ML20136H289
| ML20136H289 | |
| Person / Time | |
|---|---|
| Site: | Three Mile Island  |
| Issue date: | 01/02/1985 |
| From: | Gaines D GENERAL PUBLIC UTILITIES CORP. |
| To: | Arnold R, Phyllis Clark GENERAL PUBLIC UTILITIES CORP. |
| References | |
| SP-I-TMIA-005, SP-I-TMIA-5, NUDOCS 8508200254 | |
| Download: ML20136H289 (8) | |
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/ Inter Office Memorandum Date August 31, 1982 ~
tuclear Suoject THI-l ASLB Decision of UQ* f' D Aly 27, 1982 To .g- n L.ocadon
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R. C. Arnold P. R. Clark ~ ~
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9 7 COWIDENTIAL In response to your August 6,1982 memo, I have reviewed the TMI-l ASLB decision of k ly 27, 1982. I do not have first hand knowledge of the circumstances or events associated with the occurence at THI; therefore, my lessons learned are bated upon the report and my own experiences which may have relevance to the issue. ,In this light, I may not strike at the heart of a specific issue, but rather address general aspects of the overall concern.
In accressing your request, I have identified two very fundamental questions which must be answered:
- 1. What circumstances caused or made it possible fcr the ,
individuals to participate in the various events which occurred, and
- 2. what measures can be taken to minimize or possibly prevent similar events in the future?
In orcer tu establish a complete and accurate answer to Question Number Two, we must fully understand the answer to Question Number One. The ASLB decision does not address the first question in sufficient detail.
Therefore, it is not possible to address question two solely on the weight of the report. This is where I must utilize experience and some speculation to establish what I believe to be the circumstances behind the events.
Incividual stress is nost likely one of the principal contributing factors to the events. Commercial nuclear power is a very complex public health and safety issue which impacts upon the government, the industry, the Corporation, and any individual either closely or loose.ly related to issue. The THI-2 accident and the resulting events are proof positive of this very ccmplex, high stakes issue. At stake is the survival of an CONFIDENTIAL unm stem comsses Dedet lie. [8
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CONFIDENTIAL 2 August 31, 1982 R. C. Arriuld/P.'R. Clark ,
! industry, a corporation, and many individuals. The individual's concern for his/her job, the survival of the company, and more remotely, the
' survival of commercial nuclear power is cause for substantial individual i stress. It is stress of this sort that could cause an individual to participate in events which he/she knows to be wrong.
I Lack of confidence in one's self and/or the company is most likely a The demands that ne place principal contributing factor to the events.
I on individuals have increased dramatically, and it appears that this will j be the case for some time to come. We are not only increasing our requirements, but we are also requiring people to demonstrate that they can meet them. What about the individual who was adequate under the old i
i standards, but cannot, or perceives that he cannot, succeed under the new standards? What about the marginal individual who enters the program today? A person who lacks confidence in one's ability to succeed could 1
be motivated to achieve a goal thorough less than honorable means. Along these lines, I ask the second and more alarming question. That is, why '
didn't the individuals who were concerned about their ability to succeed, approach the company management with the concern? The individual who pursues less than honorable solutions rather then approaching the company management must have sericus concerns about the management's response if 1
f it is approached on the issue.
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) The lack of sensitivity to circumstances and events could be a principal contributing factor to the events. Going on the belief that most people are hard working, honest individuals who are trying to accomplish a job l
i in the mos.t effective way, I do not believe that all participants in the i
events perceived that their actions were wrong or that they knowingly 4 participated out of malice. I believe that some individuals were i
" victims of circumstance" and a lack of sensitivity to the issues.
The lack of management controls is most likely a principal contributing l factor to the events which occurred. This is the one factor which the i report seemed to focus upon with some detail. The lack of adequate i
Training Department management controls, along with independent quality 4
assurance oversight, is most likely a substantial factor.
When addressing the four factors, I did not address " cheating," training, or any other specific issue. This has been intentional, because I firmly believe that the circumstances behind the events are not training (or -
testing) specific. They are fundamental and go to the heart of an organization and at least some of those individuals which it comprises.
I do not believe that the presence of any single factor or combination of factors will necessary cause events such as those at TMI. Rather, I do '
! believe that specific combinations of factors are required and did exist in this case. In this light, our goal should be to prevent the right i
combination of factors from existing in the future. The actions which we l take will determine whether improper events will occur in the future; j
either in training as cheating or in some other equally unacceptable l
i form, such as:
CONFIDENTIAL
' COW IDENTIAL i
3 August 31, 1982 -
> - R. C. Arnold 7P. R. Clark
- 1. Not reporting a serious mistake made on the job, j 2. Intentionally not following procedures, a
- 3. Falsifying logs, or i
- 4. Performing a job knowing there is a lack of knowledge or
! qualification to do it.
Before I can go on, I must assure the reader that I do not believe that the combinations of circumstances which will cause individuals to become involved in such events is pervasive throughout GPUN. On the contrary, I
- ' believe that such situations are isolated, but not necessarily limited to i any single group.
I have identified four circumstances which I believe contributed to the cheating events at TMI; I do not,believe that these are necessarily the
- only circumstances. I have also stated that I believe the cheating incident was a manifestation of the right combination of circunstances rather than the fundamental problem. With this in mind, I do have some
- l thoughts on how to minimize the possibility of recurrence of such l
problems (in any form) in the future. I do believe the foundations for 1
- some of these thoughts already exist and may only require time and/or i refining to be fully effective. Some other thoughts may require a new focus. .
With regard to training, the thought behind the establishnent of the Nuclear Assurance Division and the Training and Education Department was
! sound and does provide direct, top management visibility to the subject.
The connittment of resources to Training has been substantial. Given time and attention, I believe this organization will demonstrate the j
wisdom of that decision. Substantial, positive evidence of the success of the organization already exists. However, there are troublesome areas upon which we could focus additional attention and accelerate the l
Organization's progress. One of these areas is management control. In this light, I make the following suggestions.
- 1. The desire to provide training in a competent and professional menner has been the number one priority. In an j J envirorment where priorities must be set and work delayed due to work overload, it is quite easy for training to put off the establishment and implementation of formal management controls in favor of training. In my case, I do recognize the need for management controls and have been working towards the goal; the fact that I do not have all the desired management controls in place has been a question of priorities and time. Events, such as the TMI cheating incident, do have an influence on one's priorities: however, we are trying to do a lot of work in a short period of time, and it is not possible to cover all bases in the short run.
Possible solutions include:
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- CONFIDENTIAL 4 August 31, 1982 R. C. Arnold /P. R. Clark -
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- a. Reorient priorities and devote more time to the establishment and implementation of management controls within the Training Department.
1 b. Devote additional resources to the Training Department, on a short term basis, to establish the
' management controls. Note: this has been and is being done at Oyster Creek as one of the Training and Education Department's 1982 goals through the
, utilization of an expert testing consultant. He is, among other things, helping us establish a 1
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~ comprehensive testing program; which, when implemented, should substantially upgrade the testing program. 1
- 2. The organizational structure and concept is sound; however, events during the past two years have adversely impacted i
@on the progress of the organization. From my vantage point at Oyster Creek, I believe that the Director of Training and Education and the Vice President Nuclear l Assurance have both been very much concerned with the establishment and implementation of a training organization and program at Oyster Creek. However, their ability to 1
2 actively participate in the " foundation building" and to maintain a close awareness of the department's progress, i needs and shortcomings has been affected by the hearings at
- TMI and "Special Projects" which have been assigned to i
them. I can understand how these same If weforces couldcould find have a wayhad to i
a similar impact on TMI training.
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alleviate this problem and allow the top management to devote all of its energies to the development of their ,
organizations and implementation of those responsibilities j
assigned to them in the GPUN Organization Plan, we may find l
that there will be substantial improvements in this area.
! With regard to the subject of management controls,
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dedication of resources, the expectation of management, and the ASLB report, I am not sure where the Corporation wants l to be. Maybe one the important lessons we have learned is
- that we need to establish well defined corporate policies and standards regarding training, from which the management l controls will be developed.
i As a result of the TMI accident we stepped out into l territory which has not been occ @ ied by many organizations. We have taken this big step forward with the l help of numerous investigations, inspections, evaluations,
- and consultants. We have been given volumes of j recommonations, comments, and directives. On the other hand, we look back from time to time and observe how far ahead of the average utility we are and ask curselves i
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CONFIDENTIAL 5 August 31, 1982 R. C. Arnold /P. R. Clark ,
i if we have stepped too far. In this light, we appear to be somewhere between two standards looking for a place to rest. One of the standards appears to be that standard by which we used to operate. The other i
standard appears to be that standard which is comprised of all the l
" benchmarks of excellence" which reside in the minds of all the organizations and individuals which have investigated, evaluated, and inspected GPUN's practices since the accident. Our response to this dichotomy of standards has been largely reactive. This reactive mode of j
j operation has been caused in part by the substantial workload and routine
' priority shifting which has been thrust upon the organization. We now need the opportunity to sit back and approach the overall effort of establishing and implementing the organization, management controls, and programs in an orderly and organized fashion. As long as we are reacting to problems which develop in the various elements of the system, we may !
tend to develop piecemeal solutions which leave holes in the system that For example, we should become the breeding ground for the next problem.
j take the time to develop a comprehensive testing program which addresses all aspects of testing, such as; p'reparing test questions and tests, developing methods of test validation, developing mechanisms to secure l
tests, training instructors on how to test., developing mechanisms to 2 prevent cheating during testing, and developing mechanisms to provide feemack on test results. Looking closer, we find that testing is an 1
element of the bigger effort to assure the effectiveness of training programs. Therefore, we should first address the bigger issue of establishing a comprehensive system for assuring training program j
effectiveness, from which the smaller elements (such as testing) and subelement;s (such as cheating) will evolve. We at Gyster Creek have been approaching the management controls from this direction. I strongly
' recommend that we continue on this integrated approach, whenever possible, working from the top down rather than a piecemeal fashion from the bottom up. If timeliness is a factor, I recommend we d?dicate the i
resources necessary to meet that need.
I The stress factor is a very difficult issue which, on an individual
! basis, could be composed of a combination of very complex elements.
l These elements could be influenced by many different factors such as the l
' company, fellow workers, the community, the. family, an individual's own aspirations and goals, and a fear of failure. To further compound the '
1ssue, the average person is not equipped with the skills necessary to l identify possible problem situations and to deal with them. I believe that the company has made substantial progress recognizing the problem l and in helping our supervisors / managers address this issue. The JCP&L
- GPUN's work Employee Assistance Program accumJiated numerous successes.
l with Stress Control and the " Continuous Observation of Unusual Sehavior in the Work Place Program" are both substantial steps in the right direction. I do have some thoughts which might help improve the effectiveness of the program, expand the scope, and shorten the time period before they are fully effective.
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CONF 10ENTIAL
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COWIDENTIAL l 6 August 31, 1982 !
R. C. Arnold /P. R. Clark -
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- 1. We should make the program a permanent and integral part of :
the Corporation.
- 2. We should develop a written description of the program which is suitable for wide dissemination throughout the Organization at all levels.
- 3. We should provide more extensive training to our supervisors, managers, and other key people such as instructors. This training would make these individuals more aware of how to detect stress in individuals, what tools they have at their disposal to deal with stress, and how to utilize these tools. The training so far has been very limited and f m W more on truly aberrant behavior.
- 4. We should actually promote the program as a positive program which is designed to help perfactly normal people cope with their stress, and not necessarily a program for people with serious disturbances.
- 5. We should develop innovative ways, other than the classical one on one interviews with a psychiatrist, to help people deal with stress.
' The confidence factor, in its own way, is even more difficult than the
- stress issue. The substantial and continuous change which we are going through can easily breed a lack of confidence in one's ability to succeed in the new, unknown, and ever changing environment. There is no question that some individuals will not be able to keep up with and/or acclimate l
to the changes. A similar problem exists with the marginal individual who is brought on board. What does an individual do when they decide or determine that they cannot measure up. To some degree, the answer depends on the individual, and to some degree, it depends upon the individual's knowledge or perception of how the Corporation will respond. I have the following thoughts in this area:
- 1. We need to do a'better job of identifying the individuals who are having difficulty keeping up with the system and/or acclimating to the changes.
- 2. We need to do a much better job of screening new people for their technical ability and probability cf success.
- 3. We need to do a better job of addressing the difficulties of l weak individuals early on and providing timely corrective action, j We should establish and promote the Corporate posture of '!
- 4. !
providing all reasonable assistance to help our people succeed as well as providing an equitable solution for those l individuals who honestly cannot succeed after dedicating their best possible effort. l CONFIDENTIAL i
COW IDENTIAL 7 August 31, 1982 R. C. Arnold /P. R. Clark ,
l Possible forms that this assistance could take include:
career counseling' self help programs, educational
, l assistance, training, and reassignment to appropriate . j alternative jobs. .
J 5. We need to convince employees that they can bring their legitimate job related concerns to management, and that we will listen and take appropriate action. I have a sense that we can make a lot of progress in this area.
l 6. We should work towards minimizing the "us and them" attitude which exists within the organization.
The sensitivity factor is going to require a constant effort to help l* people understand the standards, policies, and expectations of the c corporation in a general and specific sense. We need to help people see i the " big picture" and their ispect upon it. Sensitivity is both a skill
, and an art which takes years to develop. In the specific case of cheating, all the Oyster Creek personnel have read the ASLB report of Ally 27, 1982 per your direction. I have held a department meeting on l
the ASLB report at which the bulk of the department was present. I have solicited comments and questions on the report; some have been raised and addressed. The subject is common knowledge and discussed frequently. In .'
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addition, I have had other department meetings on the administration of l exams.
t One factor which has not,been previously raised in this memo, is the one of malice. Since I have no first hand information on the TMI incident, it is not ri@t for me to speculate on this factor.
Another factor which has not been addressed is attitude. I do not look i at attitude as a root; it is a combination of factors. To establish a j specific attitude or modify an undesirable attitude, we need to address l
those factors which affect an individual's attitude such as stress, confidence, sensitivity, and direction (management control). j In conclusion, I believe that the cheating incident was a complex combination of factors which resulted in a series of events that manifested themselves through training.
I Reading the ASLB report is a sobering experience which presents a lot of :
food for thoq3ht. The Training and Education Department needs to reflect upon the lessons learned and to take substantial corrective action in all four of the areas which I discussed to minimize the possibility of recurrence in the training area. This I intend to do at Oyster Creek.
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- I have also stated that the contributing factors transcend training.
Regardless, the Corporation needs to address some of the issues as a '
global concern and must work together to correct the fundamental causes.
COW IDENTIAL f
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CO WIDENTIAL R. C. Arnold g. R. Clark 8 August 31, 1982 This memo is an effort to address a very complex issue in a summary fashion. Please contact me if'it does not adequately respond to your request. Your thoughts on this response would be ated.
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