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 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

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

Look at the issues and bin them to the 3-Ball Diagram. 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

CM Model Functions #1 Protect the Design Basis #2 Modify the Plant #3 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

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

Protect the Design Basis 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

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.

NMC Tools Procedure/Work Instructions Verification and Validation 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.

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

Operate the plant Example 2 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

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

Procedure/Work Instructions 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

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.

Questions?