4.0 Summary of Major DCISC Review Topics, 16th Annual Report - July 1, 2005 thru June 30, 2006
4.11 Quality Programs
4.11.1 Overview and Previous Activities
The DCISC has followed PG&E’s quality programs continuously since 1990. The DCISC has looked at the following aspects of the quality programs in Fact-finding meetings and public meetings in previous periods:
- Overview of Quality Oversight Group
- Effectiveness of Quality Performance Assessment Reports for Tracking Broken Barriers to Unsafe Operation
- Outside Review of DCPP Quality Verification Audit Program
- Quality Assurance (QA) Self-Assessments
- Assessments of Operating Experience
- DCPP Self-Assessment Program
- Annual Review of NQS Activities, Audits and QPAR
- Software Quality Assurance Program
- NQS Assessment of Refueling Outages
- Self Assessment Around SOER for Davis-Besse
- Assessment of Radiological Risk Assessment
- Quarterly Quality Performance Assessment Reports (QPARs)
- Review of Quality Verification Observations
- Update of QA Activities
NQS and Nuclear Safety and Licensing (NSAL) had been brought together into one organization, Nuclear Quality, Analysis and Licensing (NQAL). Included in the organization are Quality Verification, Problem Prevention & Resolution, and Regulatory Services.
In previous periods the DCISC has found that the quality assurance function appeared effective.
4.11.2 Current Period Activities
During the current period, the DCISC has reviewed the following quality-related matters:
- Quality Performance Assessment Reports (QPARs)
- QV’s Assessment of Plant Performance
- Quality Verification (QV) Assessments of Corrective Action Program
- QPAR Update at the October, 2005 DCISC Public Meeting
- Quality Verification Update
- Review First Quarter QPAR & QV Assessment of 2R13 Refueling
Quality Performance Assessment Reports (QPARs)
The DCISC usually reviews DCPP Quality Performance Assessment Reports (QPARs) at each of its three Public Meetings during the reporting period and at selected Fact-finding meetings. The quarterly QPAR is the Quality Verification organization’s top-level report to plant management. The QPAR includes the QV assessments of the overall plant quality performance, individual department and selected organization quality performance, and Key Station Quality Performance Issues. The assessments are color-coded as follows:
- Green
- Overall performance is satisfactory, no significant areas of concern
- White
- Performance is consistent at meeting expectations, with minor or few areas of concern for which actions are in place
- Yellow
- Areas demonstrating behaviors or events to indicate performance not meeting expectations or actions to correct have not been fully implemented
- Red
- Overall performance not meeting expectations, chronic performance problems exist and management efforts to identify and correct the problem has been ineffective
The QPAR presentations at the DCISC Public Meetings are presented below.
QPAR Update at the October, 2005 DCISC Public Meeting
Mr. Taggart reviewed at the October, 2005 DCISC Public Meeting (Volume II, Exhibit B.3) the QPAR for the period of June 30 - September 30, 2005 and summarized quality performance as continuing to improve, with plans in place to address identified major performance issues.
The areas identified as good or improving performance at DCPP for the third quarter of 2005 were 1) Human Performance, 2) Corrective Action, 3) Personal Safety Performance (Disabling Injuries), 4) Continual Unit 1 and Unit 2 Run, 5) Operations Training Re Accreditation, 6) Work Control Schedule Adherence, 7) Operation Decision Making, 8) Reactivity Management, 9) Security Protective Strategy, 10) Engineering Programs, and 11) Engineering Support of Emerging Issues.
Key Quality Performance Issues for DCPP have Action Plans associated with specific Station objectives in the DCPP Performance Plan. These problem areas included 1) Outage Preparedness and Execution, 2) Outage Extensions Due to Equipment Failures, 3) Project Cost Estimating & Coordination, 4) Learning Organization, and 5) Equipment Issues.
Actions now being implemented to improve Quality Performance include outage planning, outage contingency planning, schedule scope stability monitoring, and revision of the generic milestone template. Improvement programs are now in place to automate the Management Observation Program process and integrate results; to implement strategic benchmarking and self-assessments; and to identify CAP improving trend metrics. The Plant Health Committee was implemented in September to address longstanding equipment issues and new troubleshooting procedures have also been implemented. Security equipment maintenance issues have been addressed, as have Operations procedure quality and the implementation of the Rework Program.
DCPP Quality Performance continues to be challenged by the Emergency Response Organization’s (ERO) exercise performance and low level human performance issues in Operations. The ERO issues were the untimely and inaccurate classification of an event by the shift managers and site emergency coordinators. A Nonconformance Report (NCR) has been written and a root cause evaluation will be performed.
Quality Performance Ratings at DCPP:
- Green: (Overall performance is satisfactory, no significant areas of concern)
- Strategic Projects including the Steam Generator Replacement Project, the Used Fuel Storage Project, the NEXIS Project and the New Fuel Racks Project
- White: (Performance is consistent at meeting expectations, with minor or few areas of concern for which actions are in place)
- Work Control
- Outage Management
- Learning Services
- Procurement Services
- Projects
- Operations
- Problem Prevention & Resolution
- Chemistry
- Engineering
- Security
- Maintenance
- Radiation Protection
- Emergency Preparedness
- Yellow: (Areas demonstrating behaviors or events to indicate performance not meeting expectations or actions to correct have not been fully implemented)
- Emergency Response Organization
- Red: (Overall performance not meeting expectations, chronic performance problems exist and management efforts to identify and correct the problem has been ineffective)
- None.
QPAR Update at the February 2006 DCISC Public Meeting
Mr. Prigmore, General Supervisor for Quality Assurance, reviewed at the October, 2005 DCISC Public Meeting (Volume II, Exhibit B.3) the QPAR for the fourth quarter of 2005.
DCPP overall Quality Performance is rated as “White”, with performance continuing to improve, departments continuing to recognize gaps to top performance and having taken or currently taking actions to close those gaps, and a new, overall, sense of staff confidence as a result of successes achieved.
Areas at DCPP identified as good or improving performance were as follows:
- Good Performance
- Second best generating year in DCPP history
- Operating without automatic reactor trip since October 1997 for Unit 2 and June 2002 for Unit 1
- No forced outages in 2005, best ever for DCPP
- Forced loss rate among industry leaders
- Conservative, operational decision making process & implementation
- Improving Performance
- New Plant Health Committee
- Resolution of many U-1 long standing equipment problems following 1R13
- Management Observation Program
- Effective implementation of the Performance Improvement Governance
- No disabling injuries - new DCPP record
- Security events during outage - new DCPP record
- Restoring the NRC Drill and Exercise Performance Indicator back to “green”
- Outage performance significantly improved
- Key Quality Performance Issues for DCPP included:
- Outage preparedness and execution
- Learning Organization performance improvement for benchmarking and self-assessment
- Long standing equipment issues
- Improving collective radiation exposure to industry best
- Improving Operations Mispositioning Errors Rate/Human Performance
- Quality Performance issues removed during 2005, included:
- Outage extensions due to equipment failures
- Learning Organization performance improvement for Management Observations and Operating Experience
- Project Cost Estimating & Coordination
- DCPP Quality Performance issues followed by QV included:
- Human performance for Maintenance, Engineering and Radiation Protection
- Improvement needed to work order documentation including “as found” condition
- Repeat adverse trend of preventative maintenance tasks exceeding grace period ithout prior evaluation
- Rework identification
- Consistent troubleshooting implementation
- Scope stability factor below target the last six months
- The Planning complete metric being “red”
- An adverse trend for Emergency Preparedness (EP) equipment problems
- Restoration of Fire Protection System to “green” not planned until 2009
- A need to focus on decreasing Recordable Injuries
QV’s Assessment of Plant Performance
The DCISC met with Dave Taggart , Manager QV (Quality Verification), Jeff Hodges, Engineering QA (Quality Assurance) Supervisor, and Bob Prigmore, Plant QA Supervisor to discuss QV’s assessment of Plant Performance at the September 7-8, 2005 Fact-finding Meeting (Volume II, Exhibit D.2, Section 3.2). Results from this meeting are included in the above QPAR descriptions and are not repeated here.
Quality Verification (QV) Assessments of Corrective Action Program
This assessment is discussed in Section 4.6 Performance Improvement Programs.
Quality Verification Update
The DCISC met with Dave Taggart, Quality Verification (QV) Manager and Bob Prigmore, General Supervisor Plant Quality Assurance at the January 18-19, 2006 Fact-finding Meeting for a Quality Verification update. (The QPAR discussion is the same as that above in the January 2006 Public Meeting section and is not repeated here.
QV had been moved organizationally January 1, 2006 to report directly to Dave Oatley, Vice-President and General Manager. This was a morale booster for QV, provided them needed independence from the station organization, and eliminated any conflict between QV and the Corrective Action Program. The DCISC believes this was a positive move. QV also believed that line ownership of quality issues (e.g., assessment findings) was satisfactory at that time.
The move of QV to report directly to the Vice-President and General Manager provides the potential for independence from the line organization and top-level management support.
QV Assessment of 2R13 Outage
The DCISC Fact-finding Team met with Dave Taggart, Manager QV (Quality Verification), Jeff Hodges, Engineering QA (Quality Assurance) Supervisor, and Bob Prigmore, Plant QA Supervisor, to review the 1st Quarter Quality Performance Assessment Report (QPAR) and QV assessment of 2R13 outage at the May 4-5, 2006 Fact-finding Meeting (Volume II , Exhibit D.9, Section 3.2). (The QPAR discussion is the same as that described above at the June 2006 DCISC Public Meeting and is not repeated here.)
Mr. Taggart now reports to Mr. Jack Keenan, Senior Vice President Generation.
QV assessed Outage 2R13 performance during Windows 1 and 2 (April 17 to April 26, 2006). Overall, outage performance to date has been satisfactory. Shutdown activities went very well; RCS clean-up went well, resulting in a good reduction in source term. For example, steam generator bowl dose rates dropped an average of 12 from 2R12 to 2R13, from 4.2 R/hr. to 3.7 R/hr. Accrued dose is tracking under the estimate, and in some cases excellent focus to achieve ALARA resulted in significant reductions in expected dose.
Core off-load was performed satisfactorily, and Security logged events are trending to a new low. To date, Operations had experienced zero noteworthy errors, and clearances have been performed as scheduled.
The plant has experienced no recordable or disabling injuries during this period. (Later in the day at the Outage Meeting, one disabling injury and one recordable injury were reported. However, a number of non-recordable injuries have occurred, in addition to non-injury “close calls.” These near misses indicate that significant additional rigor and focus on safety is needed to curtail this trend.
Through the first two windows of the outage, four noteworthy errors occurred, which is a reduction from the same period during the previous outage (five). QV believes that the significant rigor and extensive management observations over the past year has resulted in improvements in work practices, and assisted management in identifying and resolving recurring problems.
It appears that Quality Verification continues to perform good assessments of outage performance of DCPP. The assessment during the 2R13 outage identified areas where improvement has been made as well as areas that still need improvement.
4.11.3 Conclusions and Recommendations
- Conclusion:
- It appears that the DCPP Quality Verification (QV) group continues to perform well in assessing the overall quality performance of the plant through their periodic audits. Their quarterly Quality Performance Assessment Reports (QPARs) are detailed and comprehensive and appear to be a valuable management tool. In some instances they have not pursued issue resolution with sufficient vigor, being unable to effectively initiate line organization response to identified issues.
- Recommendations:
- None, but see the two recommendations on Quality Verification in Section 4.9, Nuclear Safety Oversight and Review.