ML12240A106

Integrated Improvement Plan Summary

ML12240A106
Person / Time
Site:	Browns Ferry
Issue date:	08/23/2012
From:	Swafford P Tennessee Valley Authority
To:	Document Control Desk, NRC/RGN-II
References
IR-11-008
Download: ML12240A106 (18)

Text

Tennessee Valley Authority, 1101 Market Street, Chattanooga, Tennessee 37402 August 23, 2012 10 CFR 50.4 ATTN: Document Control Desk U.S. Nuclear Regulatory Commission Washington, D.C. 20555-0001 Browns Ferry Nuclear Plant, Unit 1 Facility Operating License No. DPR-33 NRC Docket No. 50-259

Subject:

Integrated Improvement Plan Summary

Reference:

Letter from NRC to TVA, "Final Significance Determination of a Red Finding, Notice of Violation, and Assessment Follow-Up Letter (NRC Inspection Report No. 05000259/2011008) Browns Ferry Nuclear Plant," dated May 9, 2011 The Nuclear Regulatory Commission (NRC) notified the Tennessee Valley Authority (TVA) in the referenced letter that they had assessed the Browns Ferry Nuclear Plant (BFN), Unit 1, performance to be in the Multiple/Repetitive Degraded Cornerstone Column of the NRC's Action Matrix (i.e., Column 4) beginning in the fourth quarter of calendar year 2010. This assessment was based on the final significance determination for failure to establish adequate design control and perform adequate maintenance on the Unit 1 low pressure coolant injection outboard injection valve, 1-FCV-74-66, resulting in the valve being left in a significantly degraded condition that led to the Residual Heat Removal System Loop II being unable to fulfill its safety function.

In response to this event, TVA has conducted extensive reviews, assessments, and causal analyses, using insights and guidance from NRC Inspection Procedure 95003, "Supplemental Inspection for Repetitive Degraded Cornerstones, Multiple Degraded Cornerstones, Multiple Yellow Inputs or One Red Input." These reviews, assessments, and causal analyses were performed to understand the underlying issues associated with performance at BFN and to guide efforts and development of actions to achieve sustained improved performance and reduce risk.

The purpose of this letter is to provide the NRC staff with the enclosed copy of the BFN Integrated Improvement Plan Summary. The Integrated Improvement Plan was referred to in TVA's presentations at the NRC public meetings of May 15, 2012, and August 9, 2012, and the NRC Commission meeting of June 1, 2012.

Printed on recycled paper i w

U.S. Nuclear Regulatory Commission Page 2 August 23, 2012 The Integrated Improvement Plan Summary describes the approach that TVA is using to guide BFN's efforts for improving performance to sustainable levels of excellence and to reduce station risk. The Integrated Improvement Plan Summary provides an overview of the diagnostic evaluation process used for identifying the underlying fundamental problems contributing to the safety culture and operational performance issues. The summary also discusses the process for identifying the key actions and includes performance monitoring indicators that are being used to assess the effectiveness of the implemented actions. The summary describes how future events or newly identified conditions will be expeditiously evaluated and incorporated into the learning and corrective action process. The Integrated Improvement Plan Summary includes the criteria that TVA will use to determine readiness for NRC inspection according to Inspection Procedure 95003 as well as criteria that will be used for long term success determination.

There are no new regulatory commitments contained in this response. Should you have any questions concerning this submittal, please contact J. W. Shea at (423) 751-6887.

Respectfully, Preston D. Swafford Chief Nuclear Officer

Enclosure:

Integrated Improvement Plan Summary cc (Enclosure):

NRC Regional Administrator - Region II NRC Project Manager - Browns Ferry Nuclear Plant NRC Senior Resident Inspector - Browns Ferry Nuclear Plant

ENCLOSURE Tennessee Valley Authority Browns Ferry Nuclear Plant, Unit I Integrated Improvement Plan Summary

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1.0 Purpose The purpose of this document is to summarize the approach that the Tennessee Valley Authority (TVA) Browns Ferry Nuclear Plant (BFN) is using to guide station efforts for improving performance to sustainable levels of excellence and to reduce station risk.

This document provides an overview of the diagnostic evaluation process used for identifying the underlying fundamental problems contributing to the safety culture and operational performance issues. It also discusses the process for identifying the key actions and lists performance monitoring indicators that are being used to assess the effectiveness of the implemented actions. It further describes how any future events or newly identified conditions will be expeditiously evaluated and incorporated into the corrective action program. Finally, this document includes the criteria that TVA will use to determine readiness for NRC inspection according to Inspection Procedure (IP) 95003, "Supplemental Inspection for Repetitive Degraded Cornerstones, Multiple Degraded Cornerstones, Multiple Yellow Inputs or One Red Input," as well as criteria that will be used for long term success determination.

2.0 Organization and Effort Governance TVA Nuclear Power Group (NPG) developed an organization to provide fleet support and governance to the Browns Ferry team's performance improvement effort. A corporate officer was assigned full-time to this effort and led a team for the assessment and analysis phases that was comprised of site and corporate resources as well as expertise from across the industry. The effort was guided by a set of procedures that were developed using the detailed guidance in the 95003 Inspection Procedure as well as recent industry benchmarking data. These project-specific procedures were reviewed and approved by the 95003 Team to ensure quality and completeness. The procedures used for this effort include the following documents.

95003-001 Historical Data Review 95003-002 Collective Evaluation and Action Plan Development 95003-003 Identification, Assessment and Correction of Performance Deficiencies 95003-004 Assessment of Performance in the Reactor Safety Strategic Performance Area 95003-005 BFN NRC Column 4 Inspection Readiness and Administrative Controls 95003-006 Third Party Independent Nuclear Safety Culture Assessment 95003-007 Project Review Boards Following the diagnostic phase, the effort transitioned from a corporate-led effort to a line owned effort with the corporate office providing governance, oversight, and support.

3.0 Scope Identification and Process for Diagnostic Evaluation Figure 1 provides an overview of the process used for identifying the issues within the scope of the diagnostic evaluation process leading to the identification of Corrective Actions.

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Fiqure 1 The Browns Ferry 95003 Team used the following data gathering efforts to support subsequent diagnostic analysis: (1) Historical Data Review (HDR), (2) Identification, Assessment & Correction of Performance Deficiencies (IA&CPD), (3) Key Attribute Review (KAR), and (4) an Independent Nuclear Safety Culture Assessment (INSCA).

Each of these four efforts was governed by a specific procedure and the assessments were conducted consistent with documented plans. The results of each of these assessments were documented in Problem Development Sheets (PDS) to support further evaluation and aggregate analysis. In addition, the observations from the NRC's Part I and Part 2 IP 95003 Supplemental Inspections and Problem Identification &

Resolution (PI&R) inspection were considered as part of the problem development process.

The data-mining and evaluation process employed in these efforts was rigorous and extensive. The challenge process sought to produce the best products that will result in sustained performance improvement and to promote a continuous learning environment.

For example, the HDR looked at events involving regulatory/safety issues as well as other plant events and assessments going back 5 years to develop insights used in this analysis. The IA&CPD was a broad scope assessment of seven performance areas to determine whether current programs in place to identify, assess, and correct performance deficiencies are sufficient to prevent further performance degradation. The performance areas assessed included: (1) Significant Performance Deficiencies, (2)

Audit and Assessment, (3) Allocating Resources, (4) Performance Goals, (5) Employee Concerns Program (ECP), (6) Technical Resolution Dispositions, and (7) Use of Industry information. The purpose of the KAR was to evaluate and verify the high safety and risk systems capability to fulfill their intended safety functions; to identify broad based safety, organization and performance issues; and to evaluate Emergency Response Organization readiness. The scope of this review was focused on evaluating the 3

adequacy of programs and processes in six key areas: Design, Human Performance, Procedure Quality, Equipment Performance, Configuration Control, and Emergency Response Organization Readiness.

The results of these assessments, combined with the findings and results from the Performance Deficiency (failed Residual Heat Removal System Loop II outboard injection valve) Root Cause Evaluation (RCE) were integrated and collectively analyzed by the 95003 Team for patterns, trends, or groupings. In addition to the results from the various collective evaluations, the team used several techniques to develop the groupings and potential PDS. The techniques and insights included INPO Performance Objectives and Criteria (PO&Cs), trend and failure codes, and NRC safety culture components. Based on this iterative and collaborative process, the 95003 team identified the following Fundamental Problems that must be addressed in order to achieve the objectives of sustained improved performance and risk reduction.

• Management and Leadership Standards: Leaders at all levels are not effectively modeling or reinforcing high standards to drive sustained positive performance changes and are tolerating less than acceptable standards of performance.

• Operational Focus / Decision Making: Decision making at all levels of the station does not consistently demonstrate nuclear safety as the top priority and has contributed to significant events, unrecognized equipment inoperability, and deficient operability determinations.

• Resource Management: Resource allocation decisions are inconsistent and have conflicting priority in managing core business and emergent work. This weakness manifests itself in reactive responses on equipment reliability and on the margin for managing nuclear safety.

" Work Management: Work management shortfalls contribute to maintenance backlogs and adversely affect equipment performance resulting in continued challenges to safe and reliable operation of the station. Previous actions to implement a robust work management process have been ineffective.

• Corrective Action Program: Execution of the corrective action program has been inconsistent and previous actions to improve performance have been ineffective.

• Procedure Use and Adherence and Work Practices (Human Performance):

Procedures and work instructions that support plant operations, maintenance, and engineering are not followed and have contributed to plant operational events, maintenance errors, and industrial safety events.

• Equipment Performance, Monitoring and Trending: Equipment Performance Monitoring and Trending programs are not being implemented in a manner to prevent equipment failures. Performance metrics are not consistent or utilized to proactively identify and resolve equipment reliability issues.

• Strategic Equipment Management: Equipment Reliability programs and processes needed to drive and sustain high levels of equipment reliability are not being implemented in a manner that results in the timely resolution of long-standing equipment problems and the prevention of new problems.

• Technical Rigor: Insufficient technical rigor results in rework, engineering design basis documentation flaws, and/or mis-configurations requiring additional work and resources.

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• Governance, Oversight, Alignment, & Monitoring: The Nuclear Operating Model has not been effectively implemented. Governance, use of performance metrics, and corporate oversight have been less than effective at improving human and equipment performance, and regulatory margin.

• Inappropriate Reliance on Processes / Silo'd Performance: Inadequate follow through and ownership through resolution, coincident with the belief that processes, not people, solve problems has hindered performance improvement.

• Procedure/Instruction Quality: Procedures and work instructions do not fully support quality work, configuration control, human performance or record keeping and have contributed to plant events and performance deficiencies.

" Equipment Programs and System Management: Engineering Programs designed to monitor and improve equipment performance are not effectively implemented and do not support long-term equipment availability and reliability goals.

" Design/Configquration Control: Comprehensive understanding and management of design bases including key inputs, expected results, and outputs are not adequate.

Configuration documentation and control (e.g., drawings, calculations, procedures, change backlog, modification packages, observations, and long-standing clearances) challenges reliable plant operations.

• Continuous Learninq Environment: Self assessments, benchmarking, and the use and operating experience are not used effectively to improve station performance.

Each of these Fundamental Problems were entered into the Corrective Action Program and appropriate causal analysis was performed to determine underlying causes, appropriate extent of condition and extent of cause, corrective actions, and measures of effectiveness. Immediate / interim actions were considered and added for each of the fundamental problems as appropriate. The causal analysis products were reviewed by appropriate challenge boards and then processed through the site Corrective Action Review Board (CARB) for station leadership review and approval.

The identified causes and subsequent corrective actions were then integrated and reviewed in aggregate with other station high priority performance improvement initiative outputs such as Equipment Reliability Improvement Actions, Safety System Reliability Effort, efforts to implement National Fire Protection Association (NFPA) 805, "Performance-Based Standard for Fire Protection for Light Water Reactor Electric Generating Plants," and various Gaps to Excellence Plans via a challenge process to ensure the actions given specific focus were coordinated such that they did not create additional organizational stresses due to excessive workload and were appropriately prioritized. This challenge process was in accordance with 95003 readiness specific procedures (95003-007). lists the CAP Problem Evaluation Report (PER) number associated with each Fundamental Problem to support review and subsequent inspection(s).

In addition to the Fundamental Problem causal analysis and action development, an assessment of the INSCA Report was performed to determine if there were additional issues not directly addressed by the Fundamental Problem action plans. This assessment noted two issues that would benefit from additional causal analysis, 5

specifically Safety Conscious Work Environment and the Employee Concerns Program.

The problem statements are noted below.

• BFN Safety Conscious Work Environment (SCWE) Weaknesses: Identified weaknesses include examples of an unwillingness to report or inform supervisors of safety issues, and management failures to effectively use indicators/precursors of a chilled environment to correct performance. This has resulted in the SCWE at Browns Ferry being in the 4th Quartile since 2006.

• Weakness in the Execution of and Confidence in the Employee Concerns Program (ECP): These weaknesses have contributed to BFN being ineffective at evaluating and resolving potential nuclear safety issues.

4.0 Effectiveness Reviews and Performance Metrics For each of the Fundamental Problems, specific actions have been identified to assess the effectiveness of any action deemed necessary to steadily improve performance to help prevent recurrence of the identified causes. In addition, performance metrics have been established to assess the resulting effectiveness of the various actions implemented for resolving each of the Fundamental Problems.

Any Fundamental Problem having a Root Cause Analysis as specified by the TVA Corrective Action Program is required to have formal actions for determining effectiveness of the specific actions assigned by the causal analysis. For those Fundamental Problems that did not screen as requiring a formal Root Cause Analysis, but had other formal causal analysis, the actions are required to be reviewed in aggregate for effectiveness by the 95003 response process (95003-002/007). In all cases, CARB is responsible for reviewing and accepting effectiveness measures.

The overall effectiveness of the various site actions at addressing the identified Fundamental Problems is measured by Performance Metrics. These metrics were reviewed and approved by the senior leadership team on site at BFN and the executive leadership team of TVA-NPG. These performance metrics are listed in Attachment 2.

The basis for the utilized performance metrics and the associated performance thresholds is documented.

A number of the performance metrics are established metrics from the current suite of TVA-NPG Performance Indicators. In some cases, additional metrics had to be developed or specific data was taken from the established metrics to best measure the effectiveness of improving performance in the affected areas of the Fundamental Problems.

5.0 Communication To better support understanding of the fundamental problems, improved communication of issues, and alignment of employees around behavior improvement initiatives, the 15 Fundamental Problems plus the 2 issues identified by the Safety Culture Review Team were consolidated into 5 discrete Focus Areas. These Focus Areas have concise statements describing the aggregate issue and align directly to the Fundamental Problems. Associated actions and metrics were also applied from those established for the Fundamental Problems to support site personnel engagement and tracking of 6

improvement initiative effectiveness. The Fundamental Problems that were grouped to establish each Focus Area were deemed to have substantive alignment such that the groupings made sense to employees and the relationship was such that the organizational learning's from the Fundamental Problems were not diluted. The alignment of the Focus Areas to the Fundamental Problems, are provided in Attachment 3.

The focus areas have been arranged and developed for communication to BFN employees with a specific focus on the relationship of each of these areas to Safety Culture. The Focus Areas and communications tools are represented in Attachment 3.

6.0 Disposition of Newly Identified Conditions or Significant Events If events or conditions occur that either demonstrate behavior not conducive to sustained improved performance or represent a new condition or emerging trend, the condition will be reviewed and evaluated as part of the Corrective Action Program. The CAP review and screening process will properly code the identified issue to ensure the proper level of analysis is achieved and that the actions are properly addressed with a commensurate sense of urgency and responsibly tracked to completion. The issues will also be reviewed by the 95003 Team to determine if the condition (1) is significant to station performance, (2) is enveloped by the current fundamental problem statements, and (3) would have been prevented if the current corrective actions had been fully implemented. A determination will then be made to either include additional actions in the tactical response effort or if the issues or condition was unrelated to the 95003 response effort and can be handled independently in CAP. This process is controlled by guidance found in 95003-002.

7.0 Criteria for Determining Readiness for Inspection Criteria have been established to guide the leadership decision making process for assessing readiness and informing the NRC of readiness for the IP 95003 inspection. In summary, the criteria include the following.

• No risk significant event or condition

- Resulting from a cause that would alter the basis of the established plan

- Resulting from the developed corrective actions being ineffective

• Designated corrective actions have been completed (Guidance in 95003-002)

• Longer-term corrective actions are on schedule

• Performance criteria/metrics indicate adequate performance improvement and sustainability

• Assessments by the governance and oversight organizations support readiness Site and corporate executive leadership will review and concur with the evidence and make the recommendation to the Chief Nuclear Officer (CNO) that BFN is ready for inspection. The NRC will be notified when all criteria are met and leadership alignment exists concurring with readiness.

8.0 Determination of Long Term Success To ensure sustained excellent performance, long term success will be measured following completion of the IP 95003 Inspection and when the Confirmatory Action Letter 7

actions are complete. Sustained excellence will be demonstrated by noted improvements on the performance metrics and process closure will be demonstrated by the following.

• Browns Ferry in the Licensee Response Column of the NRC's Reactor Oversight Process Action Matrix

• All Designated Actions Complete (Guidance in 95003-002)

• BFN Using TVA-NPG Standard Fleet Programs and Procedures without reliance on the 95003 Team 9.0 Governance and Oversight As guided by the TVA-NPG Nuclear Operating Model (NOM), Governance and Oversight is playing and will play a key role in process development, process implementation, validation of results, readiness determinations, and assessing sustained performance. The lessons learned from this effort at Browns Ferry will be applied to the fleet as appropriate. Site ownership and alignment, complemented by strong corporate Governance and Oversight, is essential to the sustainability of improved station performance. Both the Quality Assurance and Corporate Functional Area organizations play a key role in the oversight function of Browns Ferry as part of this process. In support of the 95003 response effort, the governance and oversight function is enhanced by various measures as discussed in 95003-007. Some of the unique oversight organizations are listed below.

• Augmented Quality Assurance

• 95003 Executive Oversight Board

• Nuclear Safety Review Board

• Nuclear Oversight Committee of the TVA Board 8

Attachment 1 Fundamental Problems and Causal Analysis CAP Reference No. Fundamental Problem Causal Analysis CAP Reference 1 Management and Leadership Standards:

Leaders at all levels are not effectively modeling or reinforcinghigh standards to PER 516437 drive sustainedpositive performance changes and are toleratingless than acceptablestandards of performance.

2 Operational Focus / Decision Making:

Decision making at all levels of the station does not consistently demonstrate PER 516455 nuclear safety as the top priority and has contributed to significant events, unrecognizedequipment inoperability,and deficient operabilitydeterminations.

3 Resource Management:

Resource allocation decisions are inconsistent and have conflictingpriority in managingcore business and emergent work. This weakness manifests itself in PER 543130 reactive responses on equipment reliability and on the margin for managing nuclearsafety.

4 Work Management:

Work management shortfalls contribute to maintenance backlogs and adversely affect equipment performance resulting in continued challenges to safe and PER 516458 reliableoperation of the station. Previous actions to implement a robust work managementprocess have been ineffective.

5 Corrective Action Program:

Execution of the corrective action program has been inconsistent and previous PER 549159 actions to improve performance have been ineffective.

6 Procedure Use and Adherence and Work Practices (Human Performance):

Proceduresand work instructions that support plant operations,maintenance, PER 543135 and engineering are not followed and have contributedto plant operational events, maintenance errors, and industrialsafety events.

7 Equipment Performance, Monitoring and Trending:

Equipment Performance Monitoring and Trending programs are not being implemented in a mannerto prevent equipment failures. Performancemetrics PER 547430 are not consistent or utilized to proactively identify and resolve equipment reliabilityissues.

8 Strategic Equipment Management:

Equipment Reliabilityprogramsand processes needed to drive and sustain high levels of equipment reliabilityare not being implemented in a manner that results PER 547424 in the timely resolution of long-standingequipment problems and the prevention of new problems.

9 Technical Rigor:

Insufficient technical rigorresults in rework, engineeringdesign basis PER 543131 documentation flaws, and/or mis-configurationsrequiringadditional work and resources.

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Attachment 1 Fundamental Problems and Causal Analysis CAP Reference No. Fundamental Problem Causal Analysis CAP Reference 10 Governance, Oversight, Alignment, & Monitoring:

The Nuclear OperatingModel has not been effectively implemented.

Governance, use of performance metrics, and corporate oversight have been PER 542377 less than effective at improving human and equipment performance, and regulatorymargin.

11 Inappropriate Reliance on Processes/Silo'd Performance:

Inadequatefollow through and ownership through resolution, coincident with the PER 543134 belief that processes, not people, solve problems has hinderedperformance improvement 12 Procedure/instruction Quality:

Proceduresand work instructions do not fully support quality work, configuration PER 552135 control, human performance or record keeping and have contributedto plant events and performance deficiencies.

13 Equipment Programs and System Management:

Engineering Programsdesigned to monitor and improve equipmentperformance PER 547427 are not effectively implemented and do not support long-term equipment availabilityand reliabilitygoals.

14 Design/Configuration Control:

Comprehensive understandingand management of design bases including key inputs, expected results, and outputs are not adequate. Configuration PER 543132 documentation and control (e.g., drawings,calculations,procedures,change backlog, modification packages, observations,and long-standing clearances) challenges reliable plant operations.

15 Continuous Learning Environment:

Self assessments, benchmarking, and the use and operating experience are not PER 547431 used effectively to improve station performance.

BFN Safety Conscious Work Environment Weaknesses:

Examples of an unwillingness to report or inform supervisors of safety issues, and management failures to effectively use indicators/precursorsof a chilled PER 571348 environment to correctperformance. This has resulted in the SCWE at Browns Ferrybeing in the 4th Quartile since 2006.

Weakness in the Execution of and Confidence in the ECP:

These weaknesses have contributedto BFN being ineffective at evaluating and PER 571345 resolvingpotential nuclear safety issues.

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Attachment 2 Performance Metrics 95003 Problem Problem Statement Performance Metrics Management and Leaders at all levels are not effectively

• Total Industrial Safety Accident Rate (TISAR)

Leadership Standards modeling or reinforcing high standards e Site Human Performance Error Rate to drive sustained positive

• Collective Radiation Exposure performance changes and are

• Operational Focus Aggregate Impact tolerating less than acceptable

• Equipment Reliability Index standards of performance.

• Monthly CAP Health Operational Focus/Decision Decision making at all levels of the Operational Focus Aggregate Impact Making station does not consistently demonstrate nuclear safety as the top priority and has contributed to significant events, unrecognized equipment inoperability, and deficient operability determinations.

Resource Management Resource allocation decisions are

• On-Line Deficient Maintenance Backlog inconsistent and have conflicting (Critical WOs) priority in managing core business and

• On-Line Corrective Maintenance Backlog emergent work. This weakness (Critical WOs) manifests itself in reactive responses 0 Total PMs in 2nd Half of Grace on equipment reliability and on the 0 Site TVA Staffing margin for managing nuclear safety.

• LCO Management Work Management Work management failures contribute

• Safety System Reliability Plan (SSRP) Work Off to maintenance backlogs and Curve adversely affect equipment

• On-Line Deficient Maintenance Backlog performance resulting in continued (Critical WOs) challenges to safe and reliable

• On-Line Corrective Maintenance Backlog operation of the station. Previous (Critical WOs) actions to implement a robust work

• Total PMs in 2nd Half of Grace management process have been 0 Schedule Adherence/Completion ineffective.

• Scope Stability (T-6)

Corrective Action Execution of the corrective action

• PERs and PER Actions Closure Quality program has been inconsistent and

• Root Cause Analysis and Apparent Cause previous actions to improve Evaluation Grading performance have been ineffective.

• CAP Timeliness (A/B Level CAPs) 0 Corrective Action Backlog (Open Corrective Actions > 180 Days)

Procedure Use and Procedures and work instructions that

• Site Human Performance Error Rate Adherence and Work support plant operations, a CAP Procedure Use and Adherence Trend Practices(Human maintenance, and engineering are not Performance) followed and have contributed to plant operational events, maintenance errors, and industrial safety events.

Equipment Performance, Equipment Performance, Monitoring

• High Critical Component Failures Monitoring and Trending and Trending programs are not being

• Safety System Functional Failures implemented in a manner to prevent

• Equipment Reliability Clock Resets equipment failures. Performance 0 Equipment Reliability Index metrics are not consistent or utilized to proactively identify and resolve equipment reliability issues.

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Attachment 2 Performance Metrics 95003 Problem Problem Statement Performance Metrics Strategic Equipment Equipment Reliability programs and 0 Degraded/Non-Conforming Conditions > 1 Management processes needed to drive and sustain Cycle high levels of equipment reliability are 0 On-Line Deficient Maintenance Backlog (Critical not being implemented in a manner WOs) that results in the timely resolution of

• On-Line Corrective Maintenance Backlog long standing equipment problems and (Critical WOs) the prevention of new problems. a Critical PMs Deferred

• Equipment Reliability Clock Resets

• Safety System Reliability Plan (SSRP) Work Off Curve Technical Rigor Insufficient technical rigor results in

• Engineering Product Quality (QRT Scoring) rework, engineering design basis 0 Root Cause Analysis and Apparent Cause documentation flaws, and/or mis- Evaluation Grading configurations requiring additional

• All Department Clock Resets for Technical work and resources. Rigor Governance, Oversight, The Nuclear Operating Model has not 0 GOES Indicator Alignment and Monitoring been effectively implemented.

Governance, use of performance metrics, and corporate oversight have been less than effective at improving human and equipment performance, and regulatory margin.

Inappropriate Reliance on Inadequate follow through and

• Total Industrial Safety Accident Rate (TISAR)

Process ownership through resolution,

• Site Human Performance Error Rate coincident with the belief that 0 Collective Radiation Exposure processes, not people, solve problems . Operational Focus Aggregate Impact has hindered performance 0 Equipment Reliability Index improvement.

• Monthly CAP Health Procedure/Instruction Procedures and work instructions do a Engineering Product Quality (QRT Scoring)

Quality not fully support quality work,

• Maintenance Rework configuration control, human

• Department Clock Resets -

performance or record keeping and Planning/Maintenance have contributed to plant events and performance deficiencies.

Equipment Programs and Engineering Programs designed to

• Program Assessments Action Item Work Off System Management monitor and improve equipment Curve performance are not effectively implemented and do not support long term equipment availability and reliability goals.

Design/Configuration Comprehensive understanding and 0 Engineering Product Quality (QRT Scoring)

Control management of design bases 0 Department Clock Resets - Engineering including key inputs, expected results, (Design) and outputs are not adequate.

• Degraded/Non-Conforming Conditions > 1 Configuration documentation and Cycle control (e.g., drawings, calculations, 0 Vendor Manual Program Backlog procedures, change backlog,

• Drawing Backlog modification packages, observations,

• Partially Implemented Design Change Notices and long standing clearances)

• Timeliness Closing DCN Packages challenges reliable plant operations. 0 Open Temporary Alterations Continuous Learning Self assessments, benchmarking, and e Adherence to Self Assessment Schedule Environment the use and operating experience are

• Adherence to Benchmarking Schedule not used effectively to improve station

• Self Assessment Quality Grading performance.

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Attachment 2 Performance Metrics 95003 Problem Problem Statement Performance Metrics Safety Conscious Work Examples of an unwillingness to report

• NRC Allegations (Onsite)

Environment or inform supervisors of safety issues, 0 Anonymous HIRD PERs and management failures to effectively

• Anonymous PERs use indicators/precursors of a chilled environment to correct performance.

This has resulted in the SCWE at Browns Ferry being in the 4th Quartile since 2006.

Fire Risk Reduction BFN fire risk is high 0 Fire Protection Initiatives Progress Work Off Curve 0 Fire Protection Program Impairments Employee Concerns These weaknesses have contributed 0 NRC Allegations (Onsite)

Program to BFN being ineffective at evaluating 0 ECP Timeliness and resolving potential nuclear safety issues.

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Attachment 3 Focus Areas Focus Area Fundamental Problem Accountability 0 Management and Leadership Standards

• Procedure Use and Adherence and Work Practices Station personnel are not reinforcing and (Human Performance) complying with site standards. 0 Procedure/Instruction Quality 0 Inappropriate Reliance on Processes/Silo'd Performance 0 Safety Conscious Work Environment Operational Decision Making (Risk 0 Operations Focus / Decision Making Management)

• Resource Management

• Governance, Oversight, Alignment, & Monitoring Station personnel are not consistently evaluating issues with respectto risk.

Equipment Reliability

• Work Management 0 Engineering Programs and System Management Key programsand processes supporting

• Technical Rigor Equipment Performance have gaps or are not 0 Strategic Equipment Management being effectively implemented. 0 Equipment Performance, Monitoring and Trending 0 Design/Configuration Control Fire Risk Reduction

• Operational Focus/Decision Making Browns Ferry has high fire risk.

Corrective Action Program a Corrective Action Program 0 Continuous Learning Environment Execution of CAP is weak leading to repeat 0 Employee Concerns Program issues.

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Attachment 3 Focus Areas Sustained through Governance and Oversight Improved through Training 15