Loss of Configuration Management at Millstone

Millstone Refueling Floor Arrangement

Loss of Configuration Management at Millstone Time © Article, March 6, 1996, condemning Millstone management was released This article alleged that Millstone Unit 1 had routinely violated safety rules during refueling operations This article further criticized the Nuclear Regulatory Commission (NRC) for having knowledge of the problem while turning a blind eye to it

Loss of Configuration Management at Millstone CM Issues alleged in Time Magazine: No heat-load calculations for Spent Fuel Pool The plant had been routinely operating "beyond design basis," putting 23 million BTUs into a pool analyzed for 8 million Some Spent Fuel Pool pipes weren't designed to withstand an earthquake, as they were required to do. The Utility had conducted improper full-core off-loads for 20 years. Did not wait the requisite 150-hours to move fuel. In one case, fuel was moved after 65-hours.

Loss of Configuration Management at Millstone A key root cause of the problems at Millstone proved to be the organizational culture Employees with safety issues were routinely ignored by middle and upper management at Millstone The culture at Millstone rewarded cost cutting to the point where unreasonable and unsafe methods were overlooked if significant money was saved

Loss of Configuration Management at Millstone Northeast Utilities quickly reacted to the Time Magazine article by cleaning house at Millstone All top management, and many middle managers, were either fired relocated or took early retirement Bruce Kenyon was hired to fill the position of President and Chief Executive Officer Northeast Nuclear Energy Company

Loss of Configuration Management at Millstone Bruce persuaded three utilities with highly respected nuclear programs to help with the Millstone restart –Philadelphia Electric Power Company (PECO) –Carolina Power and Light (CP&L) –Virginia Power The most important task of the recovery effort was addressing the cultural problems

Loss of Configuration Management at Millstone The Northeast Utilities stock price dropped from about 25 dollars per share to about 7 dollars per share Northeast Utilities pleaded guilty in 1999 to twenty-five felony violations of environmental and safety regulations at its Millstone power plants between 1994 and 1996 and paid a fine of $10 million. Of the total, $5 million was related directly to nuclear operations, the largest fine in the history of the Nuclear Regulatory Commission's regulation of commercial nuclear power facilities.

Loss of Configuration Management at Millstone Northeast Utilities Stock - 10-year Period Sale Agreement Time Magazine Article

Loss of Configuration Management at Millstone 31 violations involving substantial and longstanding failures to meet design control requirements and to maintain the licensing bases, 18 violations involving longstanding unsatisfactory performance in identification and correction of significant conditions adverse to quality, 8 violations of technical specifications involving inoperable equipment and degraded conditions, and 11 failures in implementing various aspects of the quality assurance program. Millstone, Units 1,2 &3 EA , , , & Supplement I A Notice of Violation and Proposed Imposition of Civil Penalties in the amount of $2,100,000 was issued on December 10, The action was based on three Severity Level II and one Severity Level III problems consisting of: In assessing the penalty in this case, consideration was given to the varying degrees of significance and duration of the violations as well as the number of examples of the violations. The penalty was comprised of $500,000 for the violations related to inadequate engineering; $1,000,000 for the violations related to inadequate corrective actions; $500,000 for the violations related to violations of technical specifications; and $100,000 for the violations of quality assurance. In arriving at the cumulative amount of the civil penalties, the staff to exercised enforcement discretion in accordance with section VII.A of the Enforcement Policy.

Loss of Configuration Management at Millstone The culture had to change to restore the confidence of the NRC, the public, and plant employees. How does culture impact configuration management? – The entire organization must understand configuration management – The entire organization must embrace the importance of configuration management – Configuration management is a team effort that requires the support of all station workers

Loss of Configuration Management at Millstone Physical Configuration What is there Design Requirements What is required to be there Inaccurate or Missing Facility Configuration Information What is said to be there CM Equilibrium Diagram as Applied to Millstone Pre-1997

Loss of Configuration Management at Millstone Configuration management training and configuration management process improvements were needed All station workers, both utility and contractors, received the training

Loss of Configuration Management at Millstone NORTHEAST UTILITIES CONFIGURATION MANAGEMENT TRAINING OPENING STATEMENTS Why we are here Where NU Management Stands Regarding Configuration Management (CM) How CM Fits into Millstone’s Future Ownership of CM

Loss of Configuration Management at Millstone NU Training on Ownership of Configuration Management PREVIOUSLY –no assigned ownership of CM –no responsibilities –no accountabilities NOW YOU Play the Key Role for implementing effective, day- to-day CM on your unit Programs & Engineering Standards will define the standards and help to make them more accessible Unit Configuration Management Teams (UCMT) will help the Line implement and integrate CM

Loss of Configuration Management at Millstone Elements of the Licensing Basis (LB) From RAC 01 ): Regulatory Commitments Plant-Specific Design Basis & Other Plant Information Documented in the FSAR Plant-Specific NRC Requirements NRC Regulations ( e.g., orders, license conditions, exemptions, and Technical Specs, Quality Assurance Topical Reports etc.) ( e.g., 10CFR Parts 2, 19, 20, 21, 26, 30, 40, 50, 51, 54, 55, 70, 72, 73, 100 and 10CFR appendices) that are docketed and in effect While design basis information is generally located in the FSAR, it can also be found in other documents, including the TRM and docketed correspondence. Defining CM

Loss of Configuration Management at Millstone Design Bases (DB) Per 10CFR50.2 Information that identifies specific functions to be performed by a Structure, System, or Component (SSC) of a facility, and the... specific values or ranges of values chosen for controlling parameters as reference bounds for design. These values or ranges may be: 1.) restraints derived from generally accepted “state of the art” practices for achieving functional goals, or 2.) requirements derived from analysis (based on calculation and/or experiments) of the effects of a postulated accident for which a SSC must meet its functional goals. Defining CM

Loss of Configuration Management at Millstone Engineering Design Bases ( per NUREG 1397 ): The entire set of design constraints that are implemented, including those that are.... (1) part of the current licensing bases and form the bases for the staff’s safety judgment and (2) those that are not included in the current licensing bases but are implemented to achieve certain economies of operation, maintenance, procurement, installation, or construction. Defining CM

Loss of Configuration Management at Millstone Defining CM Relationships Between LB, DB, & Engineering DB LB EDB DB

Loss of Configuration Management at Millstone REQUIREMENTS Tech Specs FSAR Design Basis PHYSICAL PLANT/ SIMULATOR INFORMATION = = = CM PEOPLE PROCESSES PROGRAMS PROCEDURES Defining CM

Loss of Configuration Management at Millstone Introducing Change REQUIREMENTS Tech Specs FSAR Design Basis PHYSICAL PLANT/ SIMULATOR INFORMATION = = = CM PEOPLE PROCESSES PROGRAMS PROCEDURES Change

Loss of Configuration Management at Millstone  Modifications (Temp. and Permanent)  Replacements  Design Change Record/Notice  FSAR Change Requests  Automated Work Orders  Procedure Changes  Technical Specification Changes  Regulatory Changes Typical Sources of Change

Loss of Configuration Management at Millstone PEOPLE PROCEDURES PROCESSES PROGRAMS Configuration Management Is:

Loss of Configuration Management at Millstone The impact to the Utility from this event? –Unit 1 shut down permanently –Unit 2 and 3 were shut down over two and a half years –Billions of dollars in lost revenues and recovery costs –Utility eventually sold units to Dominion Scream (1893) by Edvard Munch

Loss of Configuration Management at Millstone The impact to the US Industry from this event? On October 9, 1996 the Nuclear Regulatory Commission issued a letter to every Nuclear Utility in the US entitled, "Request For Information Pursuant To 10 CFR ( F ) Regarding Adequacy And Availability Of Design Bases Information"

Loss of Configuration Management at Millstone a) Description of engineering design and configuration control processes, including those that implement 10 CFR 50.59, 10 CFR 50.71(e), and Appendix B to 10 CFR Part 50; (b) Rationale for concluding that design bases requirements are translated into operating, maintenance, and testing procedures; (c) Rationale for concluding that system, structure, and component configuration and performance are consistent with the design bases; (d) Processes for identification of problems and implementation of corrective actions, including actions to determine the extent of problems, action to prevent recurrence, and reporting to NRC; and (e) The overall effectiveness of your current processes and programs in concluding that the configuration of your plant(s) is consistent with the design bases. The NRC requested that each Utility provide:

Loss of Configuration Management at Millstone Dominion response to NRC 50.54(f) Letter: Preparation of design basis documents (DBD). The DBD program, in conjunction with other configuration management activities, establishes the design bases for the plants and serves as a means for maintaining and controlling changes to the plant's design basis. The DBDs will be issued by June 30,1999. Improving the Updated Final Safety Analysis Reports. The content of the Surry and North Anna UFSARs will be validated by October 1998 for consistency with design and operating information. The activity is directly responsive to the incentive offered by the NRC in its October 18, 1996 enforcement policy on departures from the UFSAR. Various format and content enhancements will also be implemented, as appropriate. Improving the Technical Specifications. License amendments will be prepared and submitted in February and April 1999 to convert, respectively, the current North Anna and Surry Technical Specifications from their current form to that of the Improved Technical Specifications (NUREG 1431).

Loss of Configuration Management at Millstone Integrated reviews of design and licensing bases information. Extensive design, licensing, and operating information will be assembled and evaluated by expert, knowledge-based, multi-disciplinary teams utilizing detailed work instructions and robust information systems to demonstrate compliance with each station's design and licensing bases. The integrated reviews are also the primary means by which the project demonstrates that the design and operation of Surry and North Anna are consistent with their UFSARs. Developing information systems. Information systems needed to support the overall project, and to improve the accessibility of design and licensing bases information will be developed and maintained. Improving configuration management. The root cause of departures from the UFSAR will be identified to ensure that the project's corrective actions are effective and comprehensive. Existing change processes will be reviewed to ensure the integrity of the design and licensing bases information is maintained. Independent assessments of project activities will be conducted. Appropriate process-oriented training will be implemented. The Integrated Configuration Management Project is a substantial undertaking initiated by Virginia Power. A new project organization has been established with adequate staffing and resources to accomplish the above tasks in the timeframes required Dominion response to NRC 50.54(f) Letter:

Loss of Configuration Management at Millstone

Impact on the Industry: Dominion response to the NRC Letter cost an estimated $50- million DC Cook Plants shutdown for over 2 years Clinton Plant shutdown for over 2 years Configuration Management improved in the industry