Report on Fact-finding Meeting by Diablo Canyon Independent Safety Committee (DCISC) at Diablo Canyon Power Plant (DCPP) on May 31 - June 1, 2006 by Dr. Per F. Peterson, Member and R. Ferman Wardell, Consultant [16th Annual Report, Exhibit D.10]

1.0 Summary

The results of the May 31 - June 1, 2006 Fact-finding trip to the Diablo Canyon Power Plant in Avila Beach, CA are presented. The subjects addressed and summarized in Section 3 include:

Groundwater Tritium Levels and Radioactive Effluent Releases
Emergency Preparedness Equipment Reliability
Margin Management Program
Human Performance Improvement for Engineering
Tour of ISFSI Construction
Security Force-on-Force Drill
2R13 Outage Results
Security Update
Meeting with New Engineering Director
Adverse Trends in Design Change Quality

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 determine if 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—Rcommendations 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

3.1 Groundwater Tritium Levels and Radioactive Effluent Releases

The DCISC Fact-finding Team met with Mark Somerville, Team Leader for Dosimetry and Radioactive Effluents Measurement Programs (REMP), to discuss groundwater Tritium levels around DCPP and DCPP radioactive effluent releases compared to the nuclear industry. The DCISC regularly reviews DCPP radioactive effluent releases and last reviewed them in July 2004 (Reference 6.1). At time the Committee concluded the following:

DCPP did not have any unusual or unexpected discharges in 2003 and the plant effluent releases were well below Tech Spec limits.

At the April 5, 2006 Nuclear Safety Oversight Committee (NSOC) meeting (Reference 6.2) the DCISC learned that NRC had become concerned about groundwater Tritium levels surrounding certain nuclear plants and that DCPP radioactive effluent releases, while well within Technical Specifications (TS) limits, were in the fourth quartile of the industry. The purpose of this Fact-finding meeting was to review these two issues.

Groundwater Tritium Levels

The specific issue is the unintentional introduction of Tritium into groundwater which is or could be used for domestic purposes including drinking, bathing, irrigation, and watering of livestock. Tritium, a radioisotope of Hydrogen, is produced in nature by interaction of cosmic rays with Nitrogen and Oxygen. With a half-life of 12.3 years and a weak beta (18.6 keV maximum) emission, Tritium is a tertiary nuclear fission product which incorporates with Oxygen to form water. "Tritiated water" behaves like water physically and chemically. Several US nuclear plants detected elevated levels of Tritium which, though not posing a health or safety hazard, were above expectations. This caused corrective actions to better limit or account for Tritium discharges at those plants and for all other US plants to review their situations.

Tritium discharges at DCPP are small and well within Technical Specifications (TS) limits. The DCPP Radiological Environmental Monitoring Program (REMP) has detected maximum Tritium levels of approximately 2700 picoCuries/liter (pC/l) in the Unit 1 Containment foundation sump and none detected at the 36 sampling stations for surface and ground water surrounding the plant. [Tritium in these sumps comes primarily from water evaporation from the Spent Fuel Pools, condensation and precipitation into roof and yard drains and into the sump.] This concentration is still very small and compares to Environmental Protection Agency limits of 20,000 pC/l for drinking water pathways and 30,000 pC/l for non-drinking water pathways (the latter being DCPP’s case). DCPP’s ground and surface water flows all go into the Pacific Ocean and not to any domestic or drinking water sources. This provides assurance that no contamination of domestic water supplies is possible.

Radioactive Effluent Releases

The DCISC regularly reviews the DCPP radiological effluent report to NRC and has found that releases have been a small fraction of TS limits and that the REMP has detected small fractions of permissible concentrations of radioactive materials (or none) in the air, water and soil samples around the plant. Following the aforementioned NSOC report, the DCISC was interested in seeing how DCPP releases compared to the industry.

Three-year weighted industry waterborne mixed release data appears as follows:

Radioactive Effluent Releases
Industry Quartile	Maximum Curies Released per Quartile
1	0.013
2	0.039
3	0.064
DCPP	0.089
4	1.389

This puts DCPP just into the fourth quartile, although the numbers are all small, and no water discharges from DCPP go to domestic water supplies. Compared to NRC 10CFR50 Appendix I which permits 5 milliRem (mRem) per year dose to the most-exposed member of the public, DCPP’s releases are calculated to generate 0.02 mRem. DCPP’s water mixed-activity releases have steadily decreased since 1997, although not as fast as the industry. Many other nuclear plants have installed advanced filtration to lower water mixed-activity releases, primarily Antimony, and to a lesser degree, Cesium, in colloidal form. DCPP plans to add connections to its waste water processing systems for mobile advanced filtration in 2008.

Conclusions:: Tritium levels surrounding DCPP do not appear to be a concern. Low levels of Tritium have been detected in a building foundation sump but not in any of 36 surrounding environmental sampling locations. Notwithstanding this, all surface and ground water on the site leads to the Pacific Ocean and not to any domestic water supplies. DCPP radioactive liquid releases are in the industry fourth quartile; however, they are small fractions of regulatory limits and PG&E plans to add additional processing to further reduce discharges. Environmental sampling has shown no unexpected levels.

3.2 Emergency Preparedness Equipment Reliability

The DCISC Fact-finding Team met with Bob Waltos, Manager of Emergency Services, to discuss Emergency Preparedness (EP) equipment reliability. This is the first review of EP equipment; however, the DCISC reviewed overall DCPP equipment reliability in March 2006 (Reference 6.3).

DCPP had observed increased EP equipment failures in 2004 and early 2005. It developed Procedure AWP EP-005, "Determining Compensatory Measures for Equipment Affecting the Implementation of the DCPP Emergency Plan". The procedure

Identifies equipment required to determine initiating conditions for Emergency Action Levels (EALs) and provides alternate equipment indicators or compensatory measures for removing equipment from service.
Identifies equipment needed for the Emergency Response Facilities (ERFs) to function during emergencies and provides guidance for the evaluation of functionality and habitability of an ERF when services have been reduced.
Is meant to augment, not supersede or replace, conditions and actions as described in Technical Specifications or Equipment Control Guidelines.

The procedure appeared comprehensive and useful.

An Action Request (AR) was initiated in November 2005 to evaluate a potential adverse trend in EP equipment reliability. A search of ARs resulted in 25 recent instances of failures in equipment such as

EARS (dose assessment hardware/software)
Safety Parameter Display System (SPDS)
Technical Support Center (TSC) power supply
Various EP computers
Various electronic equipment

The evaluation determined that these failures have been occurring for some time because of low repair and maintenance prioritization and that the equipment responsibility crosses many organizational lines. The AR concluded that "There IS an adverse trend in the equipment failures related to networked computer systems 43A, 52A and 52B. The hardware for the SPDS, Plant Process Computer (PPC), and EARS is nearing the end of their life cycle and requires significant maintenance." The A-Type Action Request Review Team (AART) determined this to be a quality problem, and Ken Bych, Manager of the Equipment Reliability Program concurred.

The first action was to prepare a comprehensive listing of EP equipment, both on-site and off-site, and develop a list of problematic equipment, including a preventive maintenance plan. An action plan for the latter was called for, along with resolution plans and priorities for presentation to the Plant Health Committee for funding. The prioritization of the equipment was determined along with the responsible Maintenance organization and vendor. This information was put into procedures. Additionally, an EP equipment/program owner was established.

The 2006 biennial assessment of the DCPP Emergency Plan resulted in 21 recommendations. These were captured in an AR for evaluation and action. One significant action was the establishment of an EP Five-Year Strategic Plan to be implemented with a change management plan. Those actions relating to EP equipment were as follows:

Include in the EP Five-Year Plan a budget for replacement or enhancement of EP equipment and facilities
EP maintenance procedures should be scheduled as any other recurring task in the plant work planning system
EP facility computers should be configured and/or used frequently to minimize the time spent for the virus scan (this has delayed activation of these computers)
The DCPP Corrective Action Program needs to be used more routinely by EP to identify and resolve issues
EP equipment management needs to be strengthened by considering the following:
Clearly identify all equipment important to EP
Establish component IDs for the above equipment
Identify EP equipment that requires compensatory measures
Establish a mechanism that is integrated with the Plant Work Control Process to assure that EP equipment problems and compensatory measures are properly addressed consistent with their significance
Establish EP equipment preventive maintenance and appropriate priority

Mr. Waltos reported that, along with the above equipment concerns and Self-Assessment recommendations, there were two additional related EP issues: (1) the NRC performance indicators for EP had gone White (degraded performance) in 2005 and (2) there are three major EP drills in 2006. Based on this activity, DCPP had decided to take an overall approach to tackle all of these issues by incorporating them into the development of the EP Strategic Plan (mentioned above) and a Long-Term EP Equipment Reliability Improvement Plan which is expected to be completed in April 2007. The DCISC should follow up on these plans. [Not related to EP equipment reliability, there were two of the 21 recommendations which were similar to previous DCISC concerns or recommendations. These were

All stakeholders should come together and determine what information should be provided to the public regarding how dose will be characterized and whether off-site dose will be discussed.
Hostile press training is recommended for PG&E Emergency Response Organization (ERO) members in the Joint Media Center (JMC) and for the staff of outside agencies.

We should follow up on these. Per and I talked about attending the October 25, 2006 graded exercise and could review it at that time.]

Conclusions:: DCPP has been experiencing an increase in failures of equipment needed by the Emergency Plan and has developed a procedure to provide compensatory measures and actions to develop a Long-Term Emergency Plan Equipment Reliability Improvement Plan, and an Emergency Preparedness Five-Year Strategic Plan. These are positive actions which the DCISC should monitor on a regular basis.

3.3 Margin Management Program

The DCISC Fact-finding Team met with Ken Bych, Equipment Reliability Engineering Supervisor, to review DCPP Margin Management. The DCISC last reviewed Margin Management in September 2005 (Reference 6.4) and concluded the following:

Although design and operating margins are tracked subjectively by System Engineers on the System Health Cards and are included in electrical load calculations, there is no formal program for identifying and managing these margins. DCPP had developed an action plan to benchmark other plants’ programs and to develop a process for managing margins. Actions began in September 2005, and completion is scheduled for July 2006. The DCISC should review this initiative as it progresses.

Margin is defined as the conservatism included in operation and design for all nuclear plant systems, structures and components (SSCs). Quantitatively, margin is the difference between actual and required performance. These margins (or conservatisms) are not always specifically documented or quantified in design basis documents or operating procedures. Margins fall into three categories: (1) analytical margins, (2) design margins, and (3) operating margins. DCPP believes it is important to manage margins so that margin is not inadvertently lost through, e.g., degraded equipment, plant modifications, procedure changes, revised calculations or human error.

DCPP’s November 2004 Margin Management Action Plan contained three phases:

Phase I: included review of system health criteria, revision, and guidance to engineers as necessary to immediately address the most important aspects of Margin Management. In this phase revisions were made to System Health Report requirements, the Design Change Procedure, and the Design Calculation Procedure to include margin considerations. Metrics for Margin Management were included in System Health Reports. Margin Management training was provided to all Engineering groups. Phase I was completed in April 2005.

Phase II: included benchmarking and refinement of the Phase III Plan based on industry input. Engineering Managers participated in an INPO Margin Management workshop, information was solicited from various plants, and a Margin Management Steering Committee was created under the leadership of the Engineering Manager. Phase II was completed in March 2006.

Phase III includes the following:

Analysis of industry benchmarking
Bringing Operations into the Steering Committee (with a focus on operating margin)
Developing of a Margin Management Administrative Procedure
Further communications and training for engineers
Identification and revision of procedures related to Margin Management

Phase III is being implemented. A change plan in the form of a procedure has been developed and is in the plant review process. Training of operators and engineers is being developed. Procedures impacted by Margin Management are being reviewed for revision. Phase III is expected to be completed in September 2006.

DCPP reported that Margin Management is an NRC focus area. An NRC team reviewed DCPP’s design and operating margins in a special inspection in January 2005 with positive results and four minor non-cited violations (NCVs). A re-inspection is expected in mid-September 2006. The DCISC should hold a follow-up review after this inspection.

Conclusions:: DCPP is progressing well in developing its Margin Management Program. Its plan appears solid, and implementation is on-schedule. This new program should benefit the safety of DCPP in the future.

3.4 Human Performance Improvement for Engineering

The DCISC Fact-finding Team met with Larry Cossette, Human Performance (HP) Coordinator for Engineering, to review HP improvements being made in Engineering. This is the first DCISC review of Engineering HP specifically.

DCPP has recently established Performance Improvement Coordinators (PICOs) for each line department which works with the Work Control Process. The job scope includes the following programs:

Corrective (CA)
Human Performance (HP)
Operating Experience (OE)
Management Observations (MO)
Self-Assessments (SA)
Benchmarking

The idea for PICOs came from a benchmarking trip to Progress Energy’s Robinson Nuclear Station, considered by INPO to be a leader in this area. Training for PICOs is being developed. The PICO process is part of the overall DCPP Performance Improvement Process.

Following Outage 1R13, for which the station performed a common cause analysis of human performance events, Engineering performed a two-year look back at its human performance. Analysis results yielded three focus areas: (1) Communications, (2) Procedure Qualification, and (3) Inattention to Detail. From this Engineering developed an “administrative human performance simulator.” In simulator sessions engineers are given a simulated work procedure involving a problem statement with built-in errors. During the sessions, distractions are introduced. The simulator is designed to focus on environmental work conditions, ability to concentrate, questioning attitudes, schedule pressure, etc. At the end of each session, a critique is held. A "stop sign" is provided during the session which the engineer can use to prevent distractions (phone calls, visits by others, etc.). After the session, a real "stop sign" is provided for use in the real work environment for minimization of distractions. The simulator has been used by engineering managers, supervisors, and now single contributors. It has been well received and found to be eye-opening by many engineers.

DCPP has consulted World Association of Nuclear Operators (WANO) Significant Event Report 2005-3, "Errors in the Preparation and Implementation of Modifications" which identifies the causes of primary errors in engineering work.

DCPP has implemented tailboards for selected assigned engineering tasks, mostly plant work such as testing. The tasks are followed up with post-job evaluations. This is similar to Operations and Maintenance tailboards and critiques.

3.5 Tour of ISFSI Construction

Steve Hamilton, Licensing Engineer, led the Fact-finding Team on a tour of the construction of the Independent Spent Fuel Storage Installation (ISFSI). The DCISC has been following the progress of the ISFSI since its beginnings. The tour included excavations and concrete pours for foundation of the pad which will hold the initial set of casks and the pad for the cask transfer station. Additionally, the hillside above the pads has been stabilized to prevent dirt and rock slides onto the pads. Construction work appeared orderly and well-controlled. Personnel safety was apparent in that all who went on the construction site were required to wear high-visibility vests to assure they were visible to heavy equipment operators.

Conclusions:: A tour of construction of the foundation of the pad for the initial spent fuel storage casks of the Independent Spent Fuel Storage Installation (ISFSI) revealed orderly and well-controlled work in-progress.

3.6 Security Force-on-Force Drill

[Note: due to the sensitivity of nuclear plant security, information classified as "Safeguards Information" cannot be presented in this report, thus limiting the breadth and scope of the report. Both Dr. Peterson and Mr. Wardell have been cleared for access to DCPP Safeguards Information.]

The DCISC Fact-finding Team met with Bob Zimkowski, DCPP Security Manager, to preview the scenario and observe the force-on-force (FOF) security drill. This was the first FOF drill the DCISC has observed.

DCPP Security is subject to four drills for each of the three shifts per year and one annual exercise per shift per year, where the annual exercises are more involved than drills. This FOF drill consisted of a simulated outside force attempting to enter the plant and disable pre-selected targets. Operations participated at the Plant Simulator which served as the Control Room. Parts of the Emergency Response Organization (ERO) participated in their normal roles. There were many observers to evaluate the drill, and there was a critique following the drill. The DCISC Fact-finding Team was located in a position with the Security Manager where much of the early action could be observed.

The pre-drill briefing was thorough and comprehensive. It included the drill objectives and rules for the drill. These included heavy emphasis on personnel and plant safety, e.g., personnel warm-ups and being careful around slippery wet spots and sensitive operating plant equipment. The briefing emphasized that the participants should immediately call a time-out if any question related to plant or personnel safety were to arise. Special consideration was made for the possibility of a real security event occurring, fire protection, communications, and real vs. simulated actions, especially the use of weapons. Laser-based weapons, similar to DCPP’s real ones, and laser targets were used.

The critique included all participants and observers and was comprehensive. Objectives were met and there were no personnel injuries or plant events. Overall, the drill was successful.

Conclusions:: The Security Force-on-Force drill observed by the DCISC appeared successful in all aspects: meeting drill objectives, personnel safety and plant safety. The DCPP Security Team appeared professional and capable. Safety risks associated with conducting the exercise outside and inside the plant were comprehensively identified and minimized during the exercise, so that the exercise achieved its security goals while maintaining appropriate plant and personnel safety levels.

3.7 2R13 Outage Results

The Fact-finding Team met with Ken Langdon, DCPP Outage Director, to review the results of Outage 2R13. The DCISC last reviewed outage results (Outage 1R13) in February 2006 (Reference 6.5).

Mr. Langdon arrived at DCPP just before Outage 1R13 in October 2005. With prior outage leadership experience, he coordinated participation in a benchmarking visit to the Three Mile Island and Seabrook Nuclear Stations, both known for quality, low radiation dose outages. Two resulting main focus areas were (1) filling the reactor cavity through the hot leg rather than cold leg to keep contamination in the Reactor Coolant System and (2) personal ownership of ALARA (As Low As Reasonably Achievable) for low radiation doses.

DCPP performed a gap analysis of critical path operations, such as improved shutdown schedule, mode change coordination, secondary plant readiness, and low power physics test elimination. These initiatives resulted in a total critical path savings of 41 hours.

Unit 2 radiation doses were approximately 10 percent lower than the previous outage due primarily to better shutdown chemistry, cleanup and the hot leg fill described above. ALARA performance was considered excellent, resulting in a total outage does of 74.1 person-Rem.

Outage results vs. goals and objectives were as follows:

Outage results vs. goals and objectives
Outage Item	Goal	Actual
Industrial Safety
- Disabling Injuries	Zero	1
- Recordable Injuries	Zero	3
Radiological Safety	< 100 P-Rem	74.1 P-Rem
Nuclear Safety
- Challenges to DHR	Zero	0
- Signf. Equip. Damage	Zero	0
- Security Violations	Zero	0
HP Station Clock Resets	Zero	2
Power Ascension	< 6 Days	5d, 6h
100% Power	> 30 Days	On Track
Schedule	< 39 Days	38d, 19h
Cost	< $43.1 MM	< $42 MM

Outage Item	Goal	Actual
Reactivity Management Events	Zero	0
Safety Schedule Changes Reducing Defense-in-Depth Level	Zero	1*
Security Events	< 20	12
2R13 CM Scope Completed	> 99%	100%
2R13 Quality Actions Completed	All	All
2R13 Commitment Actions Completed	All	All
Condenser Salt In-leakage	< 0.05 gpd	~1 gpd
T-Mods Installed Upon Restart	Zero	2

* During replacement of a source range detector, there was a period of inoperability while the instrument was being reset.

DCPP considers the following to be major 2R13 successes:

Unit 2 breaker-to-breaker run prior to 2R13
Significant improvement in ALARA
Strong alignment for outage fundamentals
Improved execution and leadership model
Long-standing equipment issues addressed as planned
Low Pressure Turbine Retrofit Project – a lessons-learned clinic
Digital Feedwater Control System Project – excellent first-time implementation
Lessons-Learned – more than double the prior best
Excellent plant performance during power ascension

The following were DCPP’s major lessons-learned from 2R13:

Foreign Material Exclusion (FME) standards in Containment
Human performance in System and Plant restoration
First-time implementation of Major Projects
Individual workload
3-dimensional space considerations
Effectiveness of pre-outage readiness reviews
Containment coordination
Better schedule detail and integration pre-outage
Stronger accountability model in execution

DCPP considers 2R13 to have been a successful outage. The DCISC Fact-finding Team would agree, especially from a nuclear safety aspect.

DCPP appears to be taking a more disciplined approach to its outages, utilizing successful techniques and tools from other nuclear plants. Along these lines, they have developed a brochure entitled "DCPP Refueling Outage Fundamentals". The brochure is a concise compilation of DCPP’s five principles of outage excellence (e.g., maintain the highest levels of plant safety) and 17 outage fundamentals (e.g., nuclear safety is the first priority and human error prevention is evident in every task). INPO has requested assessments of outage safety plans which DCPP will provide in August 2006.

DCPP will be challenged in their next set of outages, the R14 Outages, for two reasons: (1) Steam Generator (SG) replacement will occur and (2) Containment sump issues are a potential complication. Both are major projects, especially SG replacement. DCPP has taken steps to prepare for the SG replacements in having established a SG Team several years ago (now including much of the Callaway Nuclear Plant SG change-out team), benchmarking others who have replaced SGs, and in performing SG photogrammetry in both containments in the R13 series of outages.

Conclusions:: DCPP had a successful Outage 2R13, especially in nuclear safety, ALARA and collective radiation dose performance. PG&E is taking a more disciplined approach to their outages, including benchmarking others, which appears to be working. The next set of outages will include Steam Generator replacements which are very large and complex projects. The DCISC should closely monitor these outages and DCPP planning.

3.8 Security Update

The DCISC Fact-finding Team met with Bob Zimkowski, DCPP Security Manager; John Huddle, Security Shift Supervisor; and Steve Hamilton, Senior Licensing Engineer, for an update on DCPP Security since the last update in November 2005 (Reference 6.6). At that Fact-finding meeting the DCISC concluded the following:

Although based on limited review scope in the area of nuclear plant security, the Fact-finding Team believes DCPP is satisfactorily addressing NRC security requirements.

The Fact-finding Team had observed the successful Security Force-on-Force Drill the previous day (Section 3.6 above) in which DCPP had utilized a new laser-based weaponry system (MILES) in an actual drill. DCPP has been using laser-based weapons systems before, but the new MILES system is more realistic in its performance. The update discussion began with a demonstration of the laser-based weaponry and how weapons fire and hits are recorded by computer for later analysis. The system appeared impressive.

An updated Design Basis Threat (DBT) had been received from NRC and implemented at DCPP with an upgrade to the Security Plan and DCPP facilities. A recent minor sabotage event at another nuclear station has resulted in tighter access controls for temporary workers.

The latest Quality Problem Assessment Report (QPAR) for the first quarter 2006 reported overall Security performance as White. It concluded that the Security Plan continues to be satisfactorily implemented. Most individual Security measures continued to trend well into the Green status; however, security equipment health and human performance, while satisfactory, need further attention to achieve top tier performance. Both are beginning to receive appropriate attention.

NRC performed an inspection of DCPP physical security in March 2006. NRC looked at access control, owner-controlled area controls, performance indicator verification, and problem identification and resolution. The results were satisfactory, except for one " . . . finding of very low safety significance (Green)" involving access control. The item was placed into the DCPP Corrective Action Program (CAP) for resolution.

Conclusions:: DCPP Security appears to be satisfactorily implemented. Based on the successful Force-on-Force Drill, Security appears to be a capable, well-equipped organization.

3.9 Meeting with New Director of Engineering

The DCISC Fact-finding Team met with Ken Peters, the new DCPP Director of Engineering. The DCISC last met with the Engineering Director in September 2005 (Reference 6.7) when it concluded the following:

The reorganization in Engineering has moved more Engineers from Strategic Projects into Engineering Services. PG&E expects to complete the major capital projects in the 2010-2011 time frame and will do more outsourcing on a turn-key basis. DISC should review the Engineering Organization in the 3rd Quarter of 2006 to assess the results of the reorganization.

Mr. Peters has been his new job about 1½ months. An electrical engineer by education, he had worked a variety of jobs at Indian Point Plant 3 and Waterford Nuclear Stations prior to coming to DCPP. His early assessment of DCPP engineering was that system engineering is strong, equipment reliability needs work, there was good human performance in Outage 2R13, and that DCPP had received good marks from the NRC in their inspection of engineering in 2005.

His challenges for 2006 include equipment reliability, an Engineering Human Performance Plan, and benchmarking another plant’s successful engineering group. He reported that Engineering has substantially completed a ten-initiative business plan on long-standing equipment issues and that DCPP has a new engineering human performance simulator. DCPP has hired Enercon Engineering, an outside firm, for its major design work. Consisting of about 20 engineers, they report to the DCPP Engineering Projects Group.

Conclusions:: The new Director of DCPP Engineering, after 1½ months on the job, has developed what appear to be good insights into the Engineering strengths and improvements needed. The DCISC should continue to monitor performance in DCPP Engineering.

3.10 Adverse Trends in Design Change Quality

The DCISC Fact-finding Team met with Nosar Jahangir, Supervisor of Piping and Mechanical Design, to review adverse trends in design change quality. This is the first DCISC review of this subject.

Several incidents in 2004 and 2005 (e.g., Operations questions about the Positive Displacement Pump replacement not being adequately addressed and the wrong valves specified for the new Zinc injection system) prompted DCPP Engineering management to initiate an Action Request (AR) to study a potential negative trend in design quality.

An Apparent Cause Evaluation (ACE) was initiated to look at the following:: Identify and analyze recent notable errors attributable to adverse design quality; Identify common causes; Recommend preventive measures; Implement corrective actions; Monitor effectiveness
There were 16 notable cases identified during the last three year period. WANO Significant Event Report 2005-3, "Errors in the Preparation and Implementation of Modifications" methodology was used in the DCPP assessment. The WANO report showed four common causes, and DCPP added three, resulting in the following seven causes:: 1. Insufficient knowledge and skills with new technology (WANO); 2. Inadequate support by the suppliers (vendors) (DCPP); 3. Inadequate problem statement and scoping meeting (DCPP); 4. Over-reliance on the expertise of supplemental personnel (WANO); 5. Inadequate scope and depth of post-modification testing (WANO); 6. Inadequate failure modes and effects analyses (WANO); 7. Human performance factors (DCPP)
In early 2005 DCPP had revised its Design Change Procedure to address the four WANO causes. It then developed corrective actions to address the three remaining common causes with the following additional measures:: Enforcement of procedure adherence (scoping meetings with operations, etc.); Focused observations by Supervisors; Better recognition of high risk designs and assignment of additional measures to prevent human errors; Enhanced procedures on vendor interface

To monitor the effectiveness of these corrective actions DCPP will continue its Management Observations, continue its post-installation "Rev. Z" assessments, and perform Error Trend Report (ETR) trending of design errors. This appears satisfactory to the DCISC Fact-finding Team.

Conclusions:: Engineering performed a thorough and logical analysis of potential design errors which resulted in seven common error causes. It has taken appropriate corrective actions to prevent future design errors and monitor error trends.

4.0 Conclusions

4.1: Tritium levels surrounding DCPP do not appear to be a concern. Low levels of Tritium have been detected in a building foundation sump but not in any of 36 surrounding environmental sampling locations. Notwithstanding this, all surface and ground water on the site leads to the Pacific Ocean and not to any domestic water supplies. DCPP radioactive liquid releases are in the industry fourth quartile; however, they are small fractions of regulatory limits and PG&E plans to add additional processing to further reduce discharges. Environmental sampling has shown no unexpected levels.
4.2: DCPP has been experiencing an increase in failures of equipment needed by the Emergency Plan and has developed a procedure to provide compensatory measures and actions to develop a Long-Term Emergency Plan Equipment Reliability Improvement Plan, and an Emergency Preparedness Five-Year Strategic Plan. These are positive actions which the DCISC should monitor on a regular basis.
4.3: DCPP is progressing well in developing its Margin Management Program. Its plan appears solid, and implementation is on-schedule. This new program should benefit the safety of DCPP in the future.
4.4: DCPP Engineering is taking a pro-active approach to reducing human errors in engineering functions. It has analyzed the causes of errors and is focusing on the primary causes. One interesting activity is an "administrative engineering simulator" which highlights distractions, errors, and schedule pressure. These initiatives appear positive. The DCISC should follow up in about six months.
4.5: A tour of construction of the foundation of the pad for the initial spent fuel storage casks of the Independent Spent Fuel Storage Installation (ISFSI) revealed orderly and well-controlled work in-progress.
4.6: The Security Force-on-Force drill observed by the DCISC appeared successful in all aspects: meeting drill objectives, personnel safety and plant safety. The DCPP Security Team appeared professional and capable. Safety risks associated with conducting the exercise outside and inside the plant were comprehensively identified and minimized during the exercise, so that the exercise achieved its security goals while maintaining appropriate plant and personnel safety levels.
4.7: DCPP had a successful Outage 2R13, especially in nuclear safety, ALARA and collective radiation dose performance. PG&E is taking a more disciplined approach to their outages, including benchmarking others, which appears to be working. The next set of outages will include Steam Generator replacements which are very large and complex projects. The DCISC should closely monitor these outages and DCPP planning.
4.8: DCPP Security appears to be satisfactorily implemented. Based on the successful Force-on-Force Drill, Security appears to be a capable, well-equipped organization.
4.9: The new Director of DCPP Engineering, after 1½ months on the job, has developed what appear to be good insights into the Engineering strengths and improvements needed. The DCISC should continue to monitor performance in DCPP Engineering.
4.10: Engineering performed a thorough and logical analysis of potential design errors which resulted in seven common error causes. It has taken appropriate corrective actions to prevent future design errors and monitor error trends.

5.0 Recommendations: None

6.0 References

6.1 “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 3.5, 2003 Radiological Release Report to NRC.
6.2 “Diablo Canyon Independent Safety Committee Sixteenth Annual Report on the Safety of Diablo Canyon Nuclear Power Plant Operations, July 1, 2005 – June 30, 2006”, Approved October 18, 2006, Exhibit D.8, Sect. 3.1, Joint PNAC/NSOC Meeting.
6.3 “Diablo Canyon Independent Safety Committee Sixteenth Annual Report on the Safety of Diablo Canyon Nuclear Power Plant Operations, July 1, 2005 – June 30, 2006”, Approved October 18, 2006, Exhibit D.7, Sect 3.5, Equipment Reliability Status.
6.4 “Diablo Canyon Independent Safety Committee Fifteenth Annual Report on the Safety of Diablo Canyon Nuclear Power Plant Operations, July 1, 2005 – June 30, 2006”, Approved October 18, 2006, Exhibit D.1, Sect. 3.5, Change Management and Organizational Development & Sect. 3.7, Piping Corrosion of Fire Protection System.
6.5 Ibid., Exhibit D.3, Section 3.5, Margin Management Program.
6.6 Ibid., Exhibit B.6, Results of Outage 1R13.
6.7 Ibid., Exhibit D.4, Section 3.1, Plant Security Update.
6.8 Ibid., Exhibit D.2, Section 3.9, Engineering Reorganization.

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Diablo Canyon Independent Safety Committee