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RIC 2009 Reactor Oversight Process Initiatives

RIC 2009 Reactor Oversight Process Initiatives. Michael Cheok Session Chair Deputy Director Division of Inspection & Regional Support Office of Nuclear Reactor Regulation March 10, 2009. General Session Information.

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RIC 2009 Reactor Oversight Process Initiatives

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  1. RIC 2009Reactor Oversight Process Initiatives Michael Cheok Session Chair Deputy Director Division of Inspection & Regional Support Office of Nuclear Reactor Regulation March 10, 2009

  2. General Session Information • Badges and Identification – Please remember to visibly display name badges throughout the duration of the RIC. • Cell Phones and Pagers – At this time, please turn off or silence cell phones and pagers. • Presentation Materials – All provided electronic presentation materials will be posted on the U.S. NRC RIC website at www.nrc.gov, keyword: RIC. • Evaluations – Please provide us with your valuable input via the Session Evaluation Form or e-mail comments directly to RICHelpDesk@nrc.gov.

  3. Presenters • Doug Dalbey • Deputy Director, Flight Standards Service, Federal Aviation Administration • Mont Smith • Director of Safety, Air Transport Association of America • William Noll • Site Vice President, Three Mile Island Unit 1 • Frederick Brown • Director, Division of Inspection & Regional Support, NRR

  4. Beyond the Regulations: A look inside the safety culture of the FAA and those we regulate

  5. AGENDA • The Perfect Storm • Mixed Signals • Beyond The Regulations • IRT Recommendations • Risk Groups & Indicators • Continuous Improvement • Conclusion- “The FAA’s Voluntary Disclosure Programs are vitally important to the future of aviation safety, and should be retained.”

  6. The Perfect Storm – April 2008 • FAA’s Reality TV Show • A Tale Of Two Airlines & Two Airworthiness Directives

  7. Mixed Signals • Media • Public • FAA • Congress • Too cozy • Too nitpicking • Dept. of Transportation • White House

  8. Area 4 Incorrect – No wrap on Back shell of connector and no tie tape Correct – Wrap on connector and tie tape

  9. Miscellaneous Pictures Taken During FAA Follow-up Audit Chaffing

  10. Beyond The Regulations“Voluntary Programs Under Fire” • Voluntary Disclosure Reporting Program (VDRP) • Flight Operational Quality Assurance Program (FOQA) • Aviation Safety Action Program (ASAP)

  11. Independent Review Team Recommendations • The FAA should retain the right to ground any plane not in compliance with an applicable AD. • The FAA should provide timely information about new AD requirements, in advance of compliance dates, to all relevant FAA field offices. • The FAA’s Voluntary Disclosure Programs are vitally important to the future of aviation safety, and should be retained.

  12. Risk Groups and Indicators

  13. Continuous Improvement • Air Transportation Oversight System • ISO Registration • AVS Overview Course • Safety Issues Reporting System • Partnership with Industry • Lessons Learned Web Site • Flight Standards Information Management System • Internal Assistance Capability • Aviation Safety Information Analysis and Sharing (ASIAS)

  14. Conclusion • Strike A Balance • Continually Analyze Risk • Trust But Verify • Listen To Your Workforce • Take Swift Action When Necessary

  15. SMS and Aviation Safety Oversight Reactor Oversight Process Initiatives Mont J. Smith Director, Safety – Air Transport Association of America, Inc. March 10th, 2009

  16. How are Unsafe Conditions Addressed? FAA Certification Offices– e.g., Seattle ACO, Engine ECOs Air Carrier reports to FAA via SDR – Service Difficulty Report If unsafecondition exists, under 14 USC39 ACO initiates an Airworthiness Directive (AD) OEM reports to ACO & develop Service Bulletin if Airworthiness issue (optional if safety “enhancement”) Air Carrier discovers problem not anticipated by manufacturer “Lead Airline Coordination Process” - ATA Spec 111 Air Carrier reports to Original Equipment Manufacturer ACO issues Notice of Proposed Rulemaking Public comments to NPRM Air Carrier Engineering Order (EO) AD or, Immediate Adopted Rule

  17. Why Did the April 2008 Process Go Wrong? • Air Carrier and FAA Certificate Management Office did not follow AD process to the letter • Non-compliance was assessed based on failure to strictly adhere to Service Bulletin instructions beyond achievement of the safety objective–“prevent wiring bundle chafing” • Service Bulletins and some EOs did not depict variations in as-delivered wiring bundle configurations • Licensed mechanics made “on the spot” judgments to prevent chafing • FAA Inspector guidance allows determination of “non-compliance” in the strictest sense without judgment of safety assurance

  18. Compliance vs. Safety • Is there a difference? • Should regulatory compliance be based on explicit instructions to the lowest level of detail or should standard practices and judgment be assumed at certain levels? • Can you be “in compliance” but still “unsafe?” • Is it possible to assess risk (probability of occurrence vs. severity) and manage expectations accordingly? • Task for operators – adopt SMS • Task for regulator – ensure SMS is working!

  19. What are Emerging Airline Safety Initiatives? • Air Carrier - Voluntary Safety Reporting Systems • Aviation Safety Action Program (ASAP) • Flight Operations Quality Assurance (FOQA) • Internal Evaluation Program • Maintenance Reliability Review Board (MRB) • Continuing Airworthiness Surveillance (CAS) • Voluntary Disclosure Reporting Program (VDRP) • Safety Management System (SMS) • Regulator –Air Transportation Oversight Program (ATOS) • Safety Management System (SMS)

  20. Aviation Safety Information & Analysis System What is ASIAS…? A collaborative Government-Industry initiative on data sharing & analysis to proactively discover safety concerns before accidents or incidents occur, leading to timely mitigation and prevention

  21. Traffic Management Reroutes and Delays • Airport Configuration and Operations • Sector and Route Structure • Procedures De-Identified FOQA Data ATC Information De-Identified ASAP Data Surveillance Data Aviation SafetyReporting System • En route • Terminal • Airport • Runway Incursion • Surface Incident • Operational Error / Operational Deviation • Pilot Deviation • Vehicle or Pedestrian Deviation • National Transportation Safety Board • Accident/Incident Data System • Service Difficulty Reports Safety Reports • Bureau of Transportation Statistics • Weather / Winds • Manufacturer Data • Avionics Data • Worldwide Accident Data Other Information Aviation Safety Information & Analysis System

  22. Aviation Safety Information & Analysis System ASIAS Participants at Major US Airports

  23. Aviation Safety Information & Analysis System Arrival Flight Tracks Ground Proximity Warnings Protective Airspace Oakland Airport

  24. Aviation Safety Information & Analysis System Typical ASAP Narrative During a right base leg for a visual approach, Air Traffic Control switched us to a new runway with our concurrence. Both pilots switched to the appropriate Instrument Landing System frequency as a backup for the visual approach. The localizer signal was confirmed, but no glide slope signal was obtained. We had already started the landing configuration sequence and were configured with flaps 15 degrees and landing gear down on a normal descent path. As pilot monitoring, I was attempting to discern why the glide slope was unavailable for the pilot flying. The 1000 foot call was made with an airspeed of 150 knots. V-target was 141 knots. Shortly thereafter, at 500 feet above ground level, we received the warning “too low, flaps.” The pilot flying called for flaps 30 degrees and the Before Landing Checklist. I complied but I should have directed a go around. The landing was completed without incident, and the taxi to the gate was uneventful. In an attempt to offer support to the pilot flying, I had allowed myself to become distractedduring a critical phase of flight with an unnecessary piece of approach guidance for the type of approach being flown. Proper prioritization and application of pilot monitoring duties would certainly have prevented this. Pilot monitoring is also flying, just not necessarily “hands on.” Whether pilot flying or pilot monitoring, one should aviate first and avoid/contain unnecessary distractions through correct identification and prioritization of perceived problems.

  25. Aviation Safety Information & Analysis System Digital Data Provides Insight about Flights: e.g., Unstable Approaches

  26. Desirable management levels Safety Management Systems Safety management levels Baseline performance High Middle Low “Practical drift” Reactive Predictive Proactive Reactive Organization System Analysis Design Assessment Surveys Audits Performance Assessment ASRS SDR Highly efficient Very efficient Efficient Insufficient Operational performance Accident and incident reports

  27. Wilbur Wright gliding, 1901 Photographs: Library of Congress Safety Management Systems “Carelessness and overconfidence are more dangerous than deliberately accepted risk”…Wilbur Wright, 1901

  28. The Safety Continuum William G. Noll Site Vice President Three Mile Island And the Role of Oversight

  29. Three Mile Island January 15, 1979

  30. “The Front Fell Off”

  31. “The Front Fell Off” “Tanker Safety” • Design • Construction Material • Staffing • Risk Assessment • The Environment

  32. “The Front Fell Off”

  33. The Auto Industry In the 1970’s it was all mpg “Miles per Gallon”

  34. The Auto Industry In the 1990’s it was all about "SAFETY"

  35. The Auto Industry Now it is all about being "GREEN"

  36. Too Cheap to Meter ? Our children will enjoy in their homes electrical energy too cheap to meter  ...    Lewis L. Strauss    Chairman of the U.S. Atomic Energy Commission Speech to the National Association of Science Writers September 16th, 1954  

  37. TMI November 1968

  38. Adhering to the Nuclear Safety Principles in goal setting, work execution, business decisions and day-to-day activities ensures the proper focus and balance in operational execution

  39. Nuclear Energy Is Green

  40. Why Regulatethe Nuclear IndustryorAny Industry • Public Trust and Confidence • Complex Technology and Design • Potential to Impact the Environment

  41. Public Trust and Confidence

  42. Why Regulatethe Nuclear IndustryorAny Industry • Public Trust and Confidence • Complex Technology and Design • Potential to Impact the Environment

  43. Complex Technology and Design

  44. Why Regulatethe Nuclear IndustryorAny Industry • Public Trust and Confidence • Complex Technology and Design • Potential to Impact the Environment

  45. Environmental Stewardship • A requirement for Nuclear Operations NIMBY

  46. Safety Culture Principle # 5 Nuclear technology is recognized as special and unique.

  47. Safety Culture Principle # 8 Nuclear Safety Undergoes Constant Examination

  48. CORNERSTONE CHART NRC’s Overall Safety Mission PUBLIC HEALTH & SAFETY AS A RESULT OF CIVILIAN NUCLEAR REACTOR OPERATION Strategic Performance Areas Reactor Safety Radiation Safety Safeguards INITIATING EVENTS MITIGATION SYSTEMS BARRIER INTEGRITY EMERGENCY PREPAREDNESS PUBLIC OCCUPATIONAL PHYSICAL PROTECTION Crosscutting Areas SAFETY CONSCIOUS WORK ENVIRONMENT PROBLEM IDENTIFICATION AND RESOLUTION HUMAN PERFORMANCE Identifying Problems Behaviors Self Policing

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