Report on Fact-finding Meeting by Diablo Canyon Independent Safety Committee (DCISC) at Diablo Canyon Power Plant (DCPP) on May 3 & 4, 2005 by William F. Conway, Member, Dr. Sheila Sheinberg and R. Ferman Wardell, Consultants [DCISC 15th Annual Report, Exhibit D.10]

1.0 Summary

The results of the May 3-4, 2005 Fact-finding Trip to the Diablo Canyon Power Plant in Avila Beach, CA are presented. The subjects addressed and summarized in Section 3 include:

May 3, 2005 (Conway and Wardell)

  1. Plant Tour
  2. Review of 230 and 500 kV Systems with System Engineer
  3. DCISC Member Meeting with DCPP Management
  4. Boric Acid Corrosion Control Program
  5. Winter Storm Activity and Responses
  6. System Engineering Program Improvements
  7. Meeting with NRC Senior Resident Inspector
  8. DCPP Reaction to the NRC Annual Assessment Letter
  9. Audit of Design Changes and Plant Modifications

May 4, 2005 (Conway, Sheinberg and Wardell)

  1. Plans for Outage 1R13
  2. Internal Organizational Consulting at DCPP
  3. DCPP Human Performance
  4. Leading for Excellence
  5. Meeting with New Vice-President of Nuclear Services

2.0 Introduction

This Fact-finding Trip to the DCPP was made to evaluate specific safety matters for the DCISC. The objective of the evaluation was to determine if PG&E’s performance is appropriate and whether any areas revealed observations which are important enough to warrant further review, follow-up, or presentation at a public meeting. These safety matters include follow-up and/or continuing review efforts by the Committee, as well as those identified as a result of reviews of various safety-related documents.

Section 4 – Conclusions highlights the conclusions of the Fact-finding Team based on items reported in Section 3 – Discussion. These highlights also include the team’s suggested follow-up items for the DCISC, such as scheduling future Fact-finding meetings on the topic, presentations at future public meetings, and requests for future updates or information from DCPP on specific areas of interest, etc.

Section 5 – Recommendations lists specific recommendations to PG&E proposed by the Fact-finding Team. These recommendations will be considered by the DCISC. After review and approval by the DCISC, the Fact-finding Report, including its recommendations, is provided to PG&E. The Fact-finding Report will also appear in the DCISC Annual Report.

3.0 Discussion

May 3, 2005 (Conway and Wardell)

3.1 Plant Tour

The DCISC Fact-finding Team took a general plant tour with Don Malone, an engineer in the DCPP Licensing and Regulatory Compliance Group. The purpose of the tour was to acquaint new DCISC Member Bill Conway with the physical arrangement and features of the non-radiological areas of the plant. The tour included a walk through the Administration Building, Turbine Building (operating deck and lower levels), Control Room, an Emergency Diesel Generator (DG) (EDG) room, cable spreading room, and other areas adjoining the walk-through areas. In the EDG Room, the Team observed a maintenance crew working in an orderly fashion on the diesel engine. Several very minor oil leaks were properly tagged for repair. The plant appeared clean and in excellent materiel condition. Signage, painted surfaces and equipment and systems appeared well-maintained. The Team noted that the “exit” and “no exit” signs were not lighted. PG&E explained that their signs are normally dark, until a loss-of-power event, when they light automatically.

Conclusion:
During the general tour of DCPP, the DCISC found the plant to be clean and in excellent materiel condition.

3.2 Review of 230 and 500 kV Systems with System Engineer

The DCISC Fact-finding Team met with Joe Goryance, System Engineer for the 230 and 500 kV Systems, to review the system design, operation and health and to tour on-site portions of the systems. The DCISC last reviewed these systems in September 2001 (Reference 6.1).

The 230 kV line provides emergency off-site electrical power to DCPP from three sources. The 500 kV lines are the pathway for power out of the plant as well as back-up emergency power.

The Fact-finding Team took a driving tour with the System Engineer of the on-site portions of the two systems. This included the lines coming in from off-site, 230 and 500 kV switchyards, and points of entry of the lines into the plant. The Team toured the 500 kV Control Room which is separate from the main plant. Transmission System Department Operators and Maintenance Technicians here work in coordination with DCPP Plant Operators on operations, maintenance and outages.

Although operated by the Transmission Department, operation of these systems is governed by a DCPP procedure (Reference 6.2) which controls and specifies DCPP operability conditions and configurations for both the 230 and 500 kV systems. Additionally, the procedure contains:

DCPP controls breakers and other components which are important to the nuclear plant according to the NRC Maintenance Rule. Responsibilities for various components and portions of these systems are contained in a procedure specifying boundaries of jurisdiction for Transmission and Distribution facilities (Reference 6.3). Mr. Goryance believed coordination between DCPP Operations and the Switchyard Operators was good. Transmission Department Switchyard Technicians must be qualified to DCPP requirements and work under a DCPP project manager or supervisor in accordance with DCPP’s Contractor Oversight Procedure (Reference 6.4).

Among others, the procedure addresses the following items:

STARS plans to perform a self-assessment of the switchyard and its interfaces with the plant in July 2005, and INPO plans to evaluate switchyard/plant interfaces during its next evaluation. The DCISC should review both of these evaluations with DCPP.

The DCISC Fact-finding Team understood that the quality oversight for Transmission Department work in the DCPP switchyard is that performed periodically by the System Engineer (SE). The DCISC also understands (see Section 3.5 below) that changes in the SE Program will make the SE less responsible for day-to-day oversight of modifications and maintenance of his/her systems. The DCISC believes that this may lead to a lapse in quality oversight and recommends this situation be reviewed in the STARS self-assessment.

The DCISC Fact-finding Team received and reviewed the system health cards for each system which reported system health as follows:

230 kV System Health Card

  1. Performance Indicators
  1. Performance Indicator Discussion:
  1. SSCs in MR (a)(1) Status: None
  1. Scheduled Major Maintenance or Modifications
  1. System Team Comments, Concerns and/or Issues
  1. System Trends and Margin to Design Limit Concerns
  1. NRC Issues/Self-Assessments/OEA/Engineering Analysis

500 kV System Health Card

  1. Performance Indicators
  1. Performance Indicators Discussion:
  1. SCs in MR (a)(1) Status & Critical Equipment Failures: None
  1. Scheduled Major Maintenance or Modifications
  1. System Team Comments, Concerns and/or Issues
  1. System Trends and Margin to Design Limit Concerns
  1. NRC Issues/Self-Assessments/OEA/Engineering
Conclusion:
The 230 and 500 kV systems appear to be in good health, and the System Engineer appears to be knowledgeable of the systems and on top of trends and issues. It appears that quality oversight of switchyard work is performed only periodically by the System Engineer. This is a concern to the DCISC.
Recommendations:
DCPP’s July 2005 STARS self-assessment should include a review of the quality oversight of switchyard work by DCPP and non-DCPP (e.g., PG&E Transmission Department) personnel.
Basis for Recommendation:
The DCISC understands that currently the only quality oversight applied to DCPP switchyard work is that performed periodically by the System Engineer. That, in itself, appears marginal. Also, in general, System Engineers’ responsibilities are changing to focus more on engineering and less on oversight of maintenance and modification work, thus possibly reducing the current “periodic” quality oversight of switchyard work.

3.3 DCISC Member Meeting with DCPP Management

Mr. Conway met with Jim Becker, Vice-President and Station Manager, DCPP, to discuss items reviewed in the Fact-finding meeting and other items of interest.

3.4 Boric Acid Corrosion Control Program

The Fact-finding Team met with Jim Hill, an Engineer in the Engineering In-Service Inspection Group and new BACC Program Owner, for an update on the Boric Acid Corrosion Control (BACC) Program. The DCISC last reviewed BACC in July 2003 (Reference 6.5)

Leaks from nuclear systems containing boric acid can cause unwanted corrosion of carbon steel components. The industry experienced enough boric acid leakage issues prior to 1988 to cause NRC to issue Generic Letter 88-05. This prompted the first formal BACC Program at DCPP. This was followed by additional NRC bulletins, including those issued in 2003 following the Davis-Besse reactor vessel corrosion event and South Texas discovery of boric acid leakage in its reactor vessel bottom head in-core instrument lines.

DCPP developed its plant leakage procedure (Reference 6.6) following leakage it discovered and NRC GL 88-05. This procedure provides a standardized method for reporting and tracking leakage of any fluid or gas from systems at the plant. The procedure, used in conjunction with others (e.g., BACC), discusses DCPP’s commitments to NRC GL 88-05. It provides guidance for responses to leaks from the ECCS post-LOCA recirculation flow path outside of containment and responses to other leaks as well. Each leak is identified in an Action Request (AR) and evaluated and corrected with the Corrective Action Program (CAP).

DCPP’s BACC procedure (Reference 6.7), developed in mid-2003, provides a comprehensive BACC Program to address boric acid corrosion concerns associated with the reactor coolant pressure boundary and other primary systems containing boric acid. The procedure addresses the following:

The procedure appeared comprehensive and satisfactory.

Each leak is identified and tracked with an AR and is added to the Boric Acid Leaker List Database. The list includes the leaking component, applicable AR (or “walkdown” – see below), system, location, leak rate, a contact, and, in most cases, a link to a photograph. As of May 3, 2005 the list contained 519 identified leakers. This number of leakers seemed very high to the Fact-finding Team; however, essentially all of these were classified as “minor” or “very minor” or exhibiting “dry boric acid” on valve packing, followers or caps. [Also, see audit finding #4 below regarding lack of maintenance of the list.] All were being tracked and corrected with ARs or monitored by “walkdowns”, in which case they are included on the system engineers’ walkdown lists. DCPP has found no significant boric acid traces from its inspections of the reactor vessel upper or lower head connections.

Following the INPO Primary Systems Integrity Review at DCPP in mid-2003, PG&E did the following:

The DCISC should monitor the reactor vessel head replacements.

The BACC Program structure includes the following:

Current projects in BACC include:

DCPP Quality Verification (QV) performed an assessment of engineering programs, including BACC, in March and April 2005. Four potential vulnerabilities identified in the prior 2003 assessment were described as follows:

  1. The issue regarding the need for excellent communication and interdepartmental teamwork has been adequately addressed.
  2. The Alloy 600 issue, identification of all material in the plant, was still incomplete, and had been rescheduled 12 times with a completion date of April 30, 2006.
  3. The BACC Program Health Report was six months old in 2003, and the current one (October 21, 2003) is further out-of-date.
  4. Lack of maintenance of the leaker list is considered a significant issue because it contains out-of-date and incorrect information. This was determined to be a Finding with an AR initiated.

A new issue was identified: the failure to issue the required program reports and metrics. ARs were initiated for these procedure violations. QV stated that the BACC Program’s biggest issue, the program being driven from the bottom up, rather from the top down. The new Vice President, Nuclear Services is interested in BACC. The DCISC should follow this closely.

It appears that BACC program management has not been fully effective. A new program manager, Mr. Hill, with whom the Team met, is now in place and appears to be addressing these issues. The DCISC should follow up on each of these items.

Conclusion:
With exception of former ineffective program management which has now been addressed with a new Program Manager, the DCPP Boric Acid Corrosion Control Program appears satisfactory. DCPP has found no significant boric acid leaks on the reactor vessel upper or lower head connections. DCPP has identified over 500 boric acid leakers throughout the plant. Although classified as minor leakers, this number seems high to the DCISC. The DCISC notes that actions have been begun to review the list as a result of a Quality Verification assessment.

3.5 Winter Storm Activity and Responses

The Fact-finding Team met with Steve David, Operations Services Manager, to review this past winter Pacific Ocean storm activity and how it affected the plant. The DCISC last reviewed this subject in July 2004 (Reference 6.8).

Due to its location on the Pacific coast, DCPP is susceptible to winter storms. The storms consist of large high-energy waves and accompanying kelp and other floating debris. Large amounts of debris can foul or block condenser cooling water intakes, depriving the condensers of full cooling water and causing the plant to curtail power or shut down.

DCPP has an intake management program with the following goals:

DCPP’s controlling storm procedure requires that the impact of a coming storm be evaluated and plans made for placing the plant in the best position to meet the goals described above. Operations compiles an evaluation summary containing the following information:

Plant impact potential & rating (0-10.0)

Historically similar events

Team recommendations

The procedure includes a set of guidelines for actions to be taken and equipment required for service based on storm conditions and debris availability. In previous years, DCPP operators have taken prudent actions to protect the plant and avoiding negative safety impacts.

DCPP experienced the three following major storms during the 2004-2005 winter season:

  1. November 4, 2004 storm with an overall impact rating of 7.5 with “high” debris loading – the units both remained at full power.
  2. November 12, 2004 storm assigned an impact rating of 7.5 with a “high” debris loading. Operators kept both units at 100 power.
  3. March 9, 2005 storm with an initial expected impact of 9.6 and moderate debris loading caused operators to prepare for reductions in power of both units to 25. Reactor Engineering prepared a 100-25-100 power ramp plan, and operators practiced a rapid reactor shutdown from 25 power on the simulator in case full shutdown became necessary. Later analysis with updated lessened conditions (impact reduced to 7.9) allowed operators to maintain both units at 100 power.
Operations utilized the formal “Operational Decision Making Process” to review storm conditions, determine available options, reach a conclusion, and document the process. The process appeared sound. The process consisted of the steps summarized below:
Issue:
intense and rapidly moving mid-Pacific storm with hurricane force winds has generated a very long-period and powerful westerly swell.
Purpose:
to determine if there is a need to ramp unit 1 and unit 2 to approximately 25 power in anticipation of a high swell warning and a challenge to the intake screens and main circulating water pumps.
Description of Problem:
[detailed description of the issue not repeated here]
Alternative Solutions:
1. Leave both units at 100 power and ride out the swell (based on past results)
2. Make a decision to ramp both units to 25 power now
3. Postpone a decision until a conference call at 0100 on 3/9/05
4. Proceed with a plan to ramp both units to 25 power. Conduct a conference call at 0100 on 3/9/05 to validate the data. A new decision will be made if the numbers change significantly.
Decision:
Option 4 (above)
Monitoring & Backout Criteria:
Better data to be available when the swell reaches the next ocean buoy shortly after midnight. Conference call to be held at 0100.
Communication:
Ops Director to send e-mail with the decision to all plant personnel. Control Room to make a PA announcement at 1645 to alert plant personnel. Power Trading to be notified of ramp schedule. Expected return to power should be around 0900 on 3/10/05.
Training & Planning:
Crew in training to relieve the day shift control room staff shortly after 1700, when both unit 1 and unit 2 control room teams will practice a rapid reactor shutdown from 25 power [on the simulator].
The decision-making process report appeared comprehensive and well thought out.
The Ramp Procedure contained the following [in summary]:
Ramp plan parameters:
Starting power: 100 RTP
Target power: 25 RTP
Cycle exposure: 11060 MWD/MTU
100 steady State boron Conc. ~892 PPM
Start time: 3/9/05 03:00
Planned Duration: 37 hours (100 to 25 to 100 RTP)
Ramp Details [details not repeated here]
Sequence of events
Reactivity control summary table (hour-by-hour table of target power [], ramp rate [MWe/min], boric acid [gal]. primary water [gal], and rod position [steps]
Control Bank D insertion prediction vs. rod insertion limit vs. power curves
Normalized Delta I vs. power curves
Boric acid (integrated gallons) vs. power curves
Primary water (integrated gallons) vs. power curves
Xenon worth (ppmB) vs. power curves

The Ramp Procedure, based on BEACON (Best Estimate Analyzer of Core Operations Nuclear) computer code runs, was detailed and comprehensive.

Conclusion:
Although none of the three 2004-2005 winter storms caused DCPP power reductions, one initially had the potential to do so. The decision-making process and logic used by station personnel to analyze and decide what action to take appeared sound, conservative and effective. 

3.6 System Engineering Program Improvements

The DCISC Fact-finding Team met with Pat Nugent, Supervisor of NSSS Engineering and Program Manager for the System Engineering Program (SEP), to review recent changes in the DCPP SEP. The DCISC last reviewed SEP in September 2001 (Reference 6.9).

As a result of the 2003 INPO evaluation and a SE self-assessment in early 2004, DCPP initiated a SE Improvement Plan as summarized below.

Improved system health cards
Added performance indicators for Operating and Design Margins
Added discussion of actions needed to achieve Green status
Added system trends and margins to design limit concerns
Making health cards consistent (guidelines in SE Handbook)
New criteria (from benchmarking) for system health
Increased management awareness
Weekly presentations on several yellow, red and chronically-white systems by SEs to Officers and Directors and outage coordinators [it was noted this was particularly helpful in providing resources to solve long-standing Fire Protection piping corrosion problems and the CFCU anti-rotation problem]
System Engineer Center of Excellence
formed to better determine SE roles and responsibilities. A new set of SE roles & responsibilities is expected in May 2005. DCPP is headed in the direction of increasing SE focus on the engineering and health aspects of systems and decreasing focus on overseeing maintenance and modification work.
Improved SE system walkdowns
developed a new template from the INPO generic list, added housekeeping and RP considerations, and will have the SE’s manager periodically accompanying the walkdown team.
Improved trending reporting
new tools such as a computer code enabling the SE to pull up the system schematic from the plant computer to obtain specific component/system data trends. Also available for SE use is a quarterly reliability report showing adverse trends.
System Engineer notebooks
this administration burden has been eased with a computer-based tool
More involvement by the SE on the Preventive Maintenance Program in providing judgments on need, frequency, etc.

The Component Cooling Water Health Card was used as a discussion example of improved system health cards. It reported system health as follows:

Component Cooling Water System health

1. Performance Indicators
System Color Indicator: Unit 1: White Unit 2: White
Operating/Design Margins*: Unit 1: 4 Unit 2: 1
*(See 230 kV System above in Section 3.2 for a description of these margins.)
2. Performance Indicators Discussion: The following actions are required on Unit 1 to restore the system to green status:
A high-cycle fatigue situation caused a crack on RCP 1-3 upper bearing lube oil cooler. Immediate corrective actions have been completed. A contingency design change has been approved to relocate or remove the tuning mass installed on the CCW line. Another design change has been authorized for 1R13 to modify the pipe routing and pipe supports.
Leak Repairs – Valve CCW-1-FCV-307 operator has an air leak on the side. The air leak does not prevent the valve from operating. The AR is due to be completed by 8/27/05.
Degraded Reactivity Control Components – Valve CCW-1-TCV-130 shows movement with temperature decreases; however there is no detectible change in reactivity during this transient. Action Request completion is due 10/14/05.
3. SSCs in MR (a)(1) Status & Critical Equipment Failures: The Unit 1 CCW butterfly valves experienced several MPFFs due to seat leakage. Loss of train separation due to incorrectly set valve stops was the basis for the (a)(1) status. Corrective action consisted of a testing program for valves relied upon for header isolation.
4. Scheduled Major Maintenance or Modifications Maintenance outage windows:
CCWPP 11 4/18/05
CCWPP 22 5/9/05
CCWHX 21 6/13/05
CCWHX 22 6/6/05
5. System Team Comments, Concerns and/or Issues:
- Ineffective chemistry control – biocide-resistant bacteria has flourished in the molybdate/nitrate-treated CCW systems. Coolant is replaced by performing a system feed-and–bleed. Over time the system can develop microbiologically-induced corrosion (MIC). Side-stream filtration and removal of dead legs will aid in effectively controlling microbiological activity. NCR N002196 was written to address the bio-fouling issue.
6. System Trends and Margin to Design Limit Concerns:
None
7. NRC Issues/Self-Assessments/OEA/Engineering:
The 2003 INPO evaluation identified routine performance monitoring of CCW heat exchangers as an AFI. DCPP has successfully completed testing on both CCW HXs pre and post 1R12 & 2R12. Both CCW HXs will be tested prior to an outage.

The system health reports are issued quarterly. The Fact-finding Team requested, and Kent Oliver agreed, to include these in the regular DCPP document package sent to DCISC.

INPO reported at its mid-cycle review that it saw improved SE advocacy at DCPP. Mr. Nugent is working to get more Operations and Maintenance personnel at SE Meetings.

Overall, these to appear to be constructive changes. The DCISC should continue to follow up on a regular basis.

Conclusion:
The DCPP System Engineering Program appears to be satisfactory and improving. It is being supported by increased management attention and resources. There is good potential for improved system health with these improvements. The System Engineering Program Manager appears knowledgeable and dedicated to maintaining a strong program.

3.7 DCISC Meeting with Senior NRC Resident Inspector

The DCISC Fact-finding Team met with NRC Senior Resident David Proulx for an update on NRC activities and positions on DCPP. The DCISC last met with the NRC residents in July 2004 (Reference 6.10).

Mr. Proulx reported that he will be leaving DCPP in mid-June for a position in the Arlington Texas Regional Office. His replacement was already at DCPP.

He commented that the NRC had closed the substantive cross-cutting issue on Human Performance as DCPP has the right tools in-place, is headed in the right direction, and has the potential for sustained good performance.

The other cross-cutting issue, Problem Identification and Resolution (known at DCPP as the Corrective Action Program [CAP]), remains because the DCPP CAP did not have the characteristics of a mature and sustaining program, according to the NRC. DCPP has the right tools and the Corrective Action Review Board (CARB) is an improvement; however, DCPP needs a cultural change, i.e., plant employees must accept and practice the new program in a sustaining way, not treat like a “program of the month”. As an example of CAP weakness, long-standing equipment issues, such as ECCS voids, pressurizer safety valves, and CFCU reverse-rotation, linger too long. PG&E is beginning to address these and similar items.

Conclusion:
The NRC Senior Resident reported that NRC removed one substantive cross-cutting issue, human performance, but left the remaining one on corrective action because he did not consider it a full part of DCPP culture and did not yet appear sustaining.

3.8 DCPP Reaction to the NRC Annual Assessment Letter

The DCISC Fact-finding Team met with Stan Ketelsen, Manager of the Licensing and Regulatory Compliance Group, to review DCPP’s reaction to the NRC Annual Assessment Letter.

The NRC continuously inspects nuclear power plants with its on-site resident inspectors and visiting specialist inspectors. Additionally, nuclear plant operators must report to NRC any events or problems which meet prescribed criteria, such as violations of plant technical specifications and NRC regulations. Plants are measured by NRC Performance Indicators (PIs). All of the above are used by NRC to gauge overall plant performance in meeting NRC regulations. NRC issues an annual assessment letter describing each plant’s performance for the prior year. It also holds a public meeting in the vicinity of the plant to report plant performance to the public.

The March 2, 2005 letter reported that:

“Overall, Diablo Canyon operated in a manner that preserved public health and safety and fully met all cornerstone objectives. Plant performance for the most recent quarter, as well as for the first three quarters of the assessment cycle, was within the Licensee Response Column of the NRC’s Action Matrix, based on all inspection findings being classified as having very low safety significance (Green) and all PIs indicating performance at a level requiring no additional NRC oversight (Green).”

NRC had identified two substantive cross-cutting issues in its previous annual assessment letter: (1) human performance and (2) problem identification and resolution (PI&R). The first, human performance was attributed to instances of operations and maintenance failing to ensure procedure quality or failing to follow procedures. During this assessment period, NRC concluded that improved performance was a result of implementation of the DCPP Human Performance improvement Plan.

The second issue, PI&R, was attributed to degraded conditions identified by PG&E in which the extent of condition was not always fully addressed. In addition, there were examples of long-standing degraded conditions as well as conditions previously identified by industry operating experience that were not sufficiently addressed. These issues also involved inadequate root cause and problem analysis.

NRC recognized that improvements in the DCPP CAP had been made but not enough to remove the cross-cutting issue in this cycle. Specifically, long-standing degraded conditions and the inadequacy of evaluations continued to be identified, and CAP improvements have not been implemented in a manner to assure continued improvement.

PG&E has developed a plan to further improve its CAP and address NRC’s concerns. The plan includes the following:
Resolve long-standing equipment issues under a focused Non-conformance report (NCR)
Improve the adequacy of cause evaluations
Training on Apparent Cause Evaluations and Root Cause Analysis
Corrective Action Review Board (CARB) focus on root cause grading
Revised Technical Review Group (TRG) process into focused Root Cause Teams
Sustain continued improvement
Enhanced metrics to drive continuous improvement
Institutionalize Performance Improvement structured program
Review of performance metrics at Manager and Director level for line ownership
Oversight review meetings chaired by the Vice-President & General Manager, Dave Oatley

The emphasis in this plan is on line ownership. The NCR is intended to address cultural, organizational and programmatic issues. This is an important program for DCPP, and the DCISC should closely follow its progress.

Conclusion:
The NRC has closed the human performance substantive cross-cutting issue but has kept open the issue on problem identification and resolution. The DCPP recovery plan appears appropriate to bring about the needed improvements by addressing not only programmatic, but also cultural and organizational aspects.

3.9 Audit of Design Changes and Plant Modifications

The DCISC Fact-finding Team met with John Hill, auditor in Quality Verification, to review the recent (July 7, 2004 – February 10, 2005) audit on design Changes and Plant Modifications. This type of audit is performed every two years. The DCISC last reviewed this subject in April 2002 (Reference 6.11).

The audit found the Design and Modification Process to be satisfactory in that

“ . . . appropriate design change vehicles are used, individuals preparing and reviewing designs are appropriately qualified, acceptable Design Change Evaluations (DCSs) are documented, independent technical reviews (ITR) of designs were not performed by engineering supervisors, appropriate Post Modification Testing was specified, and required plant design and licensing documents were updated.”

Acceptable corrective actions were documented by Engineering for items identified in previous design audits and assessments.

In the current audit there were no findings issued, but eight minor quality problems were identified as listed below:
DCM changes associated with locking SG tube support plates were not being tracked by either the design change or license amendment process.
Two N-MODS were implemented without work orders: (1) replacement of abandoned-in-place equipment and (2) modification of a portable ramp.
There were documentation errors identified in the Subcooled Margin Monitor Replacement design change.
Two Action Requests were reviewed and approved without containing required design information and design approval.
There were three ARs with LBIE screens that were developed from an earlier screen form than what was effective.
The component database setpoint screen had not been updated twice for setpoint change ARs.
A Service Air OVID had not been updated for a temporary modification.
A RCS Makeup Flow Deviation Alarm setpoint was implemented on the Simulator before being implemented on Unit 1.

These items are being tracked through corrective action with ARs. QV believed that appropriate Engineering action was being undertaken to resolve the issues, which included program improvements to ensure the current effective versions of various forms are utilized or otherwise identified when preparing designs, and to better communicate simulator changes associated with plant modifications.

At Engineering’s request the audit team reviewed the increase in Field Changes (FCs) issued by Engineering during 2004. Although the use of FCs is normal, the number of FCs can be a measure of Engineering rework and inefficiencies.

The audit team determined that the increase was due to the following:
An increase in the number of designs and design changes issued during 3Q03, 4Q03 and 1Q04
The electrical discipline issued the most FCs and the most designs.
Two practices increased the likelihood of increased FCs:
Issuing design changes for implementation on the second unit before completing the same change on the first unit
Approving design changes with preliminary calculations
For design changes for multiple components a single design correction or adjustment resulted in an FC for each component.
The conclusion was that there had been no unusual reason for the increased FCs.
Conclusion:
The audit of engineering design changes and plant modifications appeared thorough. The auditing organization, Quality Verification, concluded that the Design and Modification process was found to be satisfactory.

May 4, 2005 (Conway, Sheinberg and Wardell)

3.10 Plans for 1R13 Outage

The DCISC Fact-finding Team met with Brand Hinds, Unit 1 Outage Coordinator, to review plans for the upcoming 1R13 outage. The DCISC last reviewed outages at its February 16-17, 2005 public meeting (Reference 6.12).

The outage is scheduled to begin October 24 and continue for a total of almost 39 days. Goals are:
Power ascension @lt;6.0 days
100 power @#62;30 days
Cost @lt;$38 million
Schedule @lt;39 days
Industrial safety Zero disabling injuries
Radiological safety @lt;120 Rem (100 Rem stretch)
Nuclear safety 1. No challenges to decay
heat removal
No significant equipment Damage
No significant Security Events
Human Performance No significant human performance events
Outage objectives are as follows:
Zero recordable injuries
@lt;30 security events
Breaker-to-breaker run
Zero plant clock resets
Zero reactivity events
Zero safety schedule changes reducing level of Safety
Plan defense-in-depth		 100 outage scope CMs completed
All 1R13 quality problem actions completed
All 1R13 commitment actions completed
No main condenser salt in-leakage on restart
DCPP is paying special attention to human performance in 1R13, including participation by the line organization. Areas of focus are:
Identification of new/different/complex tasks
Identify subject tasks and owners
Each targeted task to have a success plan including HP/OE/Safety/Procedure Sanity/Control of non-station personnel
Review of Engineering-owned activities for HP oversight
Station HP awareness for outage
Identification of error-likely situations
Outage HP foundations: procedure/electrical safety verifications
Control of non-station personnel
HP Center
Material condition
Identify group population/schedule HP Center training
Departments to provide HP coaches
HP Coordinators to train HP coaches
Outage Tools
HP binders for MS/OPS/CHEM/RP/ENGR
HP Awareness Bulletins
Daily POD message
HP Hotline for assistance in emergent work tailboards
Observation Program (“First 5 Days”)
Massive numbers of observations by managers in plant
Assigned observations with prescribed observation criteria
Identify trends and barriers: communicate trends/break down barriers
Outage Phases: Verifications/Electrical Safety/ Procedure Use/Testing
Line Ownership for Error Trending & Intervention
Early analysis & identify error trends by COE Reps Managers & Director
Trending occurs at section level; report outs at COE meetings Becker
HP Coordinators Role
Heavy OPS & MNT involvement: tailboards/observations/ worker behaviors/on-the-spot package documentation reviews
Event Investigations, emergent work HP tailboards
OCC meetings as applicable to plant evolutions/OCC visual aids, updates

Major outage scope items include:

Reactor vessel head inspection
Reactor vessel 10-year ISI
LP retrofit project
PDP replacement
RCP 1-2 internals replacement
Feedwater piping replacement
RCP 1-4 motor 10-year overhaul
CCW header isolation valves
Main condenser Plastocor coating
Repl. 4kV bus E&H door hinge wiring
4kV Bus H feeder cable replacement
SG primary eddy current testing
Incore thermocouple cable repl.
CFCU anti-rotation device modif.
CFCU drain collection piping repl.
500kV Breaker 532 replacement
Firewater deluge piping replacement

Critical path items are the RCS 10-year ISI and RCP work.

At the time of the Fact-finding meeting all outage readiness milestones to-date (19-out-of-56) were Green, meaning the plant was prepared at this stage for the outage. DCPP did not yet have data for the next milestone for all modification designs to be issued by April 29, but Engineering believed they were on track to meet this. PG&E plans to bring in an INPO Readiness-for-Outage Team in August for review and assistance.

PG&E believes that the radiological safety goal is particularly challenging. It will require the same effective source term reduction and work practices used in outage 2R12 and continuation of the ~20 reduction in source term achieved in each of the past several outages. RCS cleanup will require careful pH control, controlled shutdown chemistry control, and use of the same new resin as used in 2R12.

Conclusion:
DCPP has a large-scope outage in Outage 1R13 with challenging goals; however, their plans to meet the challenge look appropriate, especially the large emphasis on human performance and dose reduction. As of early May 2005, DCPP was on-schedule with outage preparation activities.

3.11 Internal Organizational Consulting at DCPP

The Diablo Canyon Independent Safety Committee (DCISC) Fact-finding Team met with Mr. Pierre Dube, the new Senior Organizational Development Consultant for Diablo Canyon Power Plant (DCPP).

This was the first meeting for the DCISC Fact-finding Team with Mr. Dube. The meeting covered a wide range of areas including Mr. Dube’s expertise, his roles and responsibilities, his impressions of DCPP, an agenda for the latest leadership meeting and its outcomes, the extensive strategy for “Changing a System,” which has recently been developed and is being introduced to Diablo Canyon, and individual leadership development processes being institutionalized at the plant.

Mr. Dube comes to DCPP from a career as an independent consultant working across a wide-range of businesses and organizations. In the utilities and nuclear arena, he has worked with Northeast Utilities and specifically worked at Millstone, Seabrook and Connecticut Yankee. In his work with Northeast Utilities, he presented himself as a facilitator of change (at a time of great change for Northeast Utilities) and a prime partner in the development of a leadership development program.

Mr. Dube also spoke about his work as a change agent at American Express, involved in numerous change efforts, and a partner in launching the “New Blue Card.”

As to why he came to DCPP, he said that DCPP had contacted him, he interviewed, he was favorably disposed towards the organization, and decided to shift from an independent consultant to an internal consultant, employed full-time by DCPP, reporting to Dave Oatley, Vice-President and General Manager. He took the job at DCPP was because he was quite favorably impressed with the people that he met during the interview process.

Regarding roles and responsibilities at DCPP, he saw himself as a critical change agent, facilitating change throughout the organization. He saw his work as helping the organization focus on what to change, how to change, defining a process for system-wide change, coaching throughout the organization on change-related issues, and focusing as a sort of “glue ware” to integrate the changes taking place at DCPP. Mr. Dube said he hoped to create an infrastructure throughout the organization, as he worked one-on-one and by request, to build a knowledge base and a set of actions to facilitate organizational and leadership development.

Mr. Dube has crafted a Guide & Toolkit for “Change Leadership.” The Guide is designed to be shared across DCPP to facilitate both individual and system-wide change, and focuses on the “Critical Stages to Changing a System.” The Model used is a 4-Phase System with an opening Pre-Phase. (Reference 6.13)

The Pre-Phase System begins with “ideas on why change and what better looks like.” It is during the Pre-Phase that natural leaders emerge, dissatisfaction grows with the status-quo, benchmarking begins to look at other possible passive action, and impassioned leadership steps up to move into action. This Pre-Phase to “Changing a System” requires an effective communication plan (which is outlined in the Guide).

He believes that DCPP is an organization of people who are caring and committed to excellence. Mr. Dube portrayed the leadership at DCPP as “willing partners” in the change efforts at DCPP. Mr. Dube meets with Mr. Oatley, Vice President & General Manager DCPP, every other week to discuss the best ways to integrate change efforts at DCPP, from the most senior leadership to the supervisory level.

Mr. Dube outlined a number of efforts for improvement now underway at DCPP ranging from Operations Improvement Strategy, owned by Mr. Paul Roller, Operations Services Director, DCPP, to a new program being instituted for frontline supervisors (Reference 6.14). The DCISC should review this initiative in a future Fact-finding meeting.

Regarding a coherent, integrated strategy to connect and lead all of the changes taking place at DCPP, he said that there was not such a strategy or program at this point, but was the focus of future efforts. The 2005 Performance Plan, a rolling 18-month plan, to be reviewed again in July 2005, would ultimately be based on very long-term goals and objectives, leading to an overall integrated plan at the end of 2007.

There was a discussion about change management and leading change. Mr. Dube projected change management as something that occurs on a continuous and daily basis. Everyone is involved in process improvement, in learning, and in doing a better job. Leading change is a more systemic, system-wide change initiative.

PG&E Corporation has begun a “Corporate Transformation” which would likely affect DCPP. The DCISC should review the applicability of this program to DCPP with Mitch States, the DCPP liaison for this initiative.

Additional roles and responsibilities included efforts to coach one-on-one throughout the organization as different organizational entities confronted their individual changes. He is helping the leadership look as far down the road as possible as it planned for the future. The illustration he gave is, “when you first learn to ski, you watch the tip of your skis – as you become a more experienced skier, you watch the terrain.” Mr. Dube said he is at DCPP to help the leadership learn to see the terrain.

There are a number of change initiatives that were taking place at DCPP. “Crucial Conversations” is a mechanism for facilitating dialogue, enhancing communication across DCPP. “Crucial Conversations” is being provided first for the Directors and Officers so that the leadership can create a context to use the conversations and the training throughout DCPP. Mr. Dube believes that this program is a positive intervention, and will go a long way to changing the culture to a more open, problem-solving, communicative culture than it has been in the past.

Mr. Dube, who attends DCPP Officer/Director Team Meetings, was asked to provide an Agenda and some insight into the Officer/Director Meeting. Mr. Dube provided the objectives of the March 18, 005 Officer/Director Meeting Objectives and Agenda.

The Objectives included:
Determine what actions are required after INPO site visit
Share results of Nuclear Safety Culture follow-up to gain a common understanding of strengths or vulnerabilities
Share results of Supervisor Effectiveness Assessments to understand Supervisors issues
Gain alignment on what an Operations-Led Culture means in daily work
Gain alignment on INPO 9 Block Management Model, determine vulnerabilities and actions to minimize them, and how we want to lead as a team
Determine agenda for March 24th 2005 Meeting

In reviewing the Agenda, it appears the DCPP Officers/ Directors Meeting is an opportunity for sharing information, engaging Officers/Directors in conversation, joint problem solving, learning, and making recommendations to DCPP.

Mr. Dube discussed the individual leadership development process. He said senior leaders had completed a 360@deg; feedback process, received feedback, developed Individual Development Plans (which he was not privileged to see), and were beginning to engage in a second round of 360@deg; surveys and evaluations.

Conclusions:
As a “change agent” the new internal leadership consultant has background experience in this area, and brings this knowledge to DCPP. His job is working throughout DCPP, across the system, wherever change initiatives are developing and are in progress. The consultant believes the Executive Leadership Team is open and responsive, and willing to dig in to work with him and facilitate change.
A new Guide and Toolkit for “Change Leadership” with the ability to communicate, educate, and facilitate all of the people at DCPP in this change leadership model is a valuable beginning of a systematic methodology for facilitating change at DCPP.
The DCISC should continue to follow up in this area to identify DCPP’s progress with its integrated and systemic change plan, which coordinates, connects and focuses all of the change efforts currently taking place at DCPP.

3.12 DCPP Human Performance

The DCISC Fact-finding Team met with Mr. Chuck Belmont, Nuclear Quality Analysis & Licensing Director at DCPP for an update on DCPP Human Performance. Mr. Belmont’s areas include Quality Assurance, Licensing & Regulatory Compliance, and “Performance Improvement,” which consist of the Employee Concerns Program, Probabilistic Risk Analysis, System Transient Analysis, Corrective Action Program, Human Performance, and Cause Analysis. Mr. Belmont is also the administrative contact for INPO.

The DCPP 2005 Human Performance Improvement Plan, initiated as the result of a root cause analysis of human error causes, had been revised April 25, 2005 (Reference 6.15). A summarized, poster version of the Action Plan was posted on Mr. Belmont’s wall and he referred to it throughout our conversations.

The Human Performance Improvement Plan identified 5 specific initiatives. These are:

  1. Use error prevention tools (communication and verification practices) consistently and effectively across the station.
  2. Modify the Management Observation Program so that it effectively reinforces human performance behaviors.
  3. Ensure the quality and accuracy of procedures and work packages.
  4. Implement changes to identify organizational factors in an improved root cause analysis process.
  5. Create and institutionalize a formal Human Performance Program for the station.

In terms of providing oversight and follow-through, each initiative had a specified initiative owner, a set of initiative activities, and each activity had an owner and a due date. It appears that the DCPP 2005 Human Performance Action Plan has been widely disseminated and discussed, and has become a focus for human performance improvement.

A second topic of conversation involved the recent INPO evaluation pertaining to human performance. Although a formal document had not been presented from INPO, Mr. Belmont suggested that INPO had observed a significant improvement in human performance, no longer considered human performance a cross-cutting issue, but suggested that DCPP remain vigilant for human performance improvement opportunities.

Mr. Belmont also discussed the recent NRC evaluations on human performance. The NRC evaluation identified substantial improvement in human performance, and has removed human performance as a substantive cross-cutting issue for DCPP.

To quote the Annual Assessment letter to DCPP, addressed to Mr. Gregory Rueger, Senior Vice President, Generation and Chief Nuclear Officer, “While performance in this area has not been error free, this issue has been satisfactorily addressed and the NRC plans no further focused inspections of his human performance substantive cross-cutting issue.” (Reference 6.16)

Ms. Ardela Daniels has been hired from the WANO Paris Center to come to DCPP as the Supervisor of Organizational Improvements, which includes human performance, management observations, self-assessment, and benchmarking.

Ms. Daniels is a registered psychologist, with extensive experience in organizational change. She has worked in South Africa for many years in both political and organizational change, as well as for WANO. Ms. Daniels described her areas of specialization as organizational development, human performance, safety culture, cultural issues, and diversity issues. She also identified her capacity to monitor culture and to make improvements. She was attracted to DCPP because her objective is to go where the culture and the organization shows a readiness for change.

Ms. Daniels sees her responsibilities as working with senior management, continuing to develop and refine a Human Performance (HP) Plan, connecting the HP Plan to Departmental Plans, designing and executing a Strategic 3-Year Cultural Change Plan for DCPP, examining team dynamics in the organization and exploring error rates, and providing general support to leverage the talent, knowledge, culture and capabilities of DCPP.

Ms. Daniels suggested she would also like to be able to anticipate adverse trends earlier, facilitate forecasting at DCPP, eliminate roadblocks to line ownership, reshape the culture of DCPP to be more pro-active, and to facilitate enhanced human performance into the “DNA” of DCPP.

Regarding her metrics of success, she said the real issue in cultural and organizational change is to “capture the hearts and the minds of the people.” Ms. Daniels said DCPP would be a more successful organization when peers are able to hold each other accountable, when self-reporting is the norm, and when everyone uses human performance tools. A self-assessment of the HPIP is planned for the period just before Outage 1R13, scheduled to begin October 28, 2005. The DCISC should follow-up on the self-assessment.

Conclusion:
DCPP has a very focused and concise Human Performance Improvement Plan with significant oversight, areas of responsibility, assigned actions and suspenses.
The Nuclear Regulatory Commission has taken Human Performance off the substantive crosscutting issues list for DCPP. INPO apparently still considers Human Performance to be an Area for Improvement.
The new addition to lead the Human Performance Staff possesses knowledge and experience in areas not previously covered by employees in DCPP, including diversity, cultural change, safety culture, and other related human performance arenas.

3.13 Leading for Excellence

The DCISC Fact-finding Team met with Ms. Jacquie Hinds, Assistant to David Oatley, Vice President & General Manager DCPP to discuss Leading for Excellence at DCPP. The Leading for Excellence initiative is headed by Mr. Oatley, who is assisted in this effort by Mr. Pierre Dube, Senior Organizational Development Consultant for DCPP, Michael Franklin from Mercer-Delta, and Carol Brower, Human Resources DCPP.

Leading for Excellence is a program that continues to evolve to address the leadership development needs of DCPP. Initiatives and actions are perceived to address specific needs, as well as well as general organizational development opportunities.

Leading for Excellence includes the following major elements:

Leading for Excellence focuses on life-long learning for leadership at DCPP.

The “leadership development plan includes both elements: training, which provides the fundamental knowledge of basic skills necessary to improve; and an assessment of leadership performance with a developmental plan that provides experiential challenges to improve performance.”

“In assessing performance this plan addresses both individual and organizational gaps. For instance, if assessments find the organization as a whole needs to improve in certain areas (e.g. managing conflict), a site-wide program, such as training on managing conflict will be used to close the gap.” (Reference 6.17)

Individual strengths and areas for development are currently being determined by using 360@deg; assessments.

The plan also includes site-wide cultural surveys and personal observations by senior leadership.

The key elements of Leading for Excellence include: leadership requirements, assessment and development planning, development activities and evaluation. In addition, there are enabling systems that support the plan. These enabling systems include: selection process, succession planning, performance management, compensation, rewards and recognition and incentives.

Officer/ Director Development Plans: “Most of DCPP’s Officers and Directors have Individual Development Plans based on a 360@deg; assessment. Each of the Officers and Directors with a development plan also has an assigned coach to work with them to develop the plan and to monitor completion of the plan. Improvement will be evaluated using a 360@deg; assessment by June 2005” (Reference 6.5).

There is currently a pilot being created to “. . . develop Individual Development Plans using high-potential managers to improve the developmental planning process. The objective of this pilot is to create a culture of learning and continuous improvement. Participants will improve their skill and development and seed the development culture at DCPP by disseminating tools and resources for managers to use with their supervisors.” (Reference 6.5).

Managers and supervisors are also included in the Leading for Excellence strategy. A pivotal program entitled, “Crucial Conversations” will be presented to managers and supervisors through 2005 and 2006. Mr. Dube and Mitch States will facilitate this process.

An additional initiative is to improve and enhance governance at DCPP. This governance strategy focuses on leading management, setting up meeting agendas that are more focused, setting up meeting calendars in advance, and other initiatives to improve performance.

Because Ms. Hinds is in a position to make very close observations of the efforts of leadership at DCPP, she was asked for her impressions. Ms. Hinds told the Fact-finding Team that DCPP is on the up-swing and will see change incorporated more quickly than in the past. She expects to see more positive morale at DCPP.

When asked for specifics, Ms. Hinds said that the Vision, Mission, and Values are more focused, there is a true organizational understanding of the DCPP Vision and Mission, there is a new leadership team that has been formed, and there is a consistent effort to create success, alignment, and more effective communication across DCPP.

Conclusion:
It appears that DCPP is making a concerted effort on leading for success. This effort and the actions involved run from the most senior leaders of the organization (who use 360@deg; personnel assessments and individual development plans) to the first-line supervisory level, using a 3-Year Supervisory Improvement Program.
It also appears that DCPP is putting considerable effort and time into individual development, organizational development, mastering and managing change, and enhancing overall organizational performance through people.

3.14 Meeting with the New Vice-President of Nuclear Services

The DCISC Fact-finding Committee met with Ms. Donna Jacobs, the new Vice President Nuclear Services DCPP. Issues discussed included Ms. Jacobs’s perceptions of her roles and responsibilities, her philosophy regarding nuclear safety and safety culture, and her short and long-term goals.

Ms. Jacobs outlined what she believes her contribution can be to DCPP. Her motivation in life is to “make a difference,” and she came to DCPP to do exactly that. When Ms. Jacobs was asked why she was attracted to DCPP, she said, “I bring a different way of doing things – I felt that DCPP was very open to a new way of seeing things -- a new way of doing things.”

Ms. Jacobs’s initial perceptions of DCPP, over the 4 months she has been at the station, reinforce her initial observations: that DCPP is open and responsive to thinking in new directions.

Ms. Jacobs emphasized her role at DCPP in strategic projects and specifically in design engineering. Other foci will be procurement, fuels, information technology, engineering (all the technical sides of business) with a specific focus on equipment reliability and equipment health from a long-term perspective. She feels her first priority is in engineering.

Ms. Jacobs also said she wanted to help provide a clear understanding of the role of engineering at the station. Specifically, what the work of Engineering is an Ops-led organization. This will be an effort to create more clarity for Engineering across the station. It is Ms. Jacobs’s current observation that there is not a clear set of expectations for Engineering, nor were relationships adequately explored or utilized. She also believes that there should be attention devoted to the development of individual engineers and believed that resources could be better aligned in the engineering work areas and across DCPP.

Ms. Jacob also talked about the INPO mid-cycle assessment as a catalyst for change in the organization. She said every evaluation, every assessment, every action, was an opportunity for learning. Her feedback on the INPO assessment was that, although DCPP had made significant improvements, they were nowhere near where they needed to be in the future. One of her objectives is to help DCPP, along with her colleagues and associates, “be all they can be.”

Regarding her philosophy regarding nuclear safety culture, Ms. Jacobs said she had background in nuclear safety culture, and she would work with the organization to build on the existing foundation of nuclear safety. She reported that Dave Oatley had asked her to be accountable for safety culture at DCPP. To her, safety culture is how one acts in taking responsibility, and a healthy safety culture exhibits a pro-activeness in looking at issues and having a questioning attitude.

Ms. Jacobs has developed a class on nuclear safety culture, predicated upon the INPO document, “Nuclear Safety Culture,” and the nine attributes identified in that document. This class is being offered to Officers, Directors, and Managers first. Time would also be spent searching out what other people have done in the area of nuclear safety culture to ensure DCPP was among the best in class.

Ms. Jacobs listed a number of initiatives she had begun, particularly in the Engineering arena. We did not have the opportunity to explore the implications of these initiatives, but the DCISC Fact-finding Team intends to return to Ms. Jacobs and explore her short and long-term initiatives in more detail.

Ms. Jacobs talked about the Nuclear Supervisory Effectiveness Quick Hit Assessment (6.18). This assessment focused on the four Nuclear Supervisor short-falls identified by INPO. These were: insufficient field presence; ineffective oversight; failure to confront and correct inappropriate work or behaviors; and insufficient involvement to improve work or performance.

The INPO Assessment identified five underlying attributive factors. These are: unclear roles and responsibilities; conflicting priorities; unreasonable workloads; insufficient management support; and inappropriate expectations for supervisors to compensate for weak plant process.

To determine the extent and magnitude of the underlying contributing factors, the Quick Hit Survey (Reference 6.18) attempted to assess from the perspectives of the individual contributor and the supervisor, go plant-wide (“big three” and balance of plant), assess without disrupting work schedules, and keep it simple, while looking for patterns.

Some of the Quick Hit summary insights are:
Management time with their leadership team directly impacts supervisor ability to be effective
Relationships between upper management and supervisors needs to be improved
Supervisors are not adequately connected with each other inter-departmentally to be effective
Work control is still at risk
Recommendations included:
Invest more time in upper management and supervisors trying to share in each others issues and challenges
Improve the clarity in roles and responsibilities between management levels
Resolve the disconnect between departments
Increase work control and change management efforts, especially with engineering supervisors

One suggestion made by the DCISC Team was that Ms. Ardela Daniels, Supervisor of Organizational Improvement (see Section 3.12 above), be included in the safety culture efforts.

Conclusion:
The new Vice-President, Nuclear Services, appears to be a valuable addition to the Senior Leadership Team at DCPP. She brings to her job a real people focus, an understanding of culture, recognition of the value of learning, as well as detailed knowledge of the nuclear industry and the technical arena.
The new leadership team being forged at DCPP appears to have a greater focus on development, learning, and the facilitation of change. This would appear to be beneficial in bringing about improvements in leadership, roles and responsibilities, human performance, and safety culture needed to address INPO-, NRC-, and DCISC-identified issues. The DCISC should continue to closely follow these developments.
Recommendations:
PG&E should include the new Supervisor of Organizational Improvement in the efforts to develop and implement integrated plans for DCPP.
Basis for Recommendation:
Although new at DCPP, Ms. Daniels, the Supervisor of Organizational Improvement appears to possess unique experience in working with organizations on the issues of nuclear safety culture and human performance. It was not apparent to the DCISC that she was included in the high-level planning efforts. These two issues cut across the entire organization, and would be essential elements in assuring station success.

4.0 Conclusions

4.1
During the general tour of DCPP, the DCISC found the plant to be clean and in excellent materiel condition.
4.2
The 230 and 500 kV systems appear to be in good health, and the System Engineer appears to be knowledgeable of the systems and on top of trends and issues. It appears that quality oversight of switchyard work is performed only periodically by the System Engineer. This is a concern to the DCISC.
4.3
With exception of former ineffective program management which has now been addressed with a new Program Manager, the DCPP Boric Acid Corrosion Control Program appears satisfactory. DCPP has found no significant boric acid leaks on the reactor vessel upper or lower head connections. DCPP has identified over 500 boric acid leakers throughout the plant. Although classified as minor leakers, this number seems high to the DCISC. The DCISC notes that actions have been begun to review the list as a result of a Quality Verification assessment.
4.4
Although none of the three 2004-2005 winter storms caused DCPP power reductions, one initially had the potential to do so. The decision-making process and logic used by station personnel to analyze and decide what action to take appeared sound, conservative and effective.
4.5
The DCPP System Engineering Program appears to be satisfactory and improving. It is being supported by increased management attention and resources. There is good potential for improved system health with these improvements. The System Engineering Program Manager appears knowledgeable and dedicated to maintaining a strong program.
4.6
The NRC Senior Resident reported that NRC removed one substantive cross-cutting issue, human performance, but left the remaining one on corrective action because he did not consider it a full part of DCPP culture and did not yet appear sustaining.
4.7
The NRC has closed the human performance substantive cross-cutting issue but has kept open the issue on problem identification and resolution. The DCPP recovery plan appears appropriate to bring about the needed improvements by addressing not only programmatic, but also cultural and organizational aspects.
4.8
The audit of engineering design changes and plant modifications appeared thorough. The auditing organization, Quality Verification, concluded that the Design and Modification process was found to be satisfactory.
4.9
DCPP has a large-scope outage in Outage 1R13 with challenging goals; however, their plans to meet the challenge look appropriate, especially the large emphasis on human performance and dose reduction. As of early May 2005, DCPP was on-schedule with outage preparation activities.
4.10
As a “change agent” the new internal leadership consultant has background experience in this area, and brings this knowledge to DCPP. His job is working throughout DCPP, across the system, wherever change initiatives are developing and are in progress. The consultant believes the Executive Leadership Team is open and responsive, and willing to dig in to work with him and facilitate change.
A new Guide and Toolkit for “Change Leadership” with the ability to communicate, educate, and facilitate all of the people at DCPP in this change leadership model is a valuable beginning of a systematic methodology for facilitating change at DCPP.
The DCISC should continue to follow up in this area to identify DCPP’s progress with its integrated and systemic change plan, which coordinates, connects and focuses all of the change efforts currently taking place at DCPP.
4.11
DCPP has a very focused and concise Human Performance Improvement Plan with significant oversight, areas of responsibility, assigned actions and suspenses.
The Nuclear Regulatory Commission has taken Human Performance off the substantive crosscutting issues list for DCPP. INPO apparently still considers Human Performance to be an Area for Improvement.
The new addition to lead the Human Performance Staff possesses knowledge and experience in areas not previously covered by employees in DCPP, including diversity, cultural change, safety culture, and other related human performance arenas.
4.12
It appears that DCPP is making a concerted effort on leading for success. This effort and the actions involved run from the most senior leaders of the organization (who use 360@deg; personnel assessments and individual development plans) to the first-line supervisory level, using a 3-Year Supervisory Improvement Program.
It also appears that DCPP is putting considerable effort and time into individual development, organizational development, mastering and managing change, and enhancing overall organizational performance through people.
4.13
The new Vice-President, Nuclear Services, appears to be a valuable and much needed addition to the Senior Leadership Team at DCPP. She brings to her job a real people focus, an understanding of culture, recognition of the value of learning, as well as detailed knowledge of the nuclear industry and the technical arena.
The new leadership team being forged at DCPP appears to have a greater focus on development, learning, and the facilitation of change. This would appear to be beneficial in bringing about improvements in leadership, roles and responsibilities, human performance, and safety culture needed to address INPO-, NRC-, and DCISC-identified issues. The DCISC should continue to closely follow these developments.

5.0 Recommendations

5.1
DCPP’s July 2005 STARS self-assessment should include a review of the quality oversight of switchyard work by DCPP and non-DCPP (e.g., PG&E Transmission Department) personnel. (Section 3.2)
5.2
PG&E should include the new Supervisor of Organizational Improvement in the efforts to develop and implement integrated plans for DCPP.

6.0 References

6.1
“Diablo Canyon Independent Safety Committee Twelfth Annual Report on the Safety of Diablo Canyon Nuclear Power Plant Operations, July 1, 2001 – June 30, 2002”, Approved October 5, 2002, Exhibit D.4, Section 3.11, Review of Offsite Power System.
6.2
PG&E Nuclear Power Generation Inter-departmental Administrative Procedure OP J-2: VIII, “Guidelines for Reliable Transmission Service for DCPP,” Revision 5, March 16, 2004.
6.3
PG&E Nuclear Power Generation Inter-departmental Administrative Procedure OM1.ID4, “Boundaries of Jurisdiction for Transmission and Distribution Facilities at Diablo Canyon Site,” Revision 3, June 2, 2004.
6.4
PG&E Nuclear Power Generation Inter-departmental Administrative Procedure AD7.ID6, “Nuclear Generation/ Supplemental Personnel Interface,” Revision 3, March 23, 2005.
6.5
“Diablo Canyon Independent Safety Committee Fourteenth Annual Report on the Safety of Diablo Canyon Nuclear Power Plant Operations, July 1, 2003 – June 30, 2004”, Approved October 5, 2004, Exhibit D.2, Section 3.12, Boric Acid Corrosion Control Program.
6.6
PG&E Nuclear Power Generation Inter-departmental Administrative Procedure AD4.ID2, “Plant Leakage Evaluation,” Revision 6, February 2, 2005.
6.7
PG&E Nuclear Power Generation Inter-departmental Administrative Procedure ER1.ID2, “Boric Acid Corrosion Control Program,” Revision 0, June 24, 2003.
6.8
“Diablo Canyon Independent Safety Committee Fifteenth Annual Report on the Safety of Diablo Canyon Nuclear Power Plant Operations, July 1, 2004 – June 30, 2005”, Approved October 12, 2005, Exhibit D.1, Section 3.9, Winter Storm Response.
6.9
“Diablo Canyon Independent Safety Committee Fifteenth Annual Report on the Safety of Diablo Canyon Nuclear Power Plant Operations, July 1, 2001 – June 30, 2002”, Approved October 16, 2002, Exhibit D.4, Section 3.9, System health Summaries and Long-Term Plans.
6.10
“Diablo Canyon Independent Safety Committee Fifteenth Annual Report on the Safety of Diablo Canyon Nuclear Power Plant Operations, July 1, 2004 – June 30, 2005”, Approved October 12, 2005, Exhibit D.2, Section 3.7, Meet with the NRC Inspector.
6.11
“Diablo Canyon Independent Safety Committee Twelfth Annual Report on the Safety of Diablo Canyon Nuclear Power Plant Operations, July 1, 2001 – June 30, 2002”, Approved October 16, 2002, Exhibit D.10, Section 3.8, Configuration Control and Design Control Program.
6.12
“Diablo Canyon Independent Safety Committee Fifteenth Annual Report on the Safety of Diablo Canyon Nuclear Power Plant Operations, July 1, 2004 – June 30, 2005”, Approved October 12, 2005, Exhibit B.6, Results of Outage 2R12.
6.13
Guide & Toolkit for “Change Leadership” – 12/02/04 – Rev.2
6.14
“Diablo Canyon Independent Safety Committee Fifteenth Annual Report on the Safety of Diablo Canyon Nuclear Power Plant Operations, July 1, 2004 – June 30, 2005”, Approved October 12, 2005, Exhibit D.7, Section 3.7, Supervisor Effectiveness Training.
6.15
DCPP 2005 Human Performance Action Plan – Rev. 1 – 4/25/05
6.16
Annual Assessment Letter – Diablo Canyon Power Plant (Report 05000275/2005001, 05000323/2005001) from the Nuclear Regulatory Commission, Dated March 2, 2005
6.17
Leading for Excellence, Diablo Canyon Nuclear Power Plan, Leadership Development Plan, May 4, 2005 Update
6.18
Quick Hit Self-Assessment Form, Dated February 14 – 23, 2005, DCPP Plant-Wide: Supervisor Level

For more information about DCISC contact:

Diablo Canyon Independent Safety Committee
Office of the Legal Counsel
857 Cass Street, Suite D, Monterey, California 93940
Telephone: in Califonia call 800-439-4688; outside of California call 831-647-1044
Send E-mail to: dcsafety@dcisc.org