Basis

In a nuclear operations organization having an inadequate number of trained and qualified operations personnel compromises the safety of the facility . The facility management should eliminate position vacancies by actively engaging in a recruitment process to hire qualified individuals to fill these jobs. Once personnel are hired, training should then match to the training curriculum the skills required by operations personnel to safely operate the plant. To promote nuclear safety it is essential that plant management establish an organization that encourages highly qualified personnel to work for the operations organization.

In addition to having an adequate number of trained personnel, the operations organization must have support from other organizations, such as maintenance and engineering, in order to operate the facility safely.

Symptoms

Functional Area Coordination

OA7: The assessor can determine from many different indications if there is an adequate number of properly trained personnel available for safe facility operation. For instance, are the personnel assigned to duties they are qualified to perform? Other indications to explore are the number of surveillance requirements that are not being performed or are delayed. The assessor may find a high error rate by operators, or that they work a significant amount of overtime. Another indication of inadequate staffing is the failure of operations personnel to maintain recurring training because of an excessive work load. The assessor can determine these symptoms by asking to see time reports, facility incident reports, and training records of operational personnel. The assessor should also perform plant walk-downs with operators and supervisors to see whether they are familiar with their facility.

OA8: Another way for the assessor to evaluate the capabilities of the operations staff is to observe an emergency drill. During such a drill various scenarios occur, which may require all operations personnel to be fully engaged simultaneously. The assessor should notice whether the operations personnel seem overworked or overwhelmed by the drill. If the drill taxes the operations crew, then there may be an inadequate number of qualified personnel on shift.

OA10: Inadequate staffing can also be evaluated by reviewing shift assignments and coverage on the backshifts. The backshift staffing may exhibit shortcomings when there are inadequate operations personnel. The assessor can determine staff shortfalls by reviewing the number of personnel on backshifts relative to the work load assigned and the ability of each to respond to emergency and abnormal events. The type of assignments these personnel receive may also indicate that they are assigned tasks for which they are not qualified. A review of personnel job descriptions, as well as personnel tasks or training, may reveal such symptoms of inadequate staffing.

Management Cause Analysis

2B.1: One reason for inadequate staffing might be the failure to recruit qualified personnel. Some indications of a recruitment problem may be found in the number of unfilled authorized positions and the average length of time to fill a personnel vacancy. If there are unfilled positions and it takes a long time to fill these vacancies, the management of personnel at the site may be one root cause of the problem. The working conditions at the facility may also be unfavorable. The assessor should interview personnel to find out whether working conditions, compensation or other factors may make their jobs undesirable. Additionally, the assessor may review what percentage of jobs are advertised both off-site and on-site, and how many jobs are filled by on-site recruitment. If job positions are not adequately advertised, then one of the root causes may be in the failure of the personnel department to actively recruit qualified individuals. Other recruitment problems may stem from a lack of coordination between the Program Secretarial Officer (PSO), Field Office, and contractors in meeting staffing requirements.

2B.2: A contributing factor to inadequate operations staffing might be some inadequacy in matching personnel qualifications and job requirements. It should be determined whether the skills for each position are documented and whether a process exists to assess whether personnel qualifications match these skills. This process should apply to those recruited from outside and those being transferred within the site organization. A process should exist by which job requirements can be reviewed and updated. The failure to document skills and qualifications would potentially indicate the root cause of inadequately trained operations personnel. A job task analysis (JTA) should be done to determine whether the Training Organization is teaching operators what they need to know to accomplish their job assignment.

2B.3: The failure to have sufficiently qualified operational personnel may stem from the inadequate training of individuals to meet the necessary job requirements. The training program should provide for initial and continuing training so that operators maintain their skills and become familiar with facility changes. It is important that the training curriculum meet the skills required for the personnel to do the job. To train operators effectively the Operations Organization should have an input to the JTAs for the Training Organization. Those successfully completing the required training would then be eligible for plant certification. The effectiveness of the training program could be determined by the number of personnel enrolled in the program to those that are certified. Training should include classroom studies, simulators, and on-the-job familiarization with in-plant orientation. The Training Organization staff should use criteria and data gathered from past training to determine the effectiveness of their program. Failure to perform these activities and monitor the training program may indicate that one of the root causes for inadequate staffing is in the management of the training program. Although budget issues can be the problem, they are often only the result of management going after the symptoms and not the true root causes of a problem. For example, the assessor should consider whether other factors such as poor planning and interdepartmental coordination are involved. Perhaps the Training Organization has a large number of students not being trained because the instructor staff is undermanned.

2D.1.1/2D.2.1/2D.3.1: In order to have an adequate staff of operations personnel, the PSO, Field Office Manager (FOM), and contractors must have management processes and programs to provide for personnel selection, qualification, and training at DOE facilities. Although these different organizations have their own responsibilities, they all are committed to the same goals. Some of the basic approaches in accomplishing these goals include the development of procedures and programs to meet the intent of the DOE Order 5480.20. A specific example of these programs would include having a training program that certifies personnel in site specific job requirements and having documentation of this certification. It is the responsibility of the PSO, FOM, and contractors to participate in the implementation of DOE Order 5480.20 so as to provide adequate staffing of qualified personnel at DOE facilities.

2E.1: In assessing the adequacy of plant personnel to operate the facility, consideration must be given to the amount of resources allocated to plant operations. One of the root causes for having an inadequate number of plant operators may be in the lack of sufficient resources for training, outfitting, and compensating those personnel responsible for facility operation. Funding may not be sufficient to accomplish these goals because they have not been given a high priority by plant management. The assessor should interview personnel from different organizations and review budget requests versus allocations, to see whether the root cause for not having an adequate number of qualified operators is a lack of sufficient resources.

2F.2: Each individual's sense of responsibility for safety is largely dependent on the facility safety culture. Responsibility and accountability must shared throughout all of organizational levels, with the ultimate responsibility and accountability residing at the top or the organizational structure. Since senior program managers provide the resources, select subordinate managers, conduct assessments, award contracts, provide training programs, and impact almost everything that occurs at a nuclear facility, they are primarily responsible for deficiencies. When managers attempt to avoid their responsibilities, the safety culture can be adversely affected. Plant operations personnel can be vulnerable to these breakdowns in the safety culture and may become passive participants in ensuring plant safety. Therefore, possible root causes for plant problems are organizational elements in which specific responsibilities are not well established.

Basis

Management controls are essential for the operations organization to function in a manner consistent with the goals of the nuclear safety culture. If operations at a facility were structured in an informal or haphazard fashion, then plant operators would not function in a consistent and effective manner. As a result of informal operations, plant activities would be performed in a way that could lead to operational incidents that damage equipment or injure plant personnel. The Operations Organization should be structured with clear lines of authority that lead to managers who are responsible for the safe operation of the facility. Although the manager has overall responsibility, it is important for everyone to accept individual accountability when it comes to nuclear safety.

Clear lines of authority and responsibility as well as an accountability system must be established for the effective function of the operations organization. Putting these controls in place will greatly aid in maintaining a consistent and defined method for enhancing the concepts of nuclear safety during facility operations.

Symptoms

Functional Area Coordination

OA1: One way in which an assessor can determine the structure of the operations organization is to observe how shift turnovers are handled. Plant status from the previous shift should be logged and current status should be discussed between the two shift crews, as they go through a turnover checklist. The assessor can observe a shift turnover and review the information conveyed to the new shifts to determine whether the communications between them were handled in a structured and responsible manner. The assessor should determine whether responsibilities are clearly assigned to personnel and whether those personnel accept the responsibility. Confusion or uncertainty during the next shift on plant status and planned events may indicate a weakly structured organization without strong lines of authority.

OA2: The assessor should observe the conduct among operations personnel in the control area. The formality of communications among operations personnel should be assessed and whether these communications are understood and acknowledged in a professional manner. The assessor should also determine whether the operators exhibit a sense of responsibility for their actions. Is control area access limited to those essential personnel needed for vital plant control? The assessor should note whether the operators in the control room maintain vigilance in monitoring the main control board. Failure to perform these essential activities may indicate a lack of structured organization.

OA6: By attending a briefing on an upcoming plant evolution, the assessor should be able to evaluate how well the personnel communicate with each other and how well they plan activities. During such a briefing it is very likely that the activities described will occur over several shifts. Coordination among the shift crews will require their effective communication. The assessor should notice whether the information at this meeting is presented in a formal manner with clear lines of authority and responsibility delineated for those in attendance. After the meeting, the assessor should interview those attending to determine whether they understand their responsibilities for the planned activities.

OA8: Another way for the assessor to evaluate the structure of the operations organization is to observe an emergency drill, during which various scenarios occur that require teamwork and effective communication. The assessor should notice whether the operations personnel follow procedure in handling the emergency. If conditions warrant activities outside those prescribed in the procedures, then the assessor should notice whether operations personnel formally obtain permission from superiors in bypassing established procedure. Failure to assess their actions or receive authorization (when possible) may indicate a failure by operations personnel to follow proper procedure during normal operations and may indicate a weakly structured organization.

OA12: The assessor can judge the structure of a site organization by attending a daily planning meeting where different organizations coordinate plant activities to support various events. The interaction and planning exhibited during such a meeting might reveal how well organized and structured the site organization is, and the Operations Organization in particular. The assessor should look for defined lines of authority and responsibility in delegating the tasks planned at these meetings. A lack of structure and authority will manifest itself when the attending groups are unable to work together as team with an identified leader to show the way.

OA14: An assessor can review recent incident investigations and see the current status of corrective actions, if any, to determine whether a facility has the capability to implement corrective self-assessments. The lack of follow-up on corrective actions, or the lack of corrective actions, may indicate an organization that does not have an adequate method of accountability or self-assessment. Such deficiencies may be caused by ill-defined areas of personnel responsibility.

OA15: The assessor can also review the plant operating logs from previous months to determine whether plant management has taken corrective actions on past plant problems. A review of the operating logs will show the level of information kept, and whether any follow-up entries indicate continuing problems. The logs may indicate aggressive actions taken to correct deficiencies or whether they indicate persistent problems. Recurring problems that do not receive corrective follow-up may indicate the failure of plant management to perform critical self-assessments.

Management Cause Analysis

2C.2: Responsibilities and authorities of the operations organization must be formally defined through official documents. Without a formalized program, individuals will not know the official policies and will not have a centralized document to reference. There should exist within the organization specific documents that clearly define the responsibilities and authorities of operations personnel, especially the managers. The lack of such documents may be one root cause for degraded facility operations. Accountability should also be clearly defined within the same official documents that specify responsibilities and authorities.

2D.3.4.4: The methods used to establish accountability should go hand in hand with the responsibilities and authorities defined and documented for the operations organization. An operations organization generally does not perform well without a formal method of accountability. Once a deficiency is identified in plant operations, its correction will be much more effective if there is an established accountability process. In addition to DOE personnel, it is also incumbent upon DOE contractors to hold workers and supervisors accountable for their operating performance.

2F.2: Individual operations personnel must be aware of the safety objectives as set forth by management and accept individual responsibility in daily plant activities. Operations personnel should have a working knowledge of the safety standards that they must adhere to in controlling plant equipment. This includes understanding and following all the requirements to control and operate plant equipment. Without procedure compliance by the individual, it is possible that administrative controls may be bypassed during plant operations. Individual failure to abide by the safety guidelines, as established by management, can contribute to degraded plant performance.

References

Basis

To maintain a positive nuclear safety culture it is essential that control of critical plant functions be performed in a formal and documented way. A formalized manner will encourage continuous control of the facility. Formal control of critical plant functions can be accomplished with procedures that document how plant evolutions should be accomplished. Operators should take a serious approach to operations, using instrumentation and document resources routinely. Close monitoring and response to alarms indicate a concern for plant and personnel safety.

Personnel must have the proper information on plant systems, equipment, and status to facilitate the formality of plant control. In addition, facility drawings, procedures and other information should be properly updated with current material using established document control procedures. Procedures required in plant operations should be followed closely. By formalizing critical plant operations, maximum continuous control of the facility can be obtained while maintaining nuclear safety.

Symptoms

Functional Area Coordination

OA1: One way an assessor can determine the formality of plant operations is to observe how shift turnovers are handled. Plant status from the previous shift should be logged and the current status should be discussed by the two shift crews. The assessor can observe a shift turnover and review the information conveyed to the oncoming shift to determine whether it is sufficiently formal in nature. Confusion or uncertainty during the next shift on plant status and planned events may indicate conduct of operations that is informal.

OA2: The assessor should observe the conduct among operations personnel in the control area to determine whether the plant communications are sufficiently formal, whether directions are understood and acknowledged in a professional manner, and whether operators exhibit a sense of responsibility for their actions. The assessor should observe whether access to the control area is limited to those essential personnel needed for vital plant control. The assessor should note whether the operators in the control room maintain vigilance in monitoring the main control board. Failure to perform these essential activities may indicate a lack of structured organization.

OA5: Formality in control of operations can also be determined by reviewing the procedure and process used to inform personnel returning from facility absence of any changes in plant status and administrative controls. The lack of a procedure such as required reading for updating personnel may indicate that there is no formal way of informing those returning from an absence. The assessor can determine this by reviewing the plant documents for such a new procedure and interviewing those plant operators returning from an absence.

OA6: By attending a briefing on an upcoming plant evolution, the assessor should be able to evaluate how well the personnel communicate with each other and how well they plan activities. During such a briefing it is very likely that the activities described will occur over several shifts. The assessor should notice whether the information at this meeting is presented in a formal manner with clear lines of authority and responsibility delineated for those in attendance. After the meeting, the assessor should interview those attending to determine whether they understand their responsibilities for the planned evolution.

OA8: Another way for the assessor to evaluate the structure of the operations organization is to observe an emergency drill during which various scenarios occur that require teamwork and effective communication. The assessor should notice whether the operations personnel follow procedure in handling the emergency. If conditions warrant activities outside those prescribed in the procedures, then the assessor should determine whether operations personnel formally obtain permission from superiors in bypassing established procedure. Failure by operations personnel to assess their actions or receive authorization (when possible) may indicate a failure to follow proper procedure during normal operations and may indicate a weakly structured organization.

OA13: To assess whether the facility stresses formality in plant operations the assessor should observe the conduct and supervision of in-plant trainees. To establish the formality required of plant operations personnel means that this process be emphasized during the both classroom and in-plant training stages. The assessor should look for signs of formal communications during the in-plant training exercises and whether the lack of communications is corrected by operations personnel.

TA3/TA5: The assessor evaluating classroom training should assess the quality and seriousness of training on plant operational formality. The assessor should observe operator and auxiliary operator training to determine whether the formality in the conduct of operations is stressed to trainees. Formality exercised in critical control areas should encourage an operating atmosphere conducive to maintaining and maximizing continuous control of the plant.

Management Cause Analysis

2D.3.4.17-21: In order to exercise formality in critical control areas it is essential for these areas to have controlled (limited) access. It is important for operators to be professional in their duties. These duties should be focused on monitoring and promptly responding to alarms on the main control panels. Operators should not be hindered with ancillary duties that might interfere with their ability to monitor plant parameters. Formality of operations in the control area should be established by management programs with the conduct of operations procedures.

2F.2: The individual operations personnel must be aware of the safety objectives, as set forth by management, and accept individual responsibility in daily plant activities. Operations personnel should have a working knowledge of the safety standards that they must adhere to in controlling plant equipment. This includes understanding and following all the formal requirements to control and operate plant equipment. Without procedural compliance by the individual, it is possible that administrative controls may be bypassed during plant operations. Individual failure to abide by the safety guidelines established by management can contribute to degraded plant performance.

References

Basis

The effectiveness of site operations can be gauged in the way equipment is controlled within the facility. In particular the lockout and tagout programs are an essential part of these plant operations. If these programs are not followed, then serious consequences are inevitable. Failure to properly control tagouts and lockouts may lead to personnel injury, equipment damage, and can compromise facility safety. Although it is sometimes necessary to bypass these programs in an emergency situation it is dangerous to do so in a non-emergency situation. Failure to follow these programs may be an indication of ineffective management commitment to the concepts of nuclear safety and procedure compliance.

When management fails to stress the importance of nuclear safety, then the training programs and operations procedures will fail to enforce these concepts. Proper procedures must be followed whenever personnel are handling equipment in the plant. Clear lines of authority and responsibility as well as accountability must be established for the effective function of the operations organization. Following the proper procedures for the lockout and tagout of equipment will greatly aid in enhancing the concepts of nuclear safety during facility operations. Personnel should understand their roles in ensuring safety and the importance of following plant procedures completely.

Symptoms

Functional Area Coordination

OA4: To determine whether tagout and lockouts are bypassed in non-emergency situations, the assessor should observe specific activities related to the tagout program. The assessor should note whether independent verifications are used in a system realignment or system change. To further determine whether these programs are bypassed in non-emergency situations the assessor can independently verify the status of randomly selected equipment in the plant to determine whether it is in the proper alignment.

OA8: Another way for the assessor to evaluate the handling of clearances on plant equipment is to observe an emergency drill during which it may become necessary to bypass lockouts and tagouts on equipment. The assessor should notice whether the operations personnel consider the consequences of their actions in deciding to bypass normal clearance procedures. Failure to assess their actions or receive authorization (when possible) may indicate a failure to follow proper procedure during non-emergency conditions.

Management Cause Analysis

2D.3.4.49-58: Effective control of plant equipment is the responsibility of operations supervisory personnel. To accomplish control of plant equipment requires that supervisory personnel administer the use of locks and tags. Locks and tags should be used on components that require special administrative control for safety reasons. Administrative controls should be established to accommodate temporary modifications such as jumpers, lifted leads, disabled alarms, and disabled relief or safety valves. Only with effective administrative controls on the lockout and tagout of process can plant equipment be safely controlled.

2D.3.4.59-73: To prevent the lockout and tagout program process from being bypassed during normal and emergency operations requires that effective administrative controls be established. Facilities should have an existing lockout/tagout program with approved procedures to control potentially hazardous energy sources and materials. Only qualified personnel should be authorized to perform equipment lockouts and tagouts. Plant personnel should be qualified with training that emphasizes proper lockout and tagout practices. Supervisory personnel must ensure that such lockout/tagout programs, training and procedures are in place and used by plant personnel.

2F.1: It is essential for line management to foster the development of a safety culture in order for plant personnel to follow proper procedure in the clearance of equipment. Line management should endorse the nuclear safety culture and establish safety standards for the operations organization. Failure of line management to endorse this safety culture may be a contributing cause to the failure of plant operators to follow proper procedure in the clearance of facility equipment.

2F.2: Individual operations personnel must be aware of the safety objectives as set forth by management and accept individual responsibility in daily plant activities. Operations personnel should have a working knowledge of the safety standards that they must adhere to in controlling plant equipment. This includes understanding and following all requirements and controls to clear tagouts and lockouts of equipment. Without a clear understanding by the individual of safety, administrative controls may be bypassed during a non-emergency situation. Individual failure to abide by the safety guidelines can contribute to degraded plant performance.

References

Basis

To gauge the safety of plant operations it is important to observe the control and operation of equipment within the facility. It is important that plant personnel use independent verifications whenever they manipulate plant equipment or alter system lineups. Failure to properly verify plant conditions may lead to personnel injury, equipment damage, and could compromise facility safety. Although it takes time to perform independent verification correctly, plant management should stress the importance of taking the time to do the job right. Failure to follow the process of independent verification may be an indication of ineffective management commitment to the concepts of nuclear safety.

When management fails to stress the importance of nuclear safety plant personnel will fail to enforce these safety concepts in plant operations. Proper procedures must be followed whenever personnel are handling equipment in the plant. Clear lines of authority and responsibility as well as accountability must be established for the effective function of the operations organization. Following the proper procedures for the independent verification of system status will greatly aid in enhancing the concepts of nuclear safety during facility operations.

Symptoms

Functional Area Coordination

OA4: To determine whether plant operators adhere to independent verification, the assessor should observe the tagout program. In observing this program the assessor should note whether independent verifications are used in a system realignment or system change. To further determine whether these programs are bypassed by operators, the assessor can independently verify the status of randomly selected equipment in the plant to determine whether it is in the proper alignment. The assessor should also note whether the operators seem to be in a rush, or are working together, to get the job done. Attempts to rush the process may compromise the purpose of independent verification.

OA8: Another way for the assessor to evaluate the verification of plant equipment is to observe an emergency drill during which various scenarios may necessitate bypassing normal procedural methods that involve independent verification. The assessor should notice whether the operations personnel consider the consequences of their actions in deciding to bypass established procedures. Failure to assess their actions or receive authorization (when possible) may indicate a failure to follow proper procedure as it relates to independent verification during normal plant conditions.

OA13: Plant operators learn the application of safety concepts during their training programs. Because basic safety concepts begin in the training arena, it would be prudent for the assessor to observe the conduct and supervision of in-plant trainees. The assessor should observe whether the training program stresses the proper methods for independent verification of systems status. This program should stress the need to follow procedures (unless it is an extreme emergency and supervisors have been contacted for permission to deviate from procedure) and the need to perform independent verifications. If these concepts are not taught to in-plant trainees, they may not follow correct procedure when they begin plant operations.

TA3 & TA5: The assessor should observe the certified operator and auxiliary operator training program to see whether trainees are taught the importance of safety fundamentals and safety culture. The importance of independent verification should be stressed in the training program as a vital means of supporting the concept of nuclear safety. If safety fundamentals are not taught during the training phase then it is likely that plant trainees will not carry these concepts into practice when they enter plant service.

Management Cause Analysis

2D.3.4.74-76: Plant operators must follow the independent verification process in order to maintain facility safety. Independent verification is required to assess the positions of critical plant components that are used to ensure plant safety. This verification is crucial in circumstances where there is a reasonable probability that safety related components may be mispositioned. Plant operators should be trained in the appropriate methods of independent verification. It is the responsibility of plant management to ensure that this concept of independent verification are developed and implemented through training and procedures. Failure by management to implement and endorse these programs may be the root cause for operations personnel to follow the independent verification process.

2F.1: It is essential for line management to foster the development of a safety culture in order for plant personnel to follow proper procedure in the configuration and verification of plant equipment. Line management should endorse the nuclear safety culture and establish safety standards for the operations organization. Failure of line management to endorse this safety culture, through the emphasis of independent verification may contribute to plant operator failure to follow proper procedure in the clearance of facility equipment.

2F.2: Individual operations personnel must be aware of the safety objectives as set forth by management and accept individual responsibility in daily plant activities. Operations personnel should have a working knowledge of the safety standards that they must adhere to in operating plant equipment. This includes understanding and following the concepts of independent verification for plant equipment and system status. Plant performance may be degraded without clear understanding by the individual of the importance of independent verification.

References

To create and maintain a nuclear safety culture requires personnel to communicate in a formal and documented way. This communication is essential during plant shift turnoversto maintain safe operation of the facility. Formal shift turnovers can be accomplished with procedures that outline the kind of information that should be exchanged and familiarization with such formal procedures. The formality of shift turnovers should begin with the training of facility personnel and continue with in-plant operations and management oversight. It is very important for operating crews to communicate effectively with each other in order to have continuous control of the plant during crucial activities.

It is important for oncoming crews to have as much pertinent information on plant systems and equipment as possible. The information required during a shift turnover should include the current plant status, previous and ongoing activities, equipment status, and any other relevant data that will aid the oncoming shift. Formalizing shift turnovers allows continuous safe control of the facility.

Symptoms

Functional Area Coordination

OA1: One way in which an assessor can determine the formality of plant operations is to observe how shift turnovers are handled. Plant status from the previous shift should be logged and current status should be discussed by the two shift crews. The assessor can review the information conveyed to the oncoming shifts to determine whether the process was formally documented with a checklist. Confusion or uncertainty during the next shift on plant status and planned events may indicate poor communications between the shift crews.

OA2: In addition to the need for formalized communications between the shifts, the need exists for formal communications among operations personnel in the control area. The assessor should observe communications in the control area and determine whether the information exchanged is understood and acknowledged in a formal manner. The lack of formal communications among operations personnel may be reflected in those personnel frequently asking each other what another operator was trying to convey, and in mistakes being made during subsequent plant evolutions.

OA5: Formality in control operations can also be determined by reviewing the procedure and process for informing personnel returning from absence of any changes in plant status. No formal way of doing so may exist and the assessor can determine this by reviewing the plant documents for a procedural way to update operators, and by interviewing plant operators returning from an absence.

OA6: By attending a briefing on an upcoming plant evolution, the assessor should be able to evaluate how well personnel communicate with each other and how well they plan activities. During such a briefing it is likely that the activities described will occur on more than one shift. Coordination among the shift crews will require effective communication. The assessor should notice whether the information at this meeting is presented in a formal manner and whether it is understood by those attending. By interviewing the attendees after the meeting, the assessor can assess how effectively the crews work and communicate with each other.

OA13: The assessor should observe the conduct and supervision of in-plant trainees in order to assess the formality stressed for shift turnovers. Establishing the formality required of plant personnel requires indoctrination during both the classroom and in-plant training stages. The assessor should look for signs of formal communications during the in-plant training exercises and whether the lack of communications is corrected by operations personnel.

Management Cause Analysis

2C.2: Responsibilities and authorities of the operations organization must be formally defined through official documents. Without a formalized program for the conduct of operations there may not be effective communication between the shift crews during turnover. There should exist within the organization specific documents that clearly define the responsibilities and authorities of operations personnel, especially the managers. The lack of such documents may be one root cause for degraded facility operations. Accountability should also be clearly defined within the same official documents that specify responsibilities and authorities. It is up to the individual to understand facility policies as they pertain to operational conduct during shift turnovers.

2D.3.4.77-83: Effective shift turnovers require that vital plant information be recorded in the facility logbooks for the oncoming shift to review. There should be guidance for the operators as to the type and scope of information to be entered into the facility logs. These plant logs should be reviewed by supervisory personnel to ensure that they have sufficient and legible information recorded in them. Properly maintained logbooks will aid operators in conveying vital plant information between the various shifts.

2D.3.4.84-89: Proper shift turnovers require the use of documented information between the shift crews, primarily the use of a well-developed shift turnover checklist. In addition to a checklist, it is important for the shift crews to perform a walkdown of the control panels and review of other pertinent documents. The turnover should include a full discussion of plant conditions and any abnormal events that have occurred of that presently exist. Shift turnovers are the responsibility of operations supervisors and individual operators. Management should ensure that the proper techniques of shift turnover are stressed in training and in facility operations. Lack of management commitment to these programs may be a root cause for poor facility operations.

References

One way in which an assessor can determine the structure of plant operations is to observe how shift turnovers are handled by the operators. In order to maintain a positive nuclear safety culture, it is essential for the shift crews to perform turnovers in a formal and adequate manner. Control of critical plant functions in a formalized manner is necessary to maintain continuous control of the facility. The assessor can observe a shift turnover and review the information conveyed to the new shift to determine whether it was handled in a structured and responsible manner. Confusion or uncertainty during the next shift on plant status and planned events it may indicate a weakly structured organization without strong lines of authority.

Formal control of critical plant functions can be accomplished with procedures that document proper shift turnover conduct. This formality over control should begin with the training of facility personnel and continue with in-plant operations and management oversight. It is very important for operating crews to effectively communicate with each other and with other shift crews in order to have continuous control of the plant during crucial activities.

Specific Assessment Activities

The assessor should take the following actions:

1. During a shift turnover the assessor should notice how the information on plant status is relayed between the shift crews. Determine whether the shift turnover is done in a formal way or casual manner. This manner can be evaluated by the amount of information that is transferred in hard copy form as opposed to oral transmission. Notice whether the operators on shift tell the oncoming shift of any planned or ongoing events in the facility. Note whether the oncoming shift personnel ask the standing shift questions about the plant status.

2. Examine the operating logs from these shifts to see the kinds of information that are formally recorded for use by other crews. Review the operating procedures to see whether there is one for formal shift turnovers (it might be part of another procedure) and if so, does it explicitly outlines what the operators should log and convey to other shifts.

3. Observe in-plant trainees to see whether the formality of shift turnovers is stressed to them. Observe the operator training program. Review the training curriculum to determine whether trainees are taught the conduct of operations. Interview trainees in-plant trainees to determine whether they received instruction in the conduct of control room shift turnovers.

4. Obtain, if a formal one is in use, the shift turnover checklist and evaluate the its contents. Does the list contain information on alarm status, equipment status, abnormal system lineups, and surveillances or planned activities. The checklist may contain key plant parameters, operational limits in effect, or cite unusual plant conditions. Interview operators to see whether the information on the shift turnover checklist or status boards is sufficient or whether they lack support from other on-site organizations.

Functional Area Coordination

EQ1: Assessors observing shift turnovers should assess the level of the technical information provided in turnover sheets and on status boards for clarity and adequacy. One problem may be that status boards and turnover sheets are out of date due to design changes or changes in technical requirements. In some cases, deficiencies in these areas could indicate that the Engineering Organization is not ensuring comprehensive support. This may be due to weaknesses in the assignment of responsibilities for this type of support.

MQ1: The assessor observing shift turnover should be alert to identify any backshift problems that may be caused by inadequate Maintenance Organization staffing and support. Specific examples of work or operations deferred on backshifts when such work should have proceeded on backshifts should be noted. Also, the assessor should specifically inquire regarding the adequacy of support (in general) on backshifts.

MQ4: Assessors observing shift turnover can help to ensure that the operators have control of maintenance activities by determining whether the status of all ongoing maintenance activities is explained adequately from one shift to the next. Frequently, an operator will be aware that a maintenance activity is ongoing but will not know the impact of the maintenance activity on facility operations. Oncoming operators should make thorough facility tours, ask maintenance personnel questions, review status boards, and ensure that off-going operators and maintenance personnel explain the various work being performed at the facility.

OQ2: Management controls are essential for the operations organization to function in a manner consistent with the goals of the nuclear safety culture. If operations at a facility were structured in an informal or haphazard fashion, then activities such as shift turnovers would not be properly performed. As a result of informal shift turnovers, plant activities would be performed in a way that could lead to operational incidents that damage equipment or injure plant personnel. The Operations Organization should be structured with clear lines of authority that lead to managers who are responsible for the safe operation of the facility. Clear lines of authority and responsibility as well as an accountability system must be established for the effective function of the operations organization. Putting these controls in place will greatly aid in maintaining a consistent and defined method for enhancing the concepts of nuclear safety during facility operations.

OQ3: It is essential for plant operators to perform shift turnovers in a formal and documented way to maximize continuous control of the facility. Formal control of critical plant functions can be accomplished with procedures that document how these plant evolutions should be accomplished. An assessor observing shift turnovers will be able to determine the formality of shift turnovers. This formality should begin with the training of facility personnel and continue with in-plant operations and management oversight.

OQ6: To create and maintain a positive nuclear safety culture requires operations personnel to communicate with each other in a formal and documented way. This formalized manner of communicating is essential during plant shift turnovers. Formal shift turnovers can be accomplished with procedures that outline the kind of information that should be exchanged between shift crews. This formality should begin with the training of facility personnel and continue with in-plant operations and management oversight. The information that the assessor should look for during a shift turnover should include the current plant status, previous and ongoing activities, equipment status, and any other relevant data that will aid the oncoming shift.

OQ11: Formality in control operations can also be determined by reviewing the procedure and process used to inform personnel returning from an absence of any changes in plant status. The assessor can determine whether a formal means exists to provide updates on plant status by reviewing the plant documents and by interviewing those operators returning from an absence. If there is no systematic way to do so, there may be a breakdown in plant management to effectively control the process of plant operations.

Management Cause Analysis

2C.2: Responsibilities and authorities of the operations organization must be formally defined through official documents. Without a formalized program for the conduct of operations there may not be effective communication between the shift crews during turnover. There should exist within the organization specific documents which clearly define the responsibilities and authorities of operations personnel, especially the managers. A Program Secretarial Officer (PSO) is the individual responsible and accountable for management of field and headquarters coordination of programs that will implement these processes of accountability. The lack of such programs may be one root cause for degraded facility operations. Accountability should also be clearly defined within the same official documents that specify responsibilities and authorities. It is up to the individual to understand facility policies as they pertain to operational conduct during shift turnovers.

2D.3.4.77-83: Effective shift turnovers require that vital plant information be recorded in the facility logs for the oncoming shift to review. There should be guidance for the operators as to the type and scope of information to be entered into the facility logs. These plant logs should be reviewed by supervisory personnel to ensure that they have sufficient and legible information recorded in them. Properly maintained logs will aid operators in conveying vital plant information between the various shifts.

2D.3.4.84-89: Proper shift turnovers require the use of documented information between the shift crews. This formal requirement necessitates the use of a shift turnover checklist. In addition to a checklist, it is important for the shift crews to perform a walkdown of the control panels and review of other pertinent documents. The turnover should include a full discussion of plant conditions and any abnormal events that have occurred of that presently exist. Shift turnovers are the responsibility of operations supervisors and individual operators. Management should ensure that the proper techniques of shift turnover are stressed in training and in facility operations. Lack of management commitment to these programs may be a root cause for poor facility operations.

To maintain a positive nuclear safety culture, it is essential that control of critical plant functions be performed in a formal and documented way. This control is dependent on the formal conduct of operators in the control room, whose performance can be assessed by observing their response to alarms, formality in giving instructions, and how they control access to the work area. Confusion or uncertainty during operating activities may indicate a weakly structured organization without strong lines of authority.

This formality over control should begin with the training of facility personnel and continue with in-plant operations and management oversight. It is important that operators use effective communications with each other and conduct operations properly while standing watch. Proper conduct of operations should be stressed by plant management.

Symptoms

Specific Assessment Activities

The assessor should take the following actions:

1. Observe plant operations in the control room and evaluate how operators communicate. Determine whether the shift turnover is done in a formal or casual manner based on the amount of information transferred in hard copy as opposed to oral form. Notice whether the operators on shift seem disorganized in how they accomplish plant activities. All operations personnel must participate in the process in order for proper communication to occur. Ineffective communication between operators will hamper the safety.

2. Observe in-plant trainees to see whether the formality of effective control room communication is stressed to them. Observe operator training. Review the training curriculum to determine whether the conduct of operations is stressed to the trainees. Interview trainees to determine whether they have been taught how to conduct themselves in a formal and effective way.

3. Examine shift operating logs and assess the types of information formally recorded for use by other crews. Examine control room status displays to determine whether they are up-to-date or whether they are outdated due to a lack of support from other organizations. Review the operating procedures to see whether there is one for formal shift turnovers (it might be part of another procedure) and, if so, see whether the procedure explicitly outlines what the operators should log and convey to other shifts.

Functional Area Coordination

MQ6: The assessor observing control room formality should note the extent to which operators are distracted or limited by instrumentation and control problems that may be due to inadequate calibration and testing by the Maintenance Organization.

OQ2: Management controls are essential if the operations organization is to function in a manner consistent with the goals of the nuclear safety culture. If operations are informal or haphazard plant operators cannot function in a consistent and effective manner, which could lead to operational incidents that damage equipment or injure plant personnel. To promote safety in plant operations, it is important for operators to communicate with each other in an effective manner. Clear lines of authority and responsibility as well as an accountability system must be established for the effective function of the operations organization. Putting these controls in place will greatly aid in maintaining a consistent and defined method for enhancing the concepts of nuclear safety during facility operations.

OQ3: To maintain a culture of nuclear safety plant operators must perform their duties in a formal and documented way. Formal control of critical plant functions can be accomplished with procedures that document how these plant evolutions should be accomplished. An assessor can determine whether operators are properly controlling access to the control area and whether operators are maintaining vigilance at the board. Shift turnovers between crews should also be performed in a formal and documented way. This formality should begin with the training of facility personnel and continue with in-plant operations and management oversight. By formalizing critical plant operations, continuous control of the facility can be maximized while maintaining nuclear safety.

OQ6: To create and maintain a positive nuclear safety culture requires personnel to communicate in a formal and documented way. This communication is essential during plant shift turnovers to maintain safe operation of the facility. Formal shift turnovers can be accomplished with procedures that outline the kind of information that should be exchanged and familiarization with such formal procedures. The formality of shift turnovers should begin with the training of facility personnel and continue with in-plant operations and management oversight. Formalizing shift turnovers allows continuous safe control of the facility.

OQ10: One of the ways to formalize activities in the control area is to formalize the information used by the operators. The operating logs of the plant should be complete and accurate so the operators know the past and current status of the facility. The assessor should review the plant logs to obtain some measure of the quality and quantity of information recorded by the operators as they perform their duties.

OQ11: Formality in control operations can also be determined by reviewing the procedure and process used to inform personnel returning from an absence of any changes in plant status. The lack of a procedure such as a required reading program to apprise returning personnel of changes in the facility indicates that no formal way exits to do so. The assessor can determine this by reviewing the plant documents for a procedural way to update operators, and by interviewing those plant operators returning from an absence. If no systematic way exists, there may be a breakdown in plant management to effectively control the conduct of plant operations.

Management Cause Analysis

2D.3.4.17-21: In order to exercise formality in critical control areas it is essential for these areas to have controlled (limited) access. It is important for operators to be professional in their duties. These duties should be focused on monitoring and promptly responding to alarms on the main control panels. Operators should not be hindered with ancillary duties that might interfere with their ability to monitor plant parameters. Formality of operations in the control area should be established by management programs with the conduct of operations procedures.

2F.2: Individual operations personnel must be aware of the safety objectives set forth by management and accept individual responsibility in daily plant activities. Operations personnel should have a working knowledge of the safety standards to which they must adhere to in controlling plant equipment. This includes understanding and following all the formal requirements to control and operate plant equipment. Without a clear understanding by each individual, administrative controls may be bypassed during plant operations. Individual failure to abide by the safety guidelines established by management can contribute to degraded plant performance.

References

The assessor can review the plant operating procedures to see whether they are current and whether they employ the same nomenclature used for plant equipment. Document control records can also be reviewed to see whether these procedures are periodically reviewed to reflect physical changes in the facility. There should be a formal manner in which to create, review, and update plant operating procedures. The review cycle for these procedures should include people knowledgeable about plant equipment and operations. Lack of procedural control of these documents hampers nuclear safety.

Specific Assessment Activities

The assessor should take the following actions:

1. Observe plant operations in the control room and notice how operators use procedures. If operators frequently deviate from procedure to get a job done, operating procedures may be out of date or ineffective. Interview plant operators to determine whether they believe the operating procedures are useful. Non-adherence by operators may indicate that procedures are outdated, not useful, or that operators are not following the formal conduct of operations.

2. Compare selected procedures to see whether the language used in them is consistent with that of equipment in the plant and with indications in the control room. Determine whether the facility has a master plant list to be used for consistent system and equipment labeling. The lack of a master plant system and equipment labeling list indicates that procedure nomenclature may not be consistent with plant equipment.

3. Review the operating procedures to see whether the directions are clear in meaning and sufficient in content. The procedures should not be vague and should have sufficient content to begin and end an activity without having to rely on some outside source of information (unless referenced).

4. Review the process by which operating procedures are created, reviewed, and updated. Determine whether qualified personnel are listed in the review cycle for these procedures. Inspect the records of document control to see whether the procedure cycle is formalized and whether the procedures are able to incorporate facility changes in a timely manner. Interview personnel in document control to determine how new information is incorporated into existing procedures and how often this is accomplished.

Functional Area Coordination

EQ1: Assessors reviewing operating procedures for clarity and consistency with plant equipment labels can provide insights regarding the Engineering Organization's ability to support fundamental requirements of the Operations Organization. Managers responsible for operating procedures and equipment labeling should be identifiable in each of these organizations.

OQ7: The operating procedures should be consistent and unambiguous so that operators can achieve procedural compliance without having to interpret the language in these documents. It is also crucial for these documents to be controlled in such a manner that they can be periodically updated to reflect facility changes. The assessor should review some of the operating procedures to determine whether they are consistent and unambiguous. Review of document control records will allow the assessor to determine whether the operating procedures are in fact up to date with current facility design. There should exist a formal method for incorporating any facility changes into the operating procedures. Lack of proper document control for plant procedures may indicate a failure of management to implement the necessary initiatives for such a process.

OQ8: In order to have procedural compliance, it is essential that the plant equipment, systems and rooms be labeled in a consistent manner. To facilitate consistent plant nomenclature a master plant labeling list is necessary, which the assessor should review for consistent nomenclature. Only if the plant and equipment are consistently labeled can the procedures have consistent nomenclature. The failure to have a master plant labeling list and/or consistent plant labeling indicates a failure by plant management to adhere to the principles of the nuclear safety culture.

Management Cause Analysis

2A.1.1: It is essential for operators to have current documentation on the facility design in order to effectively operate in a formal manner. This includes safety analysis reports (SAR), technical specifications, drawings and system descriptions. Without current material, it is not possible for the operations personnel to control the facility. It is essential for plant management to ensure that document control procedures are in place, which can maintain this needed information in a condition useful to plant operators.

2A.1.2: Plant operators must also have current procedures in order to operate it in a safe manner. This includes the normal and emergency operating procedures. Without current operating procedures it is not possible for the operations personnel to control the facility. It is essential for plant management to ensure that document control procedures are in place which can maintain this needed information in a condition useful to plant operators. The lack of current operating procedures may be one of the root causes for the failure of plant operators to maintain safe control of the facility.

2D.3.4.102-108: Plant operating procedures should be developed under prescribed guidelines that give them uniformity and that also incorporate human factors guidelines. These operating procedures must be approved through a review cycle that involves top plant management. All operating procedures should be under the cognizance of a document control program that will allow regular review and update. There must be a method in this procedure revision process to incorporate changes in the facility design in plant operating procedures.

2D.3.4.115-118: The nomenclature in operating procedures should be consistent with that used in the facility. A plant labeling program which uses nomenclature from a an approved Master Plant Title List is an essential part of having consistency in operating procedure nomenclature. These in-plant labels should be used on all valves, equipment, switches, breakers, cabinets, fuse blocks, instruments, motor control centers, room areas, emergency equipment and fire protection systems. To have operating procedures that are consistent with plant nomenclature requires them to be reviewed against plant equipment labels. Consistency of nomenclature in the plant and procedures will aid the operations staff in safely operating the facility. Lack of consistency between the plant and procedures may indicate the failure of management to implement programs that coordinate facility activities.

References

One way to gauge plant operations is to examine the way equipment is controlled within the facility. In particular, the lockout and tagout programs are an essential part of controlling plant equipment. Failure to properly control tagouts and lockouts may lead to personnel injury and equipment damage, which can compromise facility safety. Proper tagout of equipment requires procedural compliance by the qualified operators who know the systems they have under clearance. Performing lockout and tagout of equipment requires the operators to always follow procedure and perform independent verification. Although it is sometimes necessary to bypass these programs in an emergency situation, it is very dangerous to do so otherwise. Failure to follow these programs may be an indication of ineffective management commitment to the concepts of nuclear safety.

When management fails to stress the importance of nuclear safety, the training programs and operations procedures will fail to enforce these concepts. Proper procedures must be followed whenever personnel are handling equipment in the plant. Clear lines of authority and responsibility, as well as accountability, must be established in the tagout program for the effective function of the operations organization. Following the proper procedures for the lockout and tagout of equipment will greatly aid in enhancing the concepts of nuclear safety during facility operations.

Specific Assessment Activities

The assessor should take the following actions:

1. Observe how formally the clearance center handles information in the tagout and lockout of equipment. This can be evaluated by the amount of information that is transferred orally or in hard copy form. Determine whether the clearance center is effectively communicating with personnel in the control room as to the current status of plant equipment. Examine the clearance books to see whether they are complete and examine control room indications to see whether they are current. Inadequate or outdated information may indicate a lack of support from other site organizations.

2. Observe in-plant trainees to see whether the formality of equipment tagout and lockout are stressed by the facility. Observe operator training and review the training curriculum to determine whether the concept of independent verification and personnel accountability are emphasized. Interview trainees to see whether they understand independent verification and how it relates to nuclear safety.

3. Observe operators in the plant performing a tagout procedure. Determine whether the operators are following procedure and whether they perform independent verification as required. Review one of the check-off lists against the actual lineup of equipment in the plant. Discrepancies between actual and recorded lineups may indicate a general failure of operations personnel to follow procedure.

Functional Area Coordination

MQ2: The assessor reviewing the operational control of the tag-out program should determine whether maintenance packages are generally helpful in determining the appropriate equipment to be tagged or whether conflicts are frequent. This information could be useful in determining the effectiveness of the tag-out program as it is used in the plant between interfacing organizations such as the Operations and Maintenance Organizations.

MQ4: Assessors observing operation of the tagout program can help verify that the operators have control of maintenance activities. This can be accomplished by ensuring that tagouts related to maintenance adequately isolate the equipment or systems affected, tagouts are properly hung and verified, facility status boards are updated to show tagout requirements, and tagouts are promptly removed upon completion of a maintenance activity. Often, more than one maintenance activity can affect a single system or component. When this is the case, assessors should verify that a component is not cleared when only one of several maintenance activities affecting the component is completed.

OQ4: If tagout and lockout programs are bypassed during non-emergency situations, then there may be a general failure of operations personnel to follow the basic concepts of nuclear safety. In observing this program the assessor should note whether independent verifications are used in a system realignment or system change. If these programs are not followed, then serious consequences are inevitable. Failure to properly control tagouts and lockouts may lead to personnel injury, equipment damage, and can compromise facility safety. Although it is sometimes necessary to bypass these programs in an emergency situation it is dangerous to do so otherwise. Failure to follow these programs may be an indication of ineffective management commitment to the concepts of nuclear safety.

OQ5: In gauging the safety of plant operations the control and operation of equipment within the facility are an important element. It is important for plant personnel to use independent verification whenever they manipulate plant equipment or alter system lineups. Failure to properly verify plant conditions may lead to personnel injury and equipment damage. Although it takes time to perform independent verification correctly, plant management should stress the importance of taking the time to do the job right. Failure to follow the process of independent verification may be an indication of ineffective management commitment to the concepts of nuclear safety. Following the proper procedures for the independent verification of system status will greatly aid in enhancing the concepts of nuclear safety during facility operations.

OQ13: Plant operators learn the application of safety concepts and proper plant control during their training programs. Plant trainees should be closely supervised during in-plant training so that they learn the importance of following procedure. The training program should stress the proper methods for lockout and tagouts of equipment in the plant. This program should emphasize the need to perform independent verifications and follow procedures (unless it is an extreme emergency and supervisors have been contacted for permission to deviate from procedure). If these concepts are not taught in training, correct procedure may not be followed in the plant.

Management Cause Analysis

2D.3.4.49-58: Effective control of plant equipment is the responsibility of operations supervisory personnel. To accomplish control of plant equipment requires that supervisory personnel administer the use of locks and tags. Locks and tags should be used on components that require special administrative control for safety reasons. Administrative controls should be established to accommodate temporary modifications such as jumpers, lifted leads, disabled alarms, disabled relief or safety valves, etc. Only with effective administrative controls on the lockout and tagout of process can plant equipment be safely controlled.

2D.3.4.59-73: To prevent the lockout and tagout programs from being bypassed during normal and emergency operations requires that effective administrative controls be established. Facilities should have an existing lockout/tagout program with approved procedures to control potentially hazardous energy sources and materials. Only qualified personnel should be authorized to perform equipment lockouts and tagouts. Plant personnel should be qualified with training that emphasizes proper lockout and tagout practices. Supervisory personnel must ensure that such lockout/tagout programs, training and procedures are in place and used by plant personnel.

2F.1: Line management must foster the development of a safety culture in order for plant personnel to follow proper procedure in the clearance of equipment. Line management should also implement programs that endorse the nuclear safety culture. Failure to do so may contribute to plant operator failure to follow proper procedure in the clearance of facility equipment. Following procedure and performing independent verification are important ways of fostering nuclear safety.

2F.2: Operations personnel must be aware of the safety objectives set forth by management and accept individual responsibility in daily plant activities. Operations personnel should have a working knowledge of the safety standards that they must adhere to in controlling plant equipment. This includes understanding and following all the requirements and controls required to clear tagouts and lockouts of equipment. Without this clear understanding by the individual of safety, administrative controls may be bypassed. Individual failure to abide by the safety guidelines established by management can contribute to degraded plant performance.

References