DCISC Recommendations 2000–2001 through 2015–2016 Annual Report Periods


  1. The recommendation designator, e.g., “R14-1”, signifies the calendar period and sequential number of the recommendation for that time period. In this example “14” stands for the period July 1, 2013–June 30, 2014.
  2. All DCPP responses to recommendations were determined to be acceptable by the DCISC, some after further discussions or actions. There were no open or unresolved recommendations.

DCISC Recommendations

DCPP should reexamine the significance of the role that Operations personnel played and could have played to avoid the loss of power to Unit 2 4 kV Bus G during refueling outage 2R17.
Because of the relatively large increase in Licensee Event Reports from the previous reporting period, continuing high number of Non-Cited Violations, and the number of items in the Conservative Decision Making Cross-Cutting Aspect, the DCISC recommends that DCPP review the effectiveness of its Regulatory Excellence Action Plan.
The DCISC recommends that DCPP evaluate the various constraints on how fast spent fuel bundles can be loaded into the Independent Spent Fuel Storage Installation (ISFSI), and develop an estimate of, and the rationale for, the practical limit on the number of spent fuel bundles that can be loaded into the ISFSI on a per year basis.
DCPP should assign a manager with the authority and inclination to develop the DCPP site office and workspace seismic safety policy and devote the resources needed to implement necessary changes to avoid harm to personnel from a seismic event.
Due to the substantial increase in the numbers of NRC Non-cited Violations and Severity Level IV Violations over the last two reporting periods and because the NRC Substantive Crosscutting Issue in Problem Identification and Resolution still exists, the DCISC recommends that DCPP re-examine its earlier Root Cause Analysis for effectiveness and consider an independent review of its corrective actions by Quality Verification, the Nuclear Safety Oversight Committee, or the Institute of Nuclear Power Operations in an assist visit.
The DCISC recommended that DCPP initiate and promptly complete its first self-assessment of the significant gap in the thoroughness and rigor of its engineering evaluations, which was to have been completed by the end of 2010.
DCPP’s Post Earthquake Response Procedure should be expanded to require examination of Spent Fuel Pool (SFP) levels after an earthquake and sampling locally for indications of possible SFP liner leakage. DCPP should also consider providing permanently installed, remote wide-range SFP level monitoring capability.
DCPP needs to develop and implement a schedule for taking the necessary actions to brace furniture appropriately throughout the station, and to better educate plant staff about seismic hazards and seismic safety.
Due to the increases in the numbers of Licensee Event Reports and Severity Level IV Violations and because of the newly re-identified NRC Substantive Crosscutting Issue in Problem Identification and Resolution, the DCISC recommends that DCPP perform a comprehensive analysis to determine the cause of these negative regulatory trends.
The DCISC recommends that DCPP managers and supervisors periodically share the specific lessons learned from the series of events involving containment sump valve interlocks with station personnel at all levels, especially before the commencement of outages. The DCISC further recommends that DCPP share this same information with the industry.
DCPP should complete the MIDAS-related actions listed in the CAP in a timely manner and resolve this issue with the San Luis Obispo County APCD for use at future Emergency Drills. It is important that the modeling of plume dispersion from the plant be capable of accurately predicting which Protective Action Zones would be impacted by a release.
PG&E should carefully review its emergency response communications with the media (press briefings and releases) and with San Luis Obispo County and other government officials, and develop different approaches that better communicate risk information.  PG&E also needs to include more technical detail in its press releases, with the understanding that they are likely to be read and interpreted to the media by external experts.  If asked during press briefings for more detailed technical information, PG&E should not deflect these questions but instead should answer them using technical terms while avoiding jargon.  In future EP exercises (around half), scenarios should involve events where releases are too small to warrant public evacuation, so that PG&E and government officials can practice providing more effective information for these more likely emergency events.
Emergency Response Organization (ERO) should consider designing a drill that focuses on the information exchange with the news media. The event chosen could be less serious than those designed to challenge the operators. It could involve a low level of risk to the surrounding population, and require the Joint Media Center (JMC) personnel to communicate this effectively to the media.
DCPP should consider developing a system to categorize and catalog Operational Decision Making documents (ODMs) for future reference and use. This is especially important as DCPP brings new operators into its workforce and moves experienced operators to other plant functional areas.
PG&E should strongly consider involving craft personnel when developing industrial safety standards, procedures, or guidelines to obtain craft buy-in and ownership.
DCPP does not have a written description of all the Make-Up Water Systems with associated operating procedures. The DCISC believes this to be an unsatisfactory condition and strongly suggests DCPP management review it for appropriate correction action.
DCPP management should place special emphasis on Operations achieving Green Quality Performance status in a timely manner, correcting problems in human performance, component mispositioning errors, and procedure use and adherence. Management should deal directly and promptly with known Operations personnel issues.
DCPP should review the staffing of the QV Department to be sure they have sufficient personnel to perform the necessary audits (both regulatory required and others as needed).
DCPP should consider expanding QV audits beyond just those required by regulation to aid management and NSOC in assessing and monitoring the health of programs, processes, initiatives and systems.
DCPP should place additional emphasis and resources at the management and project level to improve the health of its Fire Protection System from Yellow status (unsatisfactory) to at least White status (satisfactory) in a timelier manner than is currently planned.
It is recommended that DCPP participate in more industry and INPO meetings and visits to be sure that DCPP is staying up with industry good practices in all areas of plant operation. DCPP should also have a QV audit of this area.
PG&E should consider using one designated Lead Public Spokesperson, an officer, for all of its media briefings on emergency information to the media and public at the Joint Media Center. Because a specific person cannot be available at all times, backup personnel also need to be designated and trained.
PG&E should work with both San Luis Obispo County and the State of California to improve the clarity and precision of their statements regarding radiation releases. This is necessary to assure that information on projected and measured offsite dose rate measurements by PG&E and County monitors are more clearly communicated to the media and public.
The Quality Verification (QV) Department should request that the NSOC Subcommittee on Corrective Action & Oversight and other outside NSOC Members recommend the areas of QV to be audited for the outside biennial audit in 2005. QV should also include the Corrective Action Group in an audit in 2005).
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. (Note: this recommendation was provided to PG&E during the DCISC June 1–2, 2005 Public Meeting).
Because necessary post-9/11 security upgrades at DCPP have been very substantial, over the next one to two years PG&E should actively monitor interactions of security with plant operations, maintenance, and emergency response to assure that potential negative security/safety interactions are identified and mitigated, as necessary to assure plant safety. Upcoming emergency exercises should be designed to test scenarios where plant operators and emergency response personnel would be expected to have significant interactions with plant security systems and forces, to confirm that effective communication and coordination are achieved.
DCPP should remain aware of the possible unintended consequences of the “Operations Leadership” initiative on the rest of DCPP and its impact on DCPP and its culture.
DCPP should examine further the employee perception that management expectations (on safety) are not consistent with performance reviews, rewards, and discipline, specifically including the relationship between the newer method of employee performance evaluation and these perceptions.
Safety culture needs to be a commonly shared and understood term at DCPP. DCPP should develop or adopt a definition of “safety culture”. Each employee at DCPP should become familiar with the concept of safety culture. Safety culture should be incorporated in training and all other activities at DCPP. A belief that safety culture is “built in” through design, testing, procedures and QA/QC is not enough. There must be a conscious effort to incorporate the concepts of safety culture into all activities, including training, coaching, supervision, management, and leadership.
There should be a responsible party over the areas of cultural change, safety culture, organizational effectiveness, and leadership so that there can be coordination and integration, and a single comprehensive plan can be developed and executed that addresses these issues as a system.
PG&E should review its specification of root causes in Corrective Action Program cause analyses to assure that they are identified accurately and clearly in order to promote the most effective corrective action. In particular, PG&E and the Human Performance Group should develop a method to assure that human performance errors are always addressed in cause analysis and are distinguished from other causes, such as organizational effectiveness issues. Management should make clear their expectations that the results of cause analyses will be stated clearly and bluntly and not softened, avoided or disguised.
DCPP should review the organization and practices of the NSOC to identify ways to ensure that all issues identified and all recommendations made by the NSOC are fully discussed and acted upon. Benchmarking of other organizations to determine evolving best practices should be included as part of this evaluation.
As previously recommended in the 2002–03 Annual Report, DCPP still needs to develop a comprehensive integrated change management plan, where all changes can be located, where interaction effects can be anticipated from changes that are occurring in the organization, where the consequences of multiple simultaneous changes can be anticipated, and the value of change (or not changing) can be ascertained.
DCPP needs to continue to utilize external consultants such as Mercer-Delta to observe the work of DCPP and coach its Executives, Directors, Officers and Managers, as well as front-line employees.
PG&E should decide when they are going to perform a life-cycle management study of the 12 kV System and complete it on schedule. In the interim, they should proceed with corrective actions on the items identified in the system health report.
PG&E should grant security clearances to two DCISC Members and a Consultant.
To make the coaching process sustainable, DCPP should further support the Coaching Center of Excellence in developing a formal structure for coaching.
PG&E should apply a focused effort to complete and implement the process for measuring and monitoring the effectiveness of its Corrective Action Program.
Emergency Preparedness should be improved by (1) extending its emergency exercises or perform separate exercises to more fully exercise its radiation release assessment and communications and Joint Media Center (JMC) spokespersons, (2) identifying the spokesperson for security-related events and having that person fill a functional JMC role at drills dealing with security events, (3) establishing better coordination with San Luis Obispo County on providing information to media and Public, (4) connecting the telecommunications between emergency centers to emergency power supplies, (5) making statements communicating radiation releases to the public easier for the public to understand, and PG&E (6) working with San Luis Obispo County to issue joint news releases to provide the public with a single, coordinated source of information about the incident at the plant, the nature and expected impact of any radioactive releases, and protective action recommendations, and (7) providing more training and practice in communicating unplanned radiation releases to the public via written news releases and through media briefings at the Joint Media Center.
NSOC should be strengthened by adding a (non-STARS plant) fourth external member.
PG&E should allocate enough resources and management attention to the Equipment Reliability Program to effectively implement the recommendations made in the Equipment Reliability Process Self-Assessment and consider expanding the Equipment Reliability Program to include all equipment important to unit availability.
DCPP should develop a coherent framework or model for cultural change showing how the various initiatives fit together and a plan to integrate the changes.
PG&E should develop strategies to monitor, on a regular basis, DCPP’s cultural change and the impact of cultural change on safety.
DCPP should institutionalize the coaching strategy, remaining aware of unintended consequences of separating personnel evaluation and coaching and ensure a close association between coaches and supervisors.
A Phase Two of the WE Culture should be initiated as soon as possible
The Process Facilitator position, for DCPP Process and Process Transition, should be filled promptly with a recognized leader.
In addition to having an internal Organization Design Specialist, it is recommended that PG&E consider “Outside help.” This would mean bringing in consultants in specialized areas of human performance, change management, and process management, to support the internal OD Specialist and the Human Performance Center of Excellence.
To enhance the human performance/behavior change process DCISC recommends that PG&E develop and implement:
These recommendations should help align and integrate the multiple change initiatives and provide a more coherent change process to the workers.
While the DCISC has not observed any adverse effect of DCPP safety incentives being dependent upon financial incentives, i.e., diminishing of a “safety first” culture, it is recommended that for future years PG&E consider revisions to the plan to ensure that good safety performance is always recognized and rewarded.
The DCISC recommends that PG&E share the results of its PRA Human Reliability Analysis, particularly the Performance Shaping Factors, with the Human Performance Coordinator and others who may benefit from the information.
PG&E should assure that human performance/behavior is fully considered by qualified people in performing event cause analysis.
It is recommended that PG&E increase efforts to resolve communications problems, especially those about radiation, for both normal and emergency situations and arrange drills to better exercise radiological field monitoring teams and public spokespersons.
PG&E should review the noise level in the Emergency Technical Support Center and consider taking steps to lower it to prevent communication problems.
It is recommended that PG&E consider discussing with the County the respective roles of PG&E and the County at the JMC. For example, it might make sense to have PG&E lead the JMC press conferences to first discuss plant events and information and then have the County present what the County is doing. Even more importantly, PG&E management may wish to ensure that their ability to release information in a timely manner is not inadvertently limited and to ensure that their spokespersons are prepared to deal with and resolve any issues which may arise with the County at the JMC. All PG&E personnel at the JMC, and particularly those who will discuss radiation, should receive better training and more practice in dealing and communicating with the media.
It is recommended that PG&E be more thorough in its critiques and assessments of emergency drills to assure effective follow-up on corrective actions on all deficiencies or questions.
It is recommended that PG&E review the availability and level of effective plant public spokespersons in the Joint Media Center. These spokespersons should be senior personnel knowledgeable in plant operations, radiological matters, and status of the emergency event. The same individuals should be regularly trained and tested in emergency exercises.
There were only three external members on the NSOC as of the writing of this report. External members provide a more independent overview; therefore it is recommended that DCPP add additional external members.
Even though the 12 kV System is a non-safety-related system, PG&E should include the 12 kV system as one of the first systems to be reviewed under the Life Cycle Management Plan. PG&E should also review the replacement schedule for Start Up Transformer 1-2 to assure replacement is timely.
It is recommended that DCPP develop and implement a method to identify and monitor the entire Engineering Work Load to assure that the necessary work is performed to effectively support safe operation of the plant and to help in ensuring adequate engineering resources are available.
Because the predominant cause of events is human error, it is recommended that DCPP more closely coordinate the Corrective Action and Human Performance Programs and utilize training in human characteristics and skills (e.g., interviewing skills, human error characteristics) for personnel preparing root cause analyses and corrective actions.
It is recommended that PG&E continue to augment its programs for operator health and aging to consider such areas as operator “aging management”, physical fitness, and mental alertness on shift to further improve operator human performance.
It is recommended that PG&E management raise its expectations of the Nuclear Safety Oversight Committee internal and external members to take a more aggressive stance in challenging problem solving and the status quo. Additionally, PG&E should consider adding independent external members (not just from STARS plants).
It is recommended that NSOC take a more active role in determining the scope of the biennial audit of NQS to give the audit more independence. The DCISC had made a similar recommendation in the previous Annual Report and requests that PG&E reconsider its response of having NSOC only review the audit plan.
It is recommended that PG&E take the initiative in dealing with staffing issues by developing a long-term staffing plan.
It is recommended that PG&E take actions necessary to improve the employees' perception of the Employee Concerns Program.
It is recommended that PG&E apply the normally used Corrective Action Program, Human Performance Program, and System Long Term Plan Program (and possibly others) to Security Services and develop an implementation plan.
It is recommended that PG&E develop a plan for how System Health Reports and Long Term Plans should be utilized by Operations and Maintenance.

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