25th Annual Report by the Diablo Canyon Independent Safety Committee, July 1, 2014—June 30, 2015
Preface | Executive Summary
Volume I TOC | Volume II TOC | PG&E Response | Contact the DCISC
25th Annual Report, Volume I, Section 4.6, Performance Improvement Programs
4.6.1 Overview and Previous Activities
Termed “Corrective Action Program” in previous reports, this section is now expanded to “Performance Improvement Programs” to include programs included in DCPP’s Performance Improvement Initiatives, such as Corrective Action, Industry Operating Experience, Benchmarking, Self-Assessments, etc. Many consider these to be “learning” programs whereby the organization learns to improve from its and others’ experience.
As have all nuclear plants, DCPP has implemented a Corrective Action Program (CAP). The CAP is a formal, controlled process used to identify and correct problems, which occur. A key part of the CAP is root cause analysis, which is utilized to ascertain the real cause of a problem or event such that corrective action can be taken to prevent its recurrence. During the previous reporting periods, the DCISC has reviewed the DCPP CAP and numerous events, which were identified and resolved using the CAP. NRC refers to this type program as Problem Identification and Resolution (PI&R).
The events, analyses, and corrective actions reviewed during the previous several reporting periods included the following:
- Operating Experience Program
- Performance Improvement Review Board
- Trending Program
- Corrective Action Program and Self-Assessment Program Audit by Quality Verification
The DCISC concluded in the last period that DCPP’s Performance Improvement Program continues to be strengthened with the improving Operating Experience Program, Trending Program, and Performance Improvement Action Plan, a multi-faceted plan to integrate the results of several assessments and reviews of the program and by dedicated management performance improvement oversight boards such as the Performance Improvement Review Board. DCPP's Performance Improvement Program is extensive and multi-faceted. It includes identification, analysis, follow-up action, and monitoring of progress with respect to aspects of internal performance as well as to issues and strengths that are reported within the industry and that are determined to be applicable to DCPP. The station's senior managers and Quality Verification Department exercise major roles with respect to the implementation of this program.
4.6.2 Current Period Activities
The DCISC reviewed the following in DCPP’s Performance Improvement Program during the current reporting period:
- Self-Assessment Program
- PIP Performance
- Untimely Corrective Action on Containment Spray System
- Benchmarking Program
- Operating Experience Program
Self-Assessment Program (Volume II, Exhibit D.3, Section 3.3)
The objective of the Self-Assessment Program (S-AP) is to promote continuous improvement. Current performance is compared to management expectations, industry standards of excellence, and regulatory requirements to identify areas needing improvement. Self-assessments also identify strengths applicable to other station groups. DCPP has six types of self-assessments:
- Formal Self-Assessment—an evaluation of a particular program, process, system or potential problem area using a structured methodology involving scheduling, planning, one or more industry peers, a team of DCPP personnel, training, documentation in written reports and Notifications, and report-outs to management and follow-through.
- Independent Assessment—an evaluation of organizations, programs, processes, activities, potential problem areas, etc. that are routinely scheduled and performed by independent oversight groups such as QV, NSOC, etc.
- Ongoing Self-Assessment—an ongoing evaluation of performance and processes performed on a regular basis to check that standards are being achieved. These activities are performed as specified by the respective program or process requirements. Examples of ongoing self-assessment activities include: management observations, trend analyses, critiques, corrective action effectiveness reviews, etc.
- Quick Hit Assessment—a narrow, snapshot look at a specific program, process, or issue, usually of one-to-two day duration, typically performed by one or two persons.
- Recurring Assessment—an assessment having a specified recurrent frequency.
- Outside Assessment—Assessments at DCPP conducted by outside groups. However, a DCPP team lead and/or sponsor is/are typically assigned to ensure “DCPP ownership” of the process and the final product. This “ownership” is not intended to influence the objectivity or the determinations of the outside group, but rather to ensure that DCPP expectations are met.
The DCPP S-AP is described and controlled by Procedure OM15. ID4, “Self-Assessment and Benchmarking.” This procedure describes the various station responsibilities for performing, reviewing, reporting and approving the various types of S-As. It outlines the process and requirements for all types of S-As, especially formal S-As. Formal S-As are subject to effectiveness reviews approximately six months after the final S-A recommendation is complete. The Self-Assessment Review Board (SARB) reviews each effectiveness review to determine if results have been achieved as expected.
The DCPP SARB, consisting of the Site Senior Management personnel, sets the number of formal S-As for the upcoming calendar year. DCPP typically performs 10-to-15 formal self-assessments per year as well as typically 10 benchmarking trips to other nuclear facilities. The self-assessments are planned in advance for the year ahead and are carried out in accordance with the S-A procedure milestone schedule. The SA Coordinator keeps track of the progress of each S-A with the milestone schedule. Effectiveness reviews are performed on each S-A upon completion.
DCPP Self-Assessments are monitored and reported in the monthly Plant Performance Improvement Report (PPIR). The report lists all ongoing and planned formal S-As along with the lead organization/manager, milestones progress compared to pre-defined time-tables, and effectiveness review status. As of the date of this Fact-finding meeting, the overall S-AP health was reported as “Green”, i.e. Top Rating. There were a number of White ratings, each of which served to indicate that the particular milestone for the S-A had not yet become due, rather than having become delinquent. Therefore, at the time of this review the station had met every predefined milestone for the 2014 Formal Self-assessments.
Brief summaries of the station strengths and improvement opportunities are identified in the two following S-A reports:
DCPP S-A Report on Pre-NRC Inspection of Problem Identification and Resolution Function
Pre-NRC Inspection Conducted 4/21/14—4/24/14
Summary of Results
- Weekly audits of equipment deficiencies related to operator workarounds were not regularly logged as required.
- Several Prompt Operability Assessments (POAs) were not updated with required refueling outage exit justifications.
- Active POAs were not always reviewed at daily management meetings.
- Some long term POAs did not meet expectations for resolution timeliness or for documentation of justification for remaining open.
- Operability Determinations were not performed on some components leaking Boric Acid.
- A need to evaluate the administration of Prompt Operability Assessments was cited in the report.
- One reportability determination was not completed within the station’s required period of 30 days.
- The requirement to accompany Extent of Condition evaluations with Operability Determinations was not documented in the governing plant procedure.
DCPP S-A on Foreign Material Exclusion (FME) Program
Summary of Results
- FME covers for station vent piping surpassed industry standards.
- FME practices at the reactor cavity were recognized as a strength as were the knowledge of the involved personnel and the coaching they provided.
- Workers in the Spent Fuel Pool area wore loose items under their protective clothing, which is contrary to industry best practices.
DCPP’s Self-Assessment Program appears to be in continuing good health. The program administrators are knowledgeable, highly organized, and efficient. The DCISC should continue to review this on a regular basis, which means about two years hence.
Performance Improvement Program (PIP) Performance (Volume II, Exhibit D.6, Section 3.3)
As its name states the PIP is a program of performance improvement instituted to achieve excellence in nuclear plant operation and safety. DCPP and all other domestic nuclear power plants have had their individual PIPs for a long time. The nuclear industry, via INPO, issued in October 2014 a new guideline, “Conduct of Performance Improvement.” The new guideline, a significant change in the behaviors and practices for PIPs was prepared and issued to focus on prevention and to reduce unnecessary administrative requirements and take a more practical approach to PI. The new NRC-approved guideline establishes a Performance Improvement Model with the following attributes:
- Engage, Identify, Prevent—establishing a culture wherein engaged employees seek to correct adverse behaviors and conditions before problems occur as well as having a low threshold for problem identification.
- Screening—screening by a cross-functional team to identify and address the more significant issues in the existing formal Corrective Action Program (CAP) and lower-level issues would be addressed more informally by line managers.
- Management Action, Approved Process, and Corrective Action—three processes or methods to address issues (1) formally (CAP) and less formally, (2) an “approved process”, and (3) management action as the issue significance directs.
- Performance Monitoring—methods to monitor performance including self-assessments, benchmarking, observation/coaching and performance indicators to facilitate identification of problems before consequential events occur. Included here would be corrective action effectiveness reviews
DCPP has revised its overall PIP Procedure OM15.ID5, “DCPP Performance Improvement Program, Revision 9, Effective October 30, 2014”, to comply with the new guidelines. The DCISC reviewed the updated procedure and found that it appropriately complied with the new industry guide. Lower-level implementing procedures are also being revised. This, along with other actions is included in a comprehensive DCPP Performance Improvement 2015 Next-Level Actions document. The DCISC believes the new streamlined approach focused on prevention will be an improvement in reducing problems at DCPP.
Related to PIP, the DCPP human error rate and the number of Station Level Human Performance Clock Resets have been improving steadily since February 2014. The 90-day and one-year event rates are well below DCPP goals, and are rated Green. This has been due primarily to an augmented management observation program, employee engagement sessions, establishment of a Human Performance Committee to review events and make recommendations, and work stand-downs when events occur. See the human performance trend chart below.
Also, the Station Level Clock Resets, though not currently meeting goal, are showing improvement.
The DCISC believes the new streamlined and prevention-based Performance Improvement Program (PIP) approach will be an improvement in reducing problems at DCPP. Human performance has improved steadily since February 2014 primarily due to augmented management observations, coaching and counseling, employee engagement, a new Human Performance Committee, and work stand-downs following events. The DCISC should continue to follow DCPP’s PIP, especially the PI 2015 Next-Level Actions document.
Untimely Corrective Action on Gas Intrusion into the Containment Spray System (Volume II, Exhibit D.6, Section 3.9)
The DCPP Containment Spray System (CSS) provides water to a spray header high inside Containment to help limit and reduce temperature and pressure of steam following a Loss of Coolant Accident (LOCA) or Main Steam Line Accident. The CSS pump takes its initial suction from the Spray Additive Tank, which adds sodium hydroxide to the liquid to be sprayed to help reduce the pH in Containment to help retain radioactive materials.
In May 2011 a Corrective Action Program (CAP) Notification was written, based on industry operating experience, to identify the potential for gas intrusion into the suction of the CSS pumps following a LOCA. The gas would have been educated from the Spray Additive Tank following draining of the solution from the tank. A Prompt Operability Assessment (POA) was written to support continued operation. The basis for the POA was a Westinghouse evaluation that a void fraction of less than 2% would occur, which would have no deleterious impact on CSS Pump operation without compensatory actions; however, because the DCPP licensing basis is zero void fraction, it was understood that corrective action would be required to preclude any air ingestion.
The original proposed corrective action was to revise a procedure to have Operations watch the tank level and isolate it when low. This was rejected by Operations, and DCPP reviewed other options until August 2014, when the original procedure change was decided upon and would finally be made. During its Problem Identification and Resolution inspection, the NRC determined it to be a Non-Cited Violation due to the three-year delay in corrective action. The procedure change is due by March 15, 2015.
DCPP initiated an Apparent Cause Evaluation to determine the cause for the delay and corrective actions to prevent recurrence. The causes were determined to be that
- Existing DCPP processes do not address timely resolution of degraded/non-conforming conditions when an item is considered operable.
- Current DCPP Processes do not adequately consider the regulatory consequences of the long-term failure to meet licensing bases for a degraded condition.
In addition to the above-mentioned procedure change, DCPP changed its process to require Plant Health Committee quarterly reviews of all POAs to concur with the corrective action, to monitor the timeliness for implementation, and to monitor the effectiveness of the interim actions.
DCPP’s action to account for the potential for gas intrusion from the Spray Addition Tank into the Containment Spray System Pump was not timely, taking three years, hence the Non-Cited Violation (NCV) be the NRC. In actuality, the gas intrusion would not have physically caused a problem; however, it violated the licensing basis, which stated zero intrusion. DCPP had itself come close to implementing its corrective action at the time of the NCV; however, it should have been timelier in its approach to satisfy the licensing basis.
Benchmarking Program (Volume II, Exhibit D.9, Section 3.7)
Station Procedure OM15.ID4, “Self-Assessment and Benchmarking Procedure, OM15.ID4”, defines benchmarking as “a study which first identifies best practices in one or more organizations and subsequently compares DCPP programs, processes, products, and services to identify gaps, develop recommendations, and set targets to improve performance.” “Formal” benchmarking is a highly structured process that involves scheduling, planning, training, conducting a site visit by a DCPP team, documenting results in written reports, planning and tracking corrective actions, and evaluating the resultant changes. “Informal” benchmarking may consist of telephone interviews, surveys, resource sharing, attendance at industry meetings, querying site visitors, or internal benchmarking. Informal benchmarking may also include a site visit or a trip to a vendor or another plant, but without the structure of a formal program.
The station’s Self-assessment Review Board (SARB) is the governing and reviewing body for all formal benchmarking. It is a group composed of appropriate members of the leadership team to provide oversight of benchmarking schedules, plans, and results, as well as oversight of operating experience and other station programs.
Station departments have the latitude to conduct informal benchmarking without having to schedule them through SARB. These can be conducted by phone or e-mail. Also, effectiveness reviews are expected to be conducted at the department level for Benchmarking activities
As a part of DCPP’s routine correspondence, DCISC is provided with copies or summaries of various station reports and other documents, some of which report the Benchmarking activities that are conducted by DCPP. Examples of the topics of some of these Benchmarking reports that have been reviewed by DCISC during the past year are as follows:
- Feedwater Iron Strategies
- “Fix It Now” Benchmark Report
- Design Drafting and Drawing Incorporation
- Work Week “T+1” Meeting
- Functioning of the Equipment Reliability Working Group
- Evaluation of Operating Crew Performance in the Simulator
- Operations Training Program
- Pressurized Water Reactor Owners Group Procedure Subcommittee Meeting, with special focus on Emergency Operating Procedures, Severe Accident Management Guidelines, Extreme Damage Mitigation Guidelines, and Fukushima Response Support Guidelines
Information in the reports reviewed by the DCISC Fact-finding Team appeared to be clear and focused, and would be expected to be of potential help to the station.
The Benchmarking Program appears to continue being an active and productive method for obtaining information supporting the achievement and maintenance of safe and reliable nuclear plant operation. It continues to provide for formal and informal examinations of a broad range of nuclear plant performance areas. The program again appears to warrant DCISC’s review no more frequently than biennially.
Operating Experience Program (Volume II, Exhibit D.9, Section 3.8)
Industry operating experience information comes from two primary sources:
- An Industry Consolidated Event System (ICES)
- Other, including NRC, industry vendors, etc.
The former has the most extensive collection of operating event information.
The Plant receives 15–20 Operating Experience (OE) documents weekly from a variety of sources as noted above. These OEs are screened and information considered to be relevant to DCPP is transmitted to department Subject Matter Experts (SMEs) who review the material for specific applicability to their areas and determine appropriate action. The process and requirements for reviewing, screening, disseminating, and evaluating this industry OE are described and controlled by plant procedure: “Assessment of Industry Operating Experience.” In addition to receiving industry OE, DCPP also provides its own operating experience reports to both NRC and for others in the industry.
The DCISC reviewed DCPP OE Program Health for the month of February 2015 as shown in DCPP’s Plant Performance Improvement Report (PPIR), dated March 16, 2015. The health report measures the following attributes:
- NRC Industry Event Report (IER) Response Timeliness
- IER Evaluation Quality
- OE Evaluation Timeliness
- Industry Consolidated Event System (ICES) Report Timeliness
- ICES Report Completion