[ Reactor Accidents Sub-Directory ] [ COMPLETE DIRECTORY ]
-- Part Two --
July 21, 1997
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Both the OHN corporate and site-specific organizations are ineffective. There are notable differences in organizational structures from site to site. At Pickering the Shift Supervisor is accountable for the maintenance staff but this is not the case of Darlington and Bruce. There is a Shift Operating Supervisor at Pickering and Bruce but not at Darlington. This variation in the shift organization has raised the concern of the AECB.
There is a feeling at the sites that they lack sufficient engineering resources; however, the current organization of roles and work assignments are resulting in poor utilization of existing staff. There are significant variations in engineering organizations from site to site.
Maintenance has not had a clear organizational priority. There is no single organizational unit which has accountability for the overall maintenance program. As a result, programs, planning and execution of maintenance are all seriously deficient and have caused erosion of OHN asset values. No central organization has the responsibility of monitoring and advising the sites on the adequacy of their maintenance programs.
Nowhere is there a defined and functioning First Line Manager role; that is, a role which is clearly understood to be part of the managerial hierarchy and accountable for the output of the first level workers. There are several supervisor roles (not manager) which do not have clearly defined accountabilities. The end result is that most first line workers are essentially disconnected from management and get most of their direction from the Power Workers' Union (PWU) leadership.
Resources
While the steady state resource levels in OHN may be adequate, there are areas such as training where there are severe shortages. These shortages generally are leading to serious backlogs in training, with the results that staff not meeting qualification requirements.
There are insufficient Authorized Nuclear Operators (ANO) to staff a properly designed shift organization. The staffing plan for ANO's must take into consideration the long lead times required to qualify ANO's.
There are not enough capable managerial staff to fill essential roles. This causes people to be placed in roles in which they cannot succeed.
Recommendations
Certain provisions of the union contracts limit the effectiveness of management. Major issues include the following:
The collective agreements are heavily slanted towards the unions and are unduly restrictive of management. Managers' ability to make efficiency and productivity improvements by changing processes and methods is often hindered by contract language and past practices. For example, the use of contractors to handle specialty or peak-type activities has to undergo an arduous and unwieldy "purchased services agreement" process that basically discourages the use of contractors by requiring union pre-approval or the payment of hefty premiums (guarantees of overtime). This hampers the managers' ability to chose the most businesslike option and perform effective leadership and management roles while recognizing the rights of the employee.
In addition, Ontario Hydro Nuclear employees should not have the right to strike because of the critical and essential nature of electricity. Electricity is as important to public health and safety as police and fire service. It should be a matter of public policy to guarantee that it is not interrupted, just as is done with police and fire. In the past, the threat of a strike has resulted in major efforts to prepare contingency plans at OHN facilities. The preparation of such plans is not only costly and disruptive to routine operations, but also results in a recognizable decrease in public safety, since personnel designated to monitor shutdown nuclear reactors and handle site emergencies are not as experienced as those normally assigned. Moreover, the public of Ontario would be severely affected by a strike at OHN's nuclear facilities, which supply more than 60 percent of the province's electricity. Management has avoided such strikes in the interests of serving the public, but only at the cost of excessive concessions to the unions.
Examples include the long-term employment guarantees and the absence of a fitness-for-duty program. A fitness-for-duty program would ensure that personnel working in critical areas of the nuclear program (those affecting nuclear safety) are free of any mind-altering substances that could inhibit their ability to discharge their duties. The company is currently prohibited from being proactive in this matter because of past arbitrator decisions and the unwillingness of the unions to agree on mandatory drug and alcohol testing or random testing.
Another example is the "Chestnut Park Accord" (CPA) agreed to by the Power Workers' Union and Building Trades Union's to alleviate the heavy burden placed on the Ontario Labour Relations board by jurisdictional disputes between the unions. The CPA's addendum was subsequently signed by OH management. On the plus side, the CPA has led to a dramatic decline in jurisdictional disputes. The drawback, however, is that management now has no input into decisions about which unions perform the rehabilitation or modification work. Instead, unions or an arbitrator make such decisions under the CPA.
Many issues related to the plant's physical security program are still outstanding even though corrective actions were identified several years ago. Legislative action will likely be necessary to achieve the required changes. These include the physical searching of personnel and their personal belongings upon entering and leaving plant property. Such search programs have been in effect in the United States for many years and are instrumental in reducing the likelihood of sabotage, theft and the introduction of contraband at the nuclear sites.
The long-standing practice of allowing many Union Officials to be on full-time release means that not enough qualified people are available for productive work. The question of who and how many will receive full-time release for union purposes is arrived at only after OHN has already determined staffing levels for each functional group. The result is a disruption of production.
All told, these restrictions arising out of the collective agreement have resulted in a passive management style. Most managers are unwilling even to enforce the existing contract. Managers believe that nothing can or will be done to try to regain the basic authority they need to manage effectively.
Recommendations
Site Specific and Corporate Reviews
Bruce Generating Station
| 1. Operations | Minimally Acceptable |
| 2. Maintenance | Minimally Acceptable |
| 3. Training | Below Standard |
| 4. Engineering | Minimally Acceptable |
| 5. Quality | Minimally Acceptable |
| 6. Radiation Protection | Minimally Acceptable |
| 7. Chemistry | Below Standard |
| 8. Emergency Preparedness | Below Standard |
| 9. Security | Confidential |
Operators continue to have difficulty maintaining positive awareness of system and equipment status. A major contributor to this issue is the excessive human error rate that continues to occur at both plants. The complexity of the work protection code also poses a significant impact on performance. The maintenance process at both plants has been unsuccessful at improving plant material condition as demonstrated by increasing backlogs. It appears that management is not holding itself, or its personnel, accountable for performance results. Compounding these problems is the fact that the Western Nuclear Training Department (WNTD) lacks sufficient resources to support plant needs adequately and to effectively implement the Nuclear Recovery Plan and Peer Improvement Plans according to established schedules. The Nuclear Recovery Plan goals to (1) achieve full qualification (initial training) in designated job families by December 31, 1999, and (2) complete continuing and re-qualification training by December 31, 2000, will not be achieved without management attention.
The engineering function lacks a clear and focused safety perspective. Operability decisions are taken in a less than rigorous manner without full consideration of all of the design and licensing bases of the plant. Furthermore, several key engineering processes are inadequately defined and controlled. These include the following:
The Quality function is not used by management as a tool to drive improvement. Neither the assessment staff nor the assessment plans are aggressive enough. Issues are not consistently identified; root cause analyses tend to be superficial; corrective actions are neither aggressive nor managed; independent oversight is weak; evaluation of the corrective action process is limited; and resources are not being effectively utilized.
The status of Radiation Protection (RP) is less than adequate to prevent the spread of contamination and to control radioactive materials. RP procedural non-compliance occurs in areas known to contain contamination and are not being corrected by line supervisors. Uncontrolled contaminated material has been discovered at the Bruce A north warehouse. Collective doses at both stations is low by international standards and self-protection may have been a significant driver for these positive results. Likewise, the chemistry program is relatively effective. System process chemistry control has generally been subject to steady improvement over the course of several years and generally meets OHN standards. However, some important exceptions still exist, such as inconsistent control of dissolved oxygen in the condensate and inadequacies in the management of hazardous materials.
Finally, the emergency preparedness function has suffered from neglect. Processes that are not operating well include the following: controlling fire loading; training for radiological emergencies; use of operating memos for procedure revisions; backlog reduction; accounting methods; and addressing fire protection system design and equipment deficiencies.
Ranking by Performance Area
| 1. Operations | Minimally Acceptable |
| 2. Maintenance | Minimally Acceptable |
| 3. Training | Minimally Acceptable |
| 4. Engineering | Minimally Acceptable |
| 5. Quality | Minimally Acceptable |
| 6. Radiation Protection | Below Standard |
| 7. Chemistry | Below Standard |
| 8. Emergency Preparedness | Below Standard |
| 9. Security | Confidential |
Although a conceptual framework for the desired safety culture has been developed, processes are not in place that will ensure long term, safe operation of the station. Currently, operations management is not setting high standards for themselves or demanding the best from other departments. This was demonstrated by the use of an alternate procedure without the proper management controls required for infrequently performed evolutions, when the normal coolant system cooldown procedures could not be used for Unit 2 because of a leaking valve. The operations group has knowledgeable, motivated people, but they are hindered by work processes which present them with frequent challenges. The station organization does not have a clear operating focus and individuals and support groups do not constantly ask how they can contribute to safe and reliable operation by assisting the operations group. This is caused by a general lack of an operational focus in the support organizations.
Several weaknesses were identified in the maintenance performance area, such as insufficient managerial leadership, inefficient work control processes, incomplete training and qualification, and inadequate conduct of maintenance. Specifically, management of the maintenance function does not provide the managerial leadership necessary to ensure that high standards are met in all aspects of the maintenance program. Ineffective communications, performance indicators, individual performance plans, and lack of top management involvement in flowdown of expectations is limiting implementation of improvements in the maintenance area.
Managers have been unsuccessful at improving the material condition and the plant as demonstrated by corrective maintenance backlogs that have increased 10 percent per year since 1994. Ineffective work control is causing equipment important to station operation, including some safety-related equipment, to be out of service longer than necessary.
Failure to analyze why increases in the preventive maintenance activity since 1995 is not causing a corresponding reduction in corrective maintenance demonstrates analytical weakness.
Finally, "bad news is not flowing up in the organization" which creates a general misplaced satisfaction that station performance is better than it really is.
The training process does not ensure that personnel are qualified to perform their duties, nor does it ensure that they retain and enhance their capabilities through appropriate continuing training. Training procedures and policies are inadequate or not adhered to by Eastern Nuclear Training Department. These deficiencies have arisen because of a lack of adequate management attention within the station and the training organizations. The training program for Chemical Technicians is an exception to the foregoing. This program meets industry standards and is a model for the design and delivery of all training programs.
Several areas within engineering require significant improvement, but there is little evidence that aggressive corrective actions are being implemented. Maintenance and accessibility of design basis information is poor and the implementation of the change control process has been slow to achieve lasting improvement. The organization lacks an effective, integrated work management system and meaningful system surveillance and life cycle management programs. Engineering's involvement in significant challenges to the plant's safe operating envelope is not proceduralized and occurs informally at the discretion of operating personnel. This is inconsistent with the role of the engineering function in protecting the designed nuclear safety margin, conservative decision-making and, in the long term, preserving the Company's financial asset (i.e., the station).
The Quality performance area has significant problems. The problem identification techniques such as operating experience and problem identification and reporting are not being effectively used. A significant impact on safety is represented by materials and parts that have been substituted without following the approved design change process. Also, a number of SERs document repetitive and ongoing problems with unauthorized and uncontrolled design changes. Most of the control maintenance procedures contain the phrase "no verification required."
Radiation dose is very low by international standards and generally the station is relatively clean of radioactive contamination. Good radiological design and continued application of the As Low As Reasonably Achievable (ALARA) Program will help maintain low exposure levels. There are several indicators that plant area contamination levels are low and that it is well contained within the station. This includes alarm frequency at the Zone 2/1 boundary, whole body counter data, radiological log entries and the low frequency of SERs related to personal contamination.
The station shipping procedures have also been revised within the last year to ensure that all appropriate controls are in place and that contaminated materials are not inadvertently shipped to non-licensed facilities. However, personnel contamination control practices are less than adequate, and if uncorrected, could lead to future loss of control. There is evidence that the Radiation Safety Section is not providing sufficient ongoing assessment and oversight of the station radiation safety program. Radiation Safety resources are severely constrained at both the professional and technician level.
Conduct of laboratory operations was found to be a strength overall. Laboratory management processes include good shift turnovers and pre- job briefings and field operations by supervisory staff. Sampling procedures are well documented and appear to be strictly followed by technicians. Lab analyses are carried out with proper attention to equipment calibration and the use of quality standards. However, improvements made in system chemistry control are not being sustained. There is a lack of management commitment to the prompt remediation of system upsets, such as condenser tube leaks, which have a critical impact on system chemistry. As a result, impurity ingress to steam generators is permitted to rise. Other key parameters are outside of the specification for significant periods of time. Finally, the program to bring hazardous chemicals under control has not progressed far enough and weaknesses exist in the station lubricating oil and FRF monitoring program.
There is no overall Corporate Emergency Preparedness Plan and the site emergency preparedness organization is not monitoring important program functions or resolving important AECB action items. Site staff who administer the EP program operate at a lower level in the program and are not in a position to understand the corporate intent and requirements for the EP program. Nevertheless, the overall EP function adequately responds to site emergencies.
Ranking by Performance Area
| 1. Operations | Minimally Acceptable |
| 2. Maintenance | Minimally Acceptable |
| 3. Training | Minimally Acceptable |
| 4. Engineering | Minimally Acceptable |
| 5. Quality | Minimally Acceptable |
| 6. Radiation Protection | Minimally Acceptable |
| 7. Chemistry | Minimally Acceptable |
| 8. Emergency Preparedness | Below Standard |
| 9. Security | Confidential |
The station does not demonstrate a strong operations focus. When issues are raised at the morning meeting or at the Quality of Work status review meeting, there is little visible collateral upper management support for the needs of operations. Work protection code problems continue to cause the potential for serious injury. The standards for the conduct of operations are not consistent with good industry practice. Management has not effectively resolved long-standing problems which have a negative impact on operator performance. Station activities are not effectively managed so that plant operation and configuration conform to design bases and remain within the bounds of analyzed conditions. Operations procedures and processes require improvement to maintain plant safety and to reduce the consequences of events.
Weaknesses were identified in the areas of maintenance leadership, work control, including outage management, conduct of maintenance, qualification and training, equipment performance and material condition, and maintenance facilities and equipment. Due to ineffective leadership, the plant material condition has deteriorated. Lack of managerial leadership has reduced the effectiveness of overall station maintenance and is demonstrated by the lack of a comprehensive maintenance plan and strategy. The failure to communicate upward frequently precludes senior station managers from obtaining accurate information on important quality of work improvement initiatives.
The training process does not ensure that personnel are qualified to perform their duties and it does not ensure that they retain and enhance their capabilities through appropriate continuing training. Plans are inadequate to correct the problem. These deficiencies have arisen because of a lack of adequate management attention in the training organization, because of a lack of adequate resources in the training organization, and because policies and procedures are either inadequate or not adhered to.
Several areas in engineering require significant improvement. Aggressive corrective actions are not being implemented. Maintenance and accessibility of design basis information is lacking. The design manuals are out of date and have not been revised to reflect plant modifications. Updating the design manuals is not a high priority for the station. In some cases (e.g., setpoints) operating information is being used to define the design basis rather than referencing design information. There are an excessive number of outstanding changes (ECN's, Jumpers, DCN's, etc.) that are not reflected in the design documentation and there have been, and continue to be, many examples of undocumented substitute parts installed in the plant. The philosophy for controlling changes is inconsistent. Directives that are issued to help control changes appear not to be understood or followed. Finally, the focus on system surveillance and performance monitoring varies from non-existent to very good.
The Quality program has many of the elements of a good program, but the pieces do not fit together into an integrated process. For example, issues are not consistently identified, the analysis of problems tends to be superficial at times, corrective actions are not aggressive and are not well managed, independent oversight is weak, receipt inspection isn't required in all cases, evaluation of the corrective action process is limited, and in-process inspections of maintenance and modification activities are generally not performed. Lastly, the QA organization is not authorized or directed to have high-priority access to management to bring issues to a head quickly, and they are not being used as the management tool they can or should be. There are very serious problems in pressure boundary work and material handling that could easily call into question the safe operation of plant systems. These processes are badly impaired and need immediate action to improve.
Management of the radiation protection program needs strengthening in several areas through a clearer understanding of the role of the radiation safety organization. At present the radiation protection management does not consider that they are ultimately responsible for the station's radiological performance, nor do they believe that they should aggressively force resolution when responsible work groups fail to correct radiological issues. Therefore, effective and aggressive corrective actions have not been taken by radiation protection management to correct weaknesses identified through Peer reviews, AECB audits, and radiation safety assessments such as procedural non-compliance, personnel contamination events, etc.
The contamination control program needs to be further strengthened through aggressive effort in controlling contamination at the source and raising plant staff sensitivity to contamination control practices. Several areas are contaminated and several contaminated items are stored in the plant; any work performed in these areas increases the likelihood of spreading contamination. There have been instances of contamination being found outside the power house or contaminated items being shipped off-site to unlicensed facilities.
Deficiencies exist in practically all aspects of the chemistry control program. Numerous long-standing problems have not been resolved, such as control of condensate dissolved oxygen and impurity ingress from condenser tube leaks. It has taken years to install the equipment required to control annulus gas chemistry, and control on all units is still not effective. It is clear to the assessment team that the lack of resolve and management commitment to improve chemistry performance at Pickering is a direct result of a lack of strong leadership in this function.
Finally, the site maintains the basic capability necessary to respond in the event of a nuclear emergency. The EP process used to check and maintain their radiological emergency equipment and supplies is very good and worthy of note. However, a number of problems were identified involving fire safety and the emergency response team, EP training, drill program, and notifications.
Safety System Functional Inspections
Bruce A SSFI Emergency Coolant Injection System
Significant deficiencies that could adversely affect the ability of the Emergency Coolant Injection (ECI) system to fulfill its design safety function were identified in each functional area examined. The following six issues were considered to be significant and deserving of prompt management attention:
Conclusion
Notwithstanding these significant issues, the SSFI team concluded the ECI system would perform its safety function as designed. However, the deficiencies identified during the inspection raise a degree of uncertainty that dictates that the problems outlined in this report be addressed on a priority basis.
Safety Culture Issues
The systems included in this SSFI were the High Pressure Service Water, Low Pressure Service Water, Common Service Water, Demineralized Water System, Closed Loop Demineralized Water, and Emergency Service Water. The extent to which each of these systems was investigated was dependent on the problems identified.
Several areas needing improvement were identified during this inspection. The following are considered the most significant:
Conclusions
The SSFI Team concluded that objective evidence, based on the issues identified, does not provide reasonable assurance that the Emergency Water System will function as intended during design basis accident conditions. The deficiencies identified should be corrected on a priority basis. For the other four service water systems, the team identified a number of issues that detract from optimum performance or had the potential for a loss of functionality. Several of these issues should receive high priority.
Darlington SSFI Compressed Air Systems
(Instrument and Service Air)
The assessment evaluated the design of Darlington's compressed air systems. The Unit 2 Instrument Air (IA) system was chosen as the principal focus of this review, which encompassed not only the system design, but also design change control and its integration into operations, maintenance, training, and other station programs.
The review found, that although the original design was robust with respect to its supply of air to the unit, several interfacing support system inadequacies were revealed that call into question the system's overall ability to perform within its stated design requirement. These inadequacies are summarized as follows:
N2 [Nitrogen] System
This safety-related portion of the IA [instrument air] system is designed to supply backup N2 [nitrogen] at a regulated pressure of 550 kPa. Some of the end-use Air-Operated-Valves (AOVs) have an indicated minimum operating pressure of 550 kPa, which cannot be met if line losses are considered. The manifold arrangement at the N2 bottles contains ½ inch piping [number missing in original] that represents a pressure drop that further reduces the available pressure. Leakage may not have been adequately considered in the capacity requirements for the system. Since adequate testing of the N2 system and its supporting check valves has never been performed, there is no assurance the N2 system can achieve its intended function.
Setpoints
A basis for setpoints or a setpoint calculation methodology was not found for the IA system. In order to evaluate setpoints for Darlington Nuclear Generating Station (DNGS), the review was expanded to the Shutdown Systems (SDS). The evaluation found that the basis for SDS setpoints did not include all possible sources of uncertainty that could, in some cases, result in insufficient margins to safety analysis limits.
Testing and Maintenance
Many examples of inadequate testing were discovered. Safety-related backup air receivers and check valves have been installed without tests to demonstrate their operability. Relief valves and gauges used in safety applications were found without adequate calibrations. Call-ups are not in place for vital equipment.
Design Change Control
A review of the IA modifications uncovered several concerns. One design change installed unit IA cross-connects even though the Design Procedures Manual, Design Manual, Safety Report and Probabilistic Safety Evaluation do not permit it. No documented analysis was available to show that the safety impact had been assessed. Numerous other inconsistencies were found. Another design change extended a seismic containment boundary. Although the modification was made over two years ago, the seismic analysis has not been completed and a seismic support within the boundary appears to be inadequate. Additionally, various jumpers were reviewed that made de facto design changes that place systems and components operability in question. Configuration control was lacking in carrying these changes through to flow sheets, training manuals, maintenance call-ups, the valve assurance program, the safety related components lists, and other documents.
The inspection team concludes, based on the vertical slice sampled, that significant improvement is required in most of the programs and processes inspected. Configuration control is not in place at all levels and in all programs evaluated. In most cases, the lack of configuration control appears to have existed since DNGS startup. More disturbing, DNGS personnel readily acknowledge configuration control problems, but do not appear to be generally committed to real and measurable improvement in this area.
Pickering Electrical Distribution System Functional Inspection (EDSFI)
The Pickering Electrical Distribution System Functional Inspection (EDSFI) included the Class I, II, III and IV Electrical Systems, Site Electrical Systems (SES), and Interstation Transfer Bus. The purpose was to determine if the Electrical Distribution System (EDS), as designed, installed, operated, and maintained, is capable of fulfilling its design functions. Particular emphasis was placed on those system aspects that could affect either the safety of the plant or the reliability of the EDS. Therefore, particular attention was given to the PNGS Operating License, Operating Policies and Principles (OP&Ps), Safety Report (SR), and their supporting analyses. Design manuals and related studies, analyses, reports, and calculations were also used as a basis for system assessments.
The review concentrated on Units 3 & 4 due to their paired electrical buses, and because Unit 4 was in an outage that afforded accessibility for walkdowns and inspections. Units 1 & 2 and PNGS B units were inspected to review unique design features, to expand an existing issue, to confirm cross-connect capability, or to provide information when not otherwise available. Issues having potential generic implications were pursued beyond the initial finding to the extent practical.
The review found that, in some cases, the ability of the EDS to fulfill its design functions was not assured. In other cases, margins appear to have been reduced to unacceptable levels. System deficiencies are primarily attributed to a failure to account adequately for the cumulative effect of design and operating changes. Ineffective maintenance further reduces confidence in the system's reliability and readiness to function under design basis conditions. Key observations are summarized below.
Engineering Design and Design Change Control
The design basis for the EDS has not been maintained. Fundamental electrical analyses and calculations are not kept current and are not reflective of the installed configuration. In many cases the calculations of record are the original analyses, which are 20 to 25 years old. System capability is indeterminate with respect to key electrical performance attributes, including short circuit, electrical coordination, power flow, voltage drop, and transient stability.
To provide confidence that the EDS is operating within acceptable limits, the inspection team modeled a portion of the EDS and conducted a limited set of analyses. The analyses revealed that the Class III and IV systems appear to be operating within limits. However, significant issues were identified on the Class I and II systems, most notably:
Maintenance and Testing
Overall, maintenance and testing associated with the EDS was evaluated as inadequate. Procedures are of poor quality. Readily known industry issues, lessons learned, and vendor recommendations are not addressed in maintenance procedures. Scheduled maintenance is not routinely performed at the designated interval. Preventive maintenance is not sufficient to maintain equipment in a high state of readiness. Testing fails to verify the required functionality of safety-related equipment in some cases. Engineering support for maintenance activities was weak. Procedural compliance problems were noted.
Contractor testing of protective relays was discovered to be inadequate, and resulted in several relays being returned to service with settings outside of calibration tolerances. The station placed a hold on future work until the problems could be corrected.
Significant improvement is needed in the area of electrical maintenance and testing to ensure the EDS is maintained to high standards.
Operations
Weaknesses in content and clarity were noted in the Operating Manuals and the Abnormal Incident Manual (AIM). The electrical AIM procedures do not appear to carry the same stature as the procedures for other abnormal events. In many instances, operators are directed to Operating Manuals, which are not written in a manner conducive to use under stress. The human factors shortcomings of the AIM place an unreasonable burden on the operators. Although discrepancies were noted in the electrical Operating Manuals, the manuals were generally viewed as satisfactory. A consensus existed among operators that the Operating Manuals had been substantially improved over the past few years.
Field operator training and qualification was discovered to be in need of attention. Approximately 20 percent of the operators have not met qualification requirements, and inadequate resources have been applied to field operator training.
Quality Assurance and Self Assessment
Several examples of a weak corrective action process and slow issue resolution were found. Most pronounced are the ongoing efforts associated with PVC cable. Concern over PVC cable has existed for more than 15 years. A substantial number of studies and tests have been completed, but decisive and effective actions have not been initiated to resolve the issues. A lack of front-line technical support and a lack of ownership of the issue are evident. The station has not exercised conservative decision-making in dealing with the issue in the near term, did not disposition the impairment with regard to immediate operability concerns, did not attempt to assess the potential safety significance and implications, and did not follow procedures. Most significantly, this issue demonstrates an inability to drive an issue with potentially significant safety consequence to closure.
Investigation into an MG set failure revealed that safety-related maintenance activities were being performed off-site by contract personnel without the requisite controls for work on safety-related components. Further evaluation showed that there were numerous problems crossing several organizational boundaries, including a general breakdown in the procurement process. Station management invoked a quarantine on requests for maintenance services as a stop-gap measure until additional controls could be put into place. This deficiency is indicative of weak programmatic controls within the areas of Maintenance, Engineering, and Quality Assurance.
Safety Awareness
Station personnel appear to be sensitive to equipment availability and the need to ensure high equipment reliability. However, two other critical areas of safety do not appear to have the same emphasis:
The SSFI equivalent for the in-service Environmental Qualification (EQ) project determined or established the status of the following:
Based on the progress to date for the in-service EQ projects and current level of activity, the likelihood thatOHN will meet the commitment dates for implementing an EQ Program at Bruce and Pickering is remote. To meet the current AECB commitment dates for having an EQ program in place, significant changes are needed in the way the project is viewed from a safety significance standpoint, as well as in how it is managed, supported and implemented. However, none of the recommended changes will be effective unless there is a corporate and site-wide commitment to implement EQ at the sites. Near-term management support of the in-service EQ in the areas of Nuclear Safety and Engineering Services is required in order to finalize the Environmental Qualification List (EQL) and environmental conditions for the in-service stations. The finalization of environmental conditions is considered a mandatory prerequisite for the site project managers to accurately assess the scope and cost of the remaining actions needed to implement the EQ program. Completion of this design input to the in-service EQ Project effectively in a timely manner is critical to the ability to manage the project.
The development of the remaining Environmental Qualification Assessments(EQA's) should be initiated after finalizing the room conditions and the EQL for all special safety and support systems. A significant improvement in productivity can be realized if the environmental conditions and the EQL for all systems are completed prior to spending significant resources on the development of EQAs. The EQAs need to be developed on a manufacturer/model basis covering all equipment of that type within the scope of the EQ program. Achievement of the improvement will require total management commitment to ensure the in-service EQ projects receive the required support from the organizations responsible for developing the environmental conditions and EQLs.
Although field implementation of EQ-related baseline maintenance and modifications should be done on a system basis, management of the overall EQ project needs to be done on a more "global" basis. Resolution of the major EQ issues, especially those requiring significant field modifications and/or equipment replacement, needs an integrated approach and should not be addressed on an emergent "system by system" basis.
For example, the schedule for implementing the cable qualification effort needs to be coordinated and integrated into the overall EQ project schedule. This approach is necessary to ensure that the potential replacement of cable is determined in sufficient time for the sites to initiate field changes in a time frame to meet their commitment dates. Given the potential ramifications for the stations, establishing the qualified status of the currently installed cables needs to be expedited as much as possible. The principal recommendations from the EQ SSFI are:
Because significant analysis has already been performed, our focus now should be on getting the plant systems qualified, not spending additional project resources on analyzing or justifying the acceptability of the current plant design/configuration. It should be recognized that implementing an EQ Program at the in-service stations will not be a paper exercise. This is because standards and criteria used during design and construction did not fully consider or recognize EQ. It was the impression of the EQ SSFI team that there is a "don't touch the plant" approach to establishing qualification. The use of analysis and/or testing to justify the current plant design and configuration should only be done when it can be shown to be the most cost effective or timely solution over the life of the plant. This approach needs to be balanced with other considerations such as:
It appears the type of qualification issues facing the in-service EQ projects will require some creative and/or non-traditional approaches to establishing environmental qualification in order to eliminate equipment from the project scope and/or minimizing the environmental conditions in which they must operate. Given the design and configuration of the plants, it does not appear practical to qualify all of the equipment located in harsh environmental areas and are relied upon during and following a DBA.
Darlington's EQ Program
Darlington's EQ program is in a general state of decline and warrants additional attention to reverse the current trend and to ensure that the EQ program's design basis and documentation is maintained current.
Fire Protection Functional Inspection
The Fire Protection assessment included three primary areas:
During the conduct of this assessment, many interviews and document reviews were performed at the corporate office and at each of the plants. It became evident that there was a lack of management leadership regarding fire protection. While elements of a fire protection program were evident, nowhere was a single individual responsible for defining a fire protection program and the appropriate interfaces found. No one was responsible for applying a global perspective, ensuring the fire hazards were being properly minimized or prevented, and identifying the necessary interfaces required to maintain control of fire hazards. This contributed to six primary weaknesses:
Because of the organizational deficiencies, there was a lack of understanding and awareness of the relationship between the everyday actions of individuals and fire safety. This results in performance deficiencies in material storage practices, housekeeping, and transient combustible control and flammable material control. This lack of awareness carries over into a lack of recognition of the relationship between fire safety and nuclear plant safety.
Consequently, there is an insufficient understanding of:
In the U.S., at some specific stations, fire is the dominant contributor to core damage frequency (CDF). Fire risk at specific OHN units is also a contributor to CDF. Effective realignment of the organization, training, monitoring and reporting, and the addition of incremental detection and suppression systems in risk-sensitive areas could dramatically reduce the risk of fires. This would correspondingly reduce the challenges to the ERT.
The Corporate IIPA Team concluded that the corporate support service Performance Areas covered herein, as presently structured and managed, lack the authority and level of plant focus and "real time" plant involvement necessary to provide pro-active and effective support to the operating stations. Further, the Team concluded that if the present structure and modus operandi of corporate support services are not changed, enhanced operating station performance will be hindered.
However, the Team also concluded that these Performance Areas have generally performed in a manner consistent with the expectations established by the OHN reorganization of 1993. For the most part, the Team found these Performance Areas to be staffed by experienced, qualified, and talented personnel working in a seller/buyer relationship with the operating stations. Work is acquired on a "fee for service" basis and is solicited by managers and supervisors. The scope of work includes the following; inspection and testing services, specific engineering projects and tasks, dosimetry services, programmatic advice and guidance, and staff augmentation to the stations. In the case of Nuclear Technology Services (NTS), generic CANDU issues and interfaces are managed on behalf of OHN and, occasionally, NTS services are sold to clients other than the operating stations. In general the Team found the scope of the work to be adequately planned and supervised and product quality to be generally satisfactory.
Yet, the Team determined that when benchmarked against the performance attributes established by the Corporate IIPA, the corporate support services that they assessed, more closely emulate contracting or consulting firms rather than fully engaged corporate entities.
The Team also determined that the major obstacles to achieving high levels of corporate performance and dedicated and effective support to the operating stations are as follows:
Management Focus on the Asset
OHN's very existence is entirely dependent on the performance of its assets - the operating stations. Without the stations there would be no OHN, no CANDU industry and no jobs. The erosion of station performance is well documented in Peer Evaluations and AECB Reports, yet senior corporate services management has failed to grasp the reality of the situation, voice its concerns with executive management, and re-direct the corporate resource. The generally relaxed atmosphere at headquarters (except in specific reactionary situations) does not reflect the level of intensity that the IIPA Team expected to find, given the reported conditions that exist at the stations.
In order to be effective, corporate support services must be totally focused on and engaged with the stations. Significant technical and operations issues identified by the stations must be treated with equal significance by corporate. Corporate must monitor and trend to the extent necessary to assist the stations in staying in front of issues rather than being a resource used for "damage control". Corporate activity should not concern itself with goals related to the external sale of resources except where these relate directly to the well-being of the asset. This is particularly true with respect to engineering resources.
Further, the practice of performing work on a "fee-for-service" basis does not promote a spirit of teamwork between the operating stations and corporate. Towards fiscal year end, the stations expect corporate personnel to be visiting in search of work for the following year. It is essential that corporate support services be regarded by the stations as an extension of themselves rather than as another contractor. The heads of corporate support services and the generating stations must work together as colleagues to ensure that the overall goals of OHN are achieved. There is absolutely no reason why corporate management cannot functionally align resources, budget activities, and manage to support station priorities.
Authority
Corporate support services require the authority necessary to establish and implement corporate strategies, and standardized procedures, processes and programs across the corresponding station functions. This is particularly important with issues such as chemistry controls, radiation protection, environmental qualification, fire protection, pressure tube life extension, and steam generator health. There is also an absence of a corporate design authority in engineering. Inconsistency and decline in performance have resulted within OHN are largely due to the absence of a strong corporate presence and mandate.
Resource Utilization, Cost of Services and Functional Alignment
The Team was often told that corporate engineering suffers from a lack of resources. However, the Team identified what appears to be an excessive application of resources to certain engineering tasks and activities. The Team also assessed the fee structure being charged for services and concluded that fees are excessive for a corporate entity.
The functional alignment of NTS groups was found to be inconsistent. For example, the environmental qualification effort resides in the Equipment and Systems Section rather than as a separate project. Additionally, Feeder Tube integrity resides in Technical Integration rather than in Chemistry and Metallurgy, where issues such as steam generators reside. And finally, the Team found it unusual to have approximately 200 "inspection" resources residing in an "engineering" organization.
With regard to corporate radiation protection services and industrial safety, it appears inconsistent for the service to be located in an Employee Services Division that is primarily occupied with human resource issues.
Analyses and Risk Assessment
The number of safety analyses performed by both corporate engineering and the station Nuclear Safety Departments is overwhelming, and appears inconsistent with the maturity of both the CANDU technology and the stations. The safe operating envelope limits are being challenged and existing safety margins are being reduced. Further, there is a lack of defined and controlled processes for performing analyses, and an absence of clear authority governing application and usage.
With regard to Probabilistic Risk Assessment (PRA), the Team concluded that there is no clear and consistent corporate direction as to PRA use by the stations. Furthermore, key PRA parameters (such as operating procedure adequacy and equipment condition) are not being factored into decisions based on probability.
Quality Assurance
There is no uniform and standard approach to quality within corporate support services. There is no written Problem Identification procedure. Additionally, self-assessments are limited in scope, frequency and intrusiveness.
Material Degradation Monitoring
The extent of "in-situ" inspections applied to Steam Generator tubes and Pressure tubes, although consistent with the requirements of applicable codes and standards, is inconsistent with the potential severity of the degradation identified to date. Over one third of the Steam Generator population has never been probed; despite the fact that experience has shown Steam Generator degradation to be unpredictable. Pressure Tubes end-of-life predications rely largely on analytical models, yet only about 10 percent of the Pressure Tubes have been inspected. This is most likely too low a percentage on which to base such an important decision. Further, the latest predictive tools available for erosion/corrosion monitoring are not being utilized.
Overall Ratings
Overall, Corporate Engineering services is rated MINIMALLY ACCEPTABLE. Chemistry, radiation protection, and Emergency Preparedness are rated YELLOW or BELOW STANDARD. A summary of the performance ratings assigned to each Performance Area is provided below:
| Corporate Engineering Services | Minimally Acceptable |
| Corporate Chemistry Services | Below Standard |
| Corporate Radiation Protection Services | Below Standard |
| Corporate Emergency Preparedness | Below Standard |
| Regulatory Affairs/Nuclear Assurance | Unrated |
A brief summary of each Performance Area is provided below:
Corporate Engineering: Minimally Acceptable
When the reorganization of 1993 took place, a major oversight was the failure to recognize the need to maintain consistency among the operating station engineering organizations in concert with an authoritative and focused corporate engineering presence. Nuclear Technical Services (NTS) was formed as the corporate engineering entity and charged with maintaining its existence on a "fee-for-service" basis through individual sales to the stations and the pursuit of outside business. NTS management has failed to recognize that the decline in station performance has been aggravated by the lack of corporate focus. The assets have suffered as a result, and it is essential for OHN management to significantly redirect NTS focus in the direction of becoming a station- oriented corporate engineering organization.
Corporate Chemistry: Below Standard
Corporate chemistry resides within the Chemistry and Metallurgy Section of NTS. As such, it suffers from the generic and detrimental remnants of the reorganization of 1993, although the outside sale of services has not been as important as with other NTS services. Regardless, corporate chemistry, given the lack of authority and charter, has attempted but has been generally unsuccessful in prescribing and enforcing consistent chemistry standards across the stations. In part, this is due to a lack of proactive behaviour on the part of management. Further, management has not been effective in communicating the adverse effects of poor chemistry controls, nor has it been proactive in correcting the condition.
Corporate Radiation Protection: Below Standard
Corporate radiation protection, known as the Health Physics Department (HPD), is provided with limited authority within the Canadian Radiation Protection Regulations. However, in practice, the stations call the shots. As with chemistry, management has neither been delegated authority to effect necessary changes, nor has it been effective in securing that authority. A more aggressive and proactive approach is needed. In part this condition has contributed to what the team perceives to be an inadequate respect for radiation.
Corporate Emergency Preparedness: Below Standard
Although OHN is capable of responding to emergencies and coordinating with off-site agencies to protect the public health, there is no integrated and overall Emergency Preparedness Plan. Poor coordination exists between corporate and the stations. Expectations, roles, responsibilities and accountabilities are ill defined. Long standing deficiencies remain unresolved, relations with governmental agencies are strained, and the likelihood of a successful CANATEX-3 is presently assessed as doubtful.
Regulatory Affairs/Nuclear Assurance: Unrated
Overall, the team rated the predecessor organizations of Regulatory Affairs/Nuclear Assurance (RANA) functions to be "minimally acceptable". The team concluded that it was premature and unfair to attempt to rate the new RANA. However, the team felt that, in general, the approach of the senior management was positive. In this regard, the team provided the new organization with numerous comments and recommendations. The team recommends that issues identified herein be included in RANA's scheduled annual assessment.
Management's failure to provide consistent direction has produced inefficiencies and mediocrity rather than excellence in the Ontario Hydro Nuclear (OHN) operation. This condition is evident in the high-level function of business planning and control, and extends down through the entire organization. Conflicting and inconsistently applied policies and goals from senior management are causing resources to be misdirected, thereby potentially compromising safety, and reducing the organization's competitiveness. Both managers and supervisors were observed personally violating known stated procedures and condoning this behavior in their subordinates.
The culture of "non-verbatim compliance" suggests a lack of confidence by management and the labor force in the value of designed policies, programs and procedures. In fact, this attitude is further noted in the variety of ways processes are designed and implemented at each station. The work invested in developing work practices at one station is not percieved as adequate for another station. In reality, one of the major issues is the ability to execute any policy, program or procedure, no matter how well they are designed.
Existing organizational structures and managerial leadership systems do not establish conditions for effectively accomplishing work and for utilizing the full capability of all employees. In many cases, work is accomplished in spite of the organization, not because of it. Many roles are established at too low a level of complexity and assigned neither the appropriate accountability nor the necessary authority to be effective. Insufficient attention has been paid to the identification and development of the managerial talent needed for the future. No clear set of expected and leadership practices is taught to all employees in managerial roles.
Finally, accountability for performance at all levels in the organization is not maintained. Non-compliance is behavior ingrained in the organization's culture. There has not been an expectation of compliance. Managers are not clear in the assignment of goals and the allocation of resources to subordinates so that they can be held accountable for their performance.
Organizational Effectiveness was reviewed from the following seven Management Business Practice perspectives and the Requisite Organization Principles perspective.
Examples of major deficiencies identified include:
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