure 95003 Attachment 02
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| * US NRC Inspection Manual Chapter 0350, Oversight of Reactor Facilities in a Shutdown Condition
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| * NUREG 2165, Safety Culture Common Language
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| * INPO 12-012, Traits of a Healthy Nuclear Safety Culture, dated March 2014
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| * Research Report RSP-0060, Development of a Regulatory Organizational and Management Review Method. Haber, S.B. and Barriere, M.T., dated June 7, 2022
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| * Task Order 01 dated January 31, 2023 (and additional documents referenced therein)
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| Safety Culture Policy Statement (76 FR 34773; dated June 14, 2011)
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| * Special Inquiry into Oversight of Research and Test Reactors, OIG Case NO. I2100162
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| * Technical Specifications for the NIST Test Reactor (NBSR) License No. TR-5 Appendix A Safety Analysis Report for the National Institute of Standards and Technology Reactor NBSR-14
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| * NEA, No. 7673, OECD, 2024, Practice for Enhancing Leadership for Safety in Nuclear Regulatory Bodies
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| * Measure of A Leader, Aubrey Daniels, published 2007.
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| Note: Various references were reviewed, verbalized, and/or presented during interviews, focus groups, and/or subsequent discussions with NCNR and INSCA team personnel. The results of the reviews, verbalizations, and/or presentations, were factored into the conclusions within this report.
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| Page 170 of 170}}
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