Dodge the Bullet Dodge the Bullet Ways to Avoid PI&R CrossWays to Avoid PI&R Cross--Cutting Cutting

Issues and CAPIssues and CAP--Related Related AFIsAFIs

1313thth Annual Human Performance Root Cause Trending ConferenceAnnual Human Performance Root Cause Trending ConferenceAugust 2007 August 2007 σσ Monterey, CaliforniaMonterey, California

Dana Cooley Dana Cooley –– SeaState Group, Inc.SeaState Group, Inc.Jack Martin Jack Martin –– Comanche Peak Steam Electric Station (Comanche Peak Steam Electric Station (LuminantLuminant))

22

AgendaAgenda

What is a What is a ““substantive crosssubstantive cross--cutting cutting issue?issue?””

What is an INPO What is an INPO ““area for area for improvement?improvement?””

Most frequent NRC and INPO citationsMost frequent NRC and INPO citations

How to How to ““dodge the bullet.dodge the bullet.””

Open discussion and questionsOpen discussion and questions

33

Who Are Jack and Dana?Who Are Jack and Dana?Tracked NRC substantive crossTracked NRC substantive cross--cutting issues since 2003.cutting issues since 2003.

Taken actions in response to INPO Taken actions in response to INPO Areas for Improvement.Areas for Improvement.

Supported plants seeking to Supported plants seeking to overcomeovercome them.them.

Supported plants seeking Supported plants seeking to to avoidavoid them.them.

44

““Substantive CrossSubstantive Cross--Cutting Cutting WhaWha’’??””

CrossCross--Cutting AreaCutting Area

CrossCross--Cutting Issue Cutting Issue

CrossCross--Cutting ComponentCutting Component

CrossCross--Cutting ThemeCutting Theme

CrossCross--Cutting AspectCutting Aspect

55

Nuclear Safety CultureNuclear Safety CultureCrossCross--Cutting AreasCutting Areas

Human PerformanceHuman Performance

Safety Conscious Work Safety Conscious Work Environment (SCWE)Environment (SCWE)

Problem Identification and Problem Identification and Resolution (PI&R)Resolution (PI&R)

66

SubstantiveSubstantive CrossCross--Cutting IssueCutting Issue

Existence of a crossExistence of a cross--cutting cutting themetheme..

CrossCross--Cutting ThemeCutting Theme: More than three NRC : More than three NRC inspection findings in one area whose inspection findings in one area whose causescausesshare the same crossshare the same cross--cutting cutting aspectaspect..

TimeframeTimeframe: Rolling 12: Rolling 12--month period.month period.

77

Anatomy of a Substantive PI&R Anatomy of a Substantive PI&R CrossCross--cutting Issuecutting Issue

Low EntryThreshold

ThoroughEvaluations

Timely, AppropriateActions

Trending

EffectiveAlternate Process

CorrectiveAction

Program

SystematicCollection

EffectiveUtilization

OperatingExperience

Frequency, Depthand Scope

Safety IndicatorTrending

Coordination,Communication, Action

Self andIndependentAssessments

Problem Identificationand Resolution

Safety Culture “Components”

Safety Culture “Aspects”

Safety Culture “Area”

1

1

12

1

1

2

234

3

88

How to How to ““QualifyQualify””

CrossCross--cutting cutting ““themetheme”” in multiple in multiple inspection findings, usually from inspection findings, usually from several several ““cornerstones.cornerstones.””

““ThemeTheme”” exists when the three exists when the three or more inspection findings or more inspection findings share the same crossshare the same cross--cutting cutting ““aspect.aspect.””

99

March 2007 PI&R StatisticsMarch 2007 PI&R Statistics

1010

PI&R Issues 3/04 to PresentPI&R Issues 3/04 to Present

0

1

2

3

4

5

6

7

8

I II III IV

1111

Most Frequent Most Frequent ““AspectsAspects””

Low EntryThreshold

ThoroughEvaluations

Timely, AppropriateActions

Trending

EffectiveAlternate Process

CorrectiveAction

Program

SystematicCollection

EffectiveUtilization

OperatingExperience

Frequency, Depthand Scope

Safety IndicatorTrending

Coordination,Communication, Action

Self andIndependentAssessments

Problem Identificationand Resolution

1212

Most Frequent PI&R Most Frequent PI&R ““AspectsAspects””

Evaluations Not ThoroughEvaluations Not Thorough –– Callaway, Fermi, Turkey Callaway, Fermi, Turkey Point, Kewaunee, Palo Verde, PerryPoint, Kewaunee, Palo Verde, Perry

Threshold (Untimely or Non SelfThreshold (Untimely or Non Self--identified)identified) –– River Bend, River Bend, Columbia, PerryColumbia, Perry

Untimely or Inappropriate ActionsUntimely or Inappropriate Actions –– Palo Verde, Cooper, Palo Verde, Cooper, Kewaunee, Perry, ANOKewaunee, Perry, ANO

Note Note –– data from new data from new andand continuing continuing PI&R crossPI&R cross--cutting issuescutting issues

1313Diagram courtesy of L. Lahti, Entergy - Palisades

1414

INPO Areas for ImprovementINPO Areas for Improvement

Performance Performance ““deltasdeltas”” from INPO 05from INPO 05--003, PI.2003, PI.2–– ““A consistent and deliberate approach to problem A consistent and deliberate approach to problem

reporting, analysis, action planning, and resolution reporting, analysis, action planning, and resolution is used to improve performance.is used to improve performance.””

–– Supported by objective evidence (e.g., Supported by objective evidence (e.g., documents, interviews, observations, performance documents, interviews, observations, performance indicators).indicators).

SelfSelf--identified (best)identified (best)

INPOINPO--identified (worst)identified (worst)

1515

““TypicalTypical”” INPO CAPINPO CAP--Related AFIRelated AFIPI.2PI.2--1: 1: ““A few performance issues have not A few performance issues have not been resolved in a timely manner, in part been resolved in a timely manner, in part because of weaknesses in the level of because of weaknesses in the level of causal analysis assigned to repetitive trends causal analysis assigned to repetitive trends in foreign material exclusion and industrial in foreign material exclusion and industrial safety practices. safety practices.

Additionally, some causal analyses were not Additionally, some causal analyses were not completed in a timely manner, and some completed in a timely manner, and some corrective actions to address these issues corrective actions to address these issues were not fully effective.were not fully effective.””

1616

Rollup of 23 INPO Rollup of 23 INPO AFIsAFIs

0 5 10 15 20

BroaderImplications

AdverseTrends

Action Rigorand Vigor

ShallowInvestigations

ManagementEngagement

1717

Management Engagement Management Engagement WeaknessesWeaknesses

Management engagement is weak in Management engagement is weak in multiple areas of the sponsorship, cause multiple areas of the sponsorship, cause determination, corrective action determination, corrective action assignment, and closure oversight assignment, and closure oversight processes. processes. Cause evaluations take place at too low a Cause evaluations take place at too low a significance level, corrective actions are significance level, corrective actions are not penetrating (especially organizational not penetrating (especially organizational and programmatic actions), and superficial and programmatic actions), and superficial or shortor short--lived corrective actions are lived corrective actions are implemented.implemented.Managers persist in acting on Managers persist in acting on ““gut feelgut feel””rather than on what the analysis tells them.rather than on what the analysis tells them.

1818

Shallow InvestigationsShallow InvestigationsInvestigations do not penetrate to Investigations do not penetrate to the level and depth warranted by the level and depth warranted by the risks embodied in the adverse the risks embodied in the adverse condition (as distinguished from the condition (as distinguished from the consequences). consequences).

Root and apparent cause Root and apparent cause determinations do not determinations do not systematically explore and describe systematically explore and describe organizational and programmatic organizational and programmatic weaknesses. Initial significance weaknesses. Initial significance level criteria may be inappropriate level criteria may be inappropriate or misapplied by CR screeners.or misapplied by CR screeners.

1919

Action Rigor and VigorAction Rigor and Vigor

Corrective action implementation and Corrective action implementation and timeliness as intended (or as needed) timeliness as intended (or as needed) are weak. are weak.

There is a relaxed approach to action There is a relaxed approach to action item closure, including presentation of item closure, including presentation of objective evidence to support objective evidence to support assertions of closure.assertions of closure.

2020

Adverse TrendsAdverse Trends

Indications of adverse trends Indications of adverse trends receive undulyreceive unduly--optimistic optimistic classification at screening, and classification at screening, and intrusive common cause intrusive common cause techniques are not applied in their techniques are not applied in their evaluation. evaluation.

There is overThere is over--reliance on memory reliance on memory and beliefs vs. factual data.and beliefs vs. factual data.

2121

Broader ImplicationsBroader ImplicationsGeneric significance is Generic significance is underappreciated or underappreciated or acknowledged too late. This acknowledged too late. This includes extent of condition and includes extent of condition and cause as well as applicability of cause as well as applicability of earlier internal and external earlier internal and external operating experience. operating experience.

The emphasis is on demonstrating The emphasis is on demonstrating uniqueness or rationalizing the uniqueness or rationalizing the organizationorganization’’s inability to s inability to anticipate.anticipate.

2222

Insights from Insights from ““SuccessfulSuccessful”” Plants Plants and Fleetsand Fleets

ExelonExelonTVA NuclearTVA NuclearFarleyFarleyComanche PeakComanche PeakGinnaGinnaCrystal RiverCrystal RiverMillstoneMillstonePalisadesPalisadesSeabrookSeabrookVermont YankeeVermont Yankee

MonticelloMonticelloBeaver ValleyBeaver ValleyFitzPatrickFitzPatrick

2323

Effective Defenses Effective Defenses -- 11

Management understands Management understands ““ramificationsramifications”” of of receiving a crossreceiving a cross--cutting issue.cutting issue.Vigorous involvement in cause evaluations, Vigorous involvement in cause evaluations, closure, and corrective action in generalclosure, and corrective action in general–– Team review (not singleTeam review (not single--manager approval)manager approval)–– Quality and timely product as committedQuality and timely product as committed–– If not, reopened.If not, reopened.

Exelon, Farley, Vermont Yankee, Exelon, Farley, Vermont Yankee, GinnaGinna, Seabrook, , Seabrook, Fitzpatrick, Beaver Valley, Crystal River, Comanche PeakFitzpatrick, Beaver Valley, Crystal River, Comanche Peak

2424

Effective Defenses Effective Defenses -- 22

Many Eyes and EarsMany Eyes and Ears–– ““Everyone questions everything.Everyone questions everything.””–– Low threshold for reporting.Low threshold for reporting.–– High worker engagement.High worker engagement.Increased training and participation.Increased training and participation.

Millstone, Vermont Yankee, Fitzpatrick, Grand GulfMillstone, Vermont Yankee, Fitzpatrick, Grand Gulf

2525

Effective Defenses Effective Defenses -- 33

Acknowledge and act on trends.Acknowledge and act on trends.–– Beat external stakeholders to the punch.Beat external stakeholders to the punch.–– Demonstrate awareness, vigor, and Demonstrate awareness, vigor, and

proactivityproactivity..

MillstoneMillstone

2626

Effective Defenses Effective Defenses -- 44

Set higher standards Set higher standards –– ““raise the barraise the bar””–– Corrective action assignment timelinessCorrective action assignment timeliness–– Root cause analysis qualityRoot cause analysis quality–– Apparent cause analysis qualityApparent cause analysis quality–– Corrective action effectivenessCorrective action effectivenessBalance against valid resource constraintsBalance against valid resource constraintsHigh equipment reliabilityHigh equipment reliability

Millstone, MonticelloMillstone, Monticello

2727

Effective Defenses Effective Defenses -- 55

Monitor the accumulation of Monitor the accumulation of identical aspects in separate identical aspects in separate findings.findings.When you see it comingWhen you see it coming……–– Acknowledge the performance problem.Acknowledge the performance problem.–– Take action to improve performance.Take action to improve performance.–– Be able to demonstrate the improvement.Be able to demonstrate the improvement.–– Communicate the plan Communicate the plan andand the improvement.the improvement.

TVA Nuclear, Palisades, TVA Nuclear, Palisades, GinnaGinna. Comanche Peak. Comanche Peak

4

2828

Our Own InsightsOur Own Insights

2929

1 1 -- Tap the Talent PoolTap the Talent Pool

Get the best possible people to serve in CAP Get the best possible people to serve in CAP and in the departments as liaisons/advocates.and in the departments as liaisons/advocates.

Don't settle for hasDon't settle for has--beens, misfits, or late career beens, misfits, or late career coasters.coasters.

Carefully examine the real talent of that OE guy Carefully examine the real talent of that OE guy or HU gal everybody loves.or HU gal everybody loves.

He or she could be sending you quietly down the He or she could be sending you quietly down the river.river.

3030

2 2 -- Acknowledge and ActAcknowledge and Act

Launch root cause analyses immediately Launch root cause analyses immediately and and ACEsACEs veryvery quickly.quickly.

Don't let the clock run while everyone Don't let the clock run while everyone tosses the hot potato around.tosses the hot potato around.

Be decisive and stick with the decision. Be decisive and stick with the decision.

3131

3 3 -- DigDigInsist that every root cause and manyInsist that every root cause and many ACEsACEsdig down to generically important issues: dig down to generically important issues: extent of condition OR the extent of cause OR extent of condition OR the extent of cause OR the ineffective previous corrective action OR the ineffective previous corrective action OR the groupthe group--toto--group effectiveness issue that the group effectiveness issue that the evaluation turns up.evaluation turns up.You don't need to findYou don't need to find one of each kind every one of each kind every time, but you must look and act. time, but you must look and act.

3232

4 4 –– Be Aware, Vigorous, and ProactiveBe Aware, Vigorous, and Proactive

Every time the NRC finds an issue Every time the NRC finds an issue before you do, launch your own before you do, launch your own separate investigation into separate investigation into howhow and and whywhy station defenses didn't pick it up station defenses didn't pick it up first.first.

That lapse by itself is a worthy problem That lapse by itself is a worthy problem statement, no matter what the technical statement, no matter what the technical details were. details were.

3333

5 5 -- CommunicateCommunicateCultivate the Resident.Cultivate the Resident. Cross cutting inputs Cross cutting inputs usually start there.usually start there.Impress him or her with the speed and efficiency Impress him or her with the speed and efficiency of your CAP.of your CAP. Show how you have captured Show how you have captured more serious items (especially budding trends) more serious items (especially budding trends) in greater quantity than he/she could ever dream in greater quantity than he/she could ever dream of doing with the naked eye.of doing with the naked eye.Show how you are using the CAP process to Show how you are using the CAP process to improveimprove the CAP process as part of daily life, not the CAP process as part of daily life, not as a grandiose action plan as a grandiose action plan

3434

6 6 –– Deploy Many Eyes and EarsDeploy Many Eyes and EarsTrain and qualify ACE evaluators.Train and qualify ACE evaluators. Really do it, Really do it, not just in a CBT or twonot just in a CBT or two--hour slide flip.hour slide flip. In many In many ways, ACE is the new root cause.ways, ACE is the new root cause.–– There just aren't enough good disasters anymore, There just aren't enough good disasters anymore,

and good people sufferand good people suffer when management assigns a when management assigns a burdensome root cause to an ordinary issue just burdensome root cause to an ordinary issue just because they feel angry that morning.because they feel angry that morning.

Send in a lightly armed commando or two for a Send in a lightly armed commando or two for a couple of days and come out with a strong ACE couple of days and come out with a strong ACE before everybody gets sick of hearing aboutbefore everybody gets sick of hearing about the the issue.issue.

3535

7 7 –– Engage ManagementEngage Management

Find the Find the ““CAP animalsCAP animals”” in your management in your management teamteam

–– Get them in the daily rag, in front of allGet them in the daily rag, in front of all--hands hands meetings, on video, at CARB/screening meetings, on video, at CARB/screening meetings, visiting the troops, etc.meetings, visiting the troops, etc.

Make CAP come alive in the offices and shops.Make CAP come alive in the offices and shops.

Let the supportive leaders stamp their Let the supportive leaders stamp their hooveshooves and shake their manes a bit. and shake their manes a bit.

3636

AppreciationAppreciationLaurie Lahti Laurie Lahti –– PalisadesPalisadesMarie Marie GolsonGolson –– ExelonExelonRichard Courtney Richard Courtney –– EntergyEntergyGreg Greg HalnonHalnon –– FirstEnergyFirstEnergySarah Glenn Sarah Glenn –– INPOINPOJoe Bell Joe Bell –– TVA NuclearTVA NuclearLori Lori StavaloneStavalone –– GinnaGinnaBrian Finn Brian Finn –– Vermont YankeeVermont Yankee

Robert Still Robert Still –– FarleyFarleyDoug Tilton Doug Tilton –– MillstoneMillstoneTherese Burnett Therese Burnett –– Crystal RiverCrystal RiverGeorge George TasickTasick –– FitzPatrickFitzPatrickBill Bill GuldemondGuldemond –– MonticelloMonticelloElaine Lentz Elaine Lentz –– SeabrookSeabrookRichard Courtney Richard Courtney –– Grand GulfGrand Gulf

3737

You, Too, May Dodge the Bullet!You, Too, May Dodge the Bullet!Questions Now?Questions Now?Questions Later?Questions Later?

Dana E. CooleyDana E. CooleySeaState Group, Inc.SeaState Group, Inc.(302) 234(302) 234--81888188seastate@verizon.netseastate@verizon.netwww.fixwww.fix--itit--once.comonce.com

Jack MartinJack MartinComanche PeakComanche Peak(254) 897(254) 897--63216321Jack.Martin@luminant.comJack.Martin@luminant.com

3838

ReferencesReferencesNRC Inspection Procedure 71152 NRC Inspection Procedure 71152 ““Identification and Resolution of Identification and Resolution of Problems,Problems,”” June 22, 2006June 22, 2006

NRC Inspection Manual Chapter 0305 NRC Inspection Manual Chapter 0305 ““Operating Reactor Operating Reactor Assessment Program,Assessment Program,”” April 4, 2007April 4, 2007

NRC Annual Assessment Letters, various datesNRC Annual Assessment Letters, various dates

Performance Objectives and Criteria (INPO 05Performance Objectives and Criteria (INPO 05--003), May 2005003), May 2005

SeaState Group, Inc. SemiSeaState Group, Inc. Semi--annual Crossannual Cross--cutting Issue Summaries cutting Issue Summaries (2003(2003--2007)2007)

SeaState Group, Inc. Survey of 30 Nuclear Power Plants, 2007SeaState Group, Inc. Survey of 30 Nuclear Power Plants, 2007