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Sonja Myers / Mike Nordin Nuclear Management Company Fleet Design Engineering

Analyzing CM-Related Condition Reports. Sonja Myers / Mike Nordin Nuclear Management Company Fleet Design Engineering June 11-14, 2006 Richmond, VA. Analyzing CM Condition Reports. Understand What your Corrective Action Program is Indicating

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Sonja Myers / Mike Nordin Nuclear Management Company Fleet Design Engineering

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  1. Analyzing CM-Related Condition Reports Sonja Myers / Mike Nordin Nuclear Management Company Fleet Design Engineering June 11-14, 2006Richmond, VA

  2. Analyzing CM Condition Reports • Understand What your Corrective Action Program is Indicating • Work through 2 examples to compare where the issues are in the 3-Ball Diagram • Bin the issues in both the 3-ball diagram and in your own Human Performance tools • Process improvements to place barriers to prevent recurrence of issues

  3. CM Related Issues • In-Process Errors committed during preparation of Engineering Products can be subtle: • Latent Errors go undetected for years • Errors caught in reviews may not get into CRs • Limits the feedback and course correction

  4. How to do this • Look at the issues and bin them to the 3-Ball Diagram. • Determine where the issue caused an unbalance • Take this information and apply your station’s Human Performance tools

  5. CM Model Functions #1 Protect the Design Basis Design Basis Configuration #2 Modify the Plant Engineering Change Control #3 Operate the Plant Operational Configuration Control #4 Maintain the Plant Configuration of SSCs not in service #5 Test the Plant Plant Design Validation 25

  6. NMC Picture Of Excellence Tools • Qualified Workers • Job Planning and Preparation • Procedure/Work Instructions • Verification and Validation • Supervisor Oversight • Worker Practices

  7. Example 1 • Protect the Design Basis • Instrument Air Compressor Room Temperature • Compressor Room Temperature was limited to 100 F • Intake Air for the Compressor was limited to 85 F • Intake Air was drawn from inside the Compressor room. • Station monitored the room temperature and assured the temperature did not exceed 100F

  8. Upsets in the 3-Ball Diagram Upsets Between Design Requirements & Facility Configuration Information • What went wrong • Design characteristics and bounding parameters needed for the design to work • The design had assumed the compressor intake air came from outside air. • The intake actually came from inside the room. • The limit was selected on other parameters for the compressor. • Must be verified or monitored to confirm that design is valid • Operator rounds recorded the temperature, but had the wrong limit.

  9. NMC Tools • Procedure/Work Instructions • Procedures at the time allowed assumptions to be made without justification for why they were valid. • Verification and Validation • Assumption was made in the analysis and not verified • Worker Practices • Preparer thought intake was from the outside and incorrectly assessed the equipment requirements • Reviewer did not identify this.

  10. Operate the Plant Objective: Assure that alignment of in-service equipment is consistent with approved design through use of approved technical procedures.

  11. Example 2 • Operate the plant • Recurring T-mod to allow testing of Safety-Related Batteries in Modes 5 and 6 • Temporary cable to allow the battery loads to be supplied by a smaller sized batteries • HELB pressure boundaries need to be maintained

  12. Upsets in 3-Ball Diagram • Upsets Between Physical Configuration & Facility Configuration Information • What went wrong • HELB boundary requires a special permit and engineering review to assure analysis assumptions and technical requirements are met • Temporary procedure did not have a verification the permit was obtained

  13. NMC tools • Procedure/Work Instructions • Procedures for installation did not have a step to assure the HELB boundary permit was obtained • Procedure for T-mods did not include a review of the recurring T-mod procedure to assure all critical aspects were included • Verification and Validation • T-mod assumption was that the installation procedure had the permit, engineer did not verify this was included. • Procedure verification did not identify this issue

  14. Conclusions • Although many issues in CM are found a long time after the error was made, the barriers to prevent an error from entering the plant, may still be the same. • Look at the processes and where the issues entered the plant to strengthen your CM program • Focus on the tools.

  15. Questions?

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