Nuclear Report Card : Ontario’s Reactors are Minimally Acceptable

N u c l e a r R e p o r t C a r d :

Ontario’s Reactors are Minimally Acceptable

— Part One —

A Report to Ontario Hydro Management

The IIPA/SSFI Evaluation
Findings and Recommendations

Prepared for:
Dr. O. Allan Kupcis, O.H. President and Chief Executive Officer
and
Mr. G. Carl Andognini, Executive Vice-President and Chief Nuclear Officer

July 21, 1997

TABLE OF CONTENTS

1. Executive Summary

2. Introduction

Basic Goals
Key Issues
Results at a Glance

3. Findings and Recommendations

Managerial Leadership

Key Deficiencies
Recommendations

Culture and Standards

Culture
Nonconservative Decision-Making
Standards
Recommendations

People and Performance

People
Performance
Recommendations

Processes and Procedures

Inadequate Performance Monitoring
Inadequate Procedural Compliance
Inadequate Quality Assurance
Inadequate Work Protection
Root Causes Not Identified
Security Program Needs
Incomplete or Flawed Processes
Recommendations

Plant (Hardware) and Design

Operability Determinations
Design Documentation & Change
Systems Engineering and Programs
Safety System Functional Inspections
Plant Status and Configuration Control
Recommendations

Organization and Resources

Resources
Recommendations

Labour Relations

Issues Affecting Performance
Recommendations

4. Site-Specific and Corporate Reviews

Bruce Generating Station

Darlington Generating Station

Pickering Generating Station

Safety System Functional Inspections

Bruce A Emergency Coolant Injection
Bruce B Service Water Systems
Darlington Compressed Air Systems
Pickering Electrical Distribution System
Engineering Design and Design Change
In-Service Environmental Qualification
Fire Protection Functional Inspection

Corporate

Management Focus on the Asset
Authority
Resource Utilization & Cost of Services
Analyses and Risk Assessment
Quality Assurance
Material Degradation Monitoring
Performace Area Ratings

Organizational Effectiveness

1. EXECUTIVE SUMMARY

Long standing management, process and equipment problems in Ontario Hydro Nuclear (OHN) plants are well known but have not been aggressively resolved. As a result, the overall performance of OHN is well below the level of performance typically achieved by the best nuclear utilities. Immediate attention is needed to improve performance so that the value of OHN‘s assets does not depreciate beyond recovery. There is still a tendency to look backward at past performance and take comfort rather than address the significant challenges of the future. In spite of the consequences of carrying on with the current course of action, a sense of urgency to move quickly towards substantial and sustained improvement in performance is not evident throughout the organization.

These concerns as well as other strategic issues led Ontario Hydro’s Chief Executive Officer, Dr. O. Allan Kupcis to hire Mr. G. Carl Andognini as Executive Vice President and Chief Nuclear Officer (CNO) in December, 1996. Dr. Kupcis immediately directed Mr. Andognini to secure the type of “brutally honest” assessment of OHN conducted by the American nuclear industry. In January, 1997, Mr. Andognini chartered the Nuclear Performance Advisory Group (NPAG) to perform an Independent, Integrated Performance Assessment (IIPA) of OHN. The IIPA was conducted over a three month period. This report to management presents the findings of the IIPA assessment.

A portion of NPAG’s charter is to recommend to the CNO if and when they determine that conditions in the plant(s) degrade to a point where minimum nuclear safety standards are not being met. The CNO will respond quickly to any situation that seriously reduces or challenges the safe operating envelope, up to and including partial or full shutdown of the operating unit(s).

In this regard, while the current course of action has significant financial consequence, the IIPA team confirmed that all of the plants were being operated in a manner that meets defined regulations and accepted standards related to nuclear safety. During the course of the assessment, a few issues were identified by the team that could undermine defense in depth barriers. These issues were raised to senior plant management and resolved to the satisfaction of the team.

In general, the IIPA team ranked all of the operating stations (Pickering , Bruce and Darlington) “Minimally Acceptable”. Immediate management attention however, is needed to improve performance or even to maintain current performance. The rank “minimally acceptable” is consistent with the lower ranks that the Institute of Nuclear Power Operators (INPO) would issue and still permit the plants to operate if in America. NPAG believes it is also consistent with a United States Nuclear Regulatory Commission (NRC) Systematic Assessment of Licensee Performance (SALP) rating that would likely result in the plants being placed on the “NRC watch list”.

Initiatives such as the OHN Nuclear Recovery Plan and the Pickering Quality of Work Program have identified and/or addressed some key problem issues. In selected areas, progress is being made. For example, the improvement in the visual appearance of several stations and increased reporting of lower level events in the corrective action system are two examples. In other areas, the ability to take corrective actions is inhibited by an insufficiently detailed understanding of the standards and practices required to achieve excellence in nuclear operations.

Unless fundamental problems, most notably a lack of authoritative and accountable managerial leadership, are addressed and corrected, there is limited potential for success at OHN. Moreover, many problems are so deeply entrenched within all aspects of OHN (organizational structures, practices, policies and systems) that individual managers are unable or unwilling to take corrective action.

Clearly, OHN did not make a smooth transition from it’s original and highly successful design and construction phase to the second stage, focused on operating and maintaining its nineteen operating nuclear units. A full transition to the second stage requires a new approach to the culture, structure, and management of OHN, as well as a rethinking of employee skill mixes and the regulatory process. To excel, OHN must transform itself into a world class organization with a primary focus on operating and maintaining its existing assets. These standards of excellence were the basis for the IIPA assessment convened by the CNO.

OHN staff at every level are reluctant to ask difficult questions of themselves and others. Failure to establish a questioning attitude is a primary cause of the reduction in the “defense-in-depth” concept. There is no real independent evaluation of proposed operations by people not directly involved in formulating the planned actions, (e.g., is this the safest way to accomplish an operation? Are the operators challenged unnecessarily by the proposed change? Will all required structures, systems and components remain capable of performing their intended functions for their day-to-day mission and all credible accident scenarios?).

In summary, there is much work to be done, at all levels in the organization, to reach the established standards of excellence expected in the nuclear industry. However, OHN is in a unique situation where success can be achieved if the proper actions are taken in a timely manner. The management and cultural problems identified by the IIPA, while extensive, are not substantially different than the effort required to turn around troubled plants in the United States. The members of NPAG have extensive experience directly applicable to such turnaround efforts and their involvement throughout the recovery will enable OHN to achieve success in the most effective, efficient and sustainable manner.

OHN recognizes and acknowledges it’s indebtedness to the nuclear professionals who expended more than 35,000 person hours to assess and recommend the overall corrective actions contained within this report and it’s supporting reports. The detailed corrective actions are contained in separate documents and plans.

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2. INTRODUCTION

Ontario Hydro Nuclear (OHN) has well recognized strengths in terms of people, technology and facilities. Unfortunately, it has become increasingly evident in recent years that OHN‘s strengths are being progressively eroded by deficiencies within all levels of the organization and in all key performance areas.

The Independent and Integrated Performance Assessment (IIPA) assessed the following:

The operating stations located at the Pickering, Bruce and Darlington sites;
Certain nuclear support services divisions located at corporate headquarters and elsewhere (e.g. Nuclear Technical Services, Nuclear Waste and Environmental Services, Nuclear Training, Bruce Central Maintenance Facility, and Regulatory Affairs).

The IIPA also included six Safety System Functional Inspections (SSFI’s) of specific plant systems and/or programs, modeled on the “vertical slice” methodology developed by the U.S. Nuclear Regulatory Commission (NRC).

The IIPA, including the SSFI‘s, was conducted by a multi-disciplined team of over 75 experienced personnel from both the Canadian and American nuclear industries. This ensured the teams were able to make the independent, “no-holds-barred” assessment required to develop credible findings and conclusions.

While immediate action is required in many areas, the deficiencies identified by the IIPA team have not yet undermined the minimum safety envelope at the sites to an unacceptable level as determined by OHN or its’ regulators.

The IIPA process, by definition, focuses exclusively on deficiencies and not good practices. However, there are many noteworthy and successful programs at the OHN corporate level and specific sites that meet or exceed industry standards. For example, the training program at Darlington for Chemical Technicians, although only a small fraction of the overall training for the station is exceptional and should become the OHN standard.

The IIPA utilized the IPAP methodology developed by the USNRC (Inspection Procedure No. 93808), and addressed nuclear safety issues with the same rigor.

It also examined performance areas not covered in the IPAP methodology, including organizational effectiveness & regulatory affairs.

Additionally, the Performance Area Attributes defined in Attachment B of Inspection Procedure No. 93808 were augmented with attributes extracted from the following sources;

INPO-96-006 (Performance Objectives and Criteria),
OHN Performance Objectives and Criteria, and
attributes developed by the IIPA Performance Area Leads.

The IIPA assessed ten functional performance areas:

Operations,
Maintenance,
Training,
Engineering,
Chemistry/Radiation Protection,
Quality,
Emergency Preparedness,
Security,
Organizational Effectiveness and
Regulatory Affairs.

Independent assessments somewhat similar to the level of scrutiny of an IIPA have led to dramatic performance improvements at stations such as Arizona Public Service’s Palo Verde Nuclear Generating Station and the Carolina Power and Light’s Brunswick Nuclear Station. Each of these stations was rated at the lowest threshold of acceptable performance when the assessments were initiated. In each case, subsequent recovery plans, undertaken at significant cost, re-established each station as a leader in nuclear safety, and as well as a competitive performer in the industry.

Basic Goals

Development of IIPA results and recommendations will be the key precursor to the development of an integrated, consistent OHN Business Plan. This work is consistent with the overall goals of executive management and the Ontario Hydro Board of Directors:

Improving nuclear safety and plant reliability; sustaining and enhancing the value of the nuclear asset; increasing credibility with both the Atomic Energy Control Board (AECB) and the people of Ontario; achieving upper quartile World Association of Nuclear Operations (WANO) ratings in the year 2000.

The IIPA of 1997 provides the baseline for future assessments of OHN people, plant and processes. It gives executive management the ability to gauge the effectiveness of future business plan initiatives while monitoring progress. The use of outside experts ensured that OHN performance was assessed by individuals without regulatory or utility restraints and whose conclusions would be “brutally honest”. It is anticipated that a systematic process such as this will be developed for use within OHN in the future.

Key Issues

Underlying the generic and site-specific issues are fundamental causes that are in whole or in part related to:

Managerial Leadership
Culture and Standards
People and Performance
Processes and Procedures
Plant (Hardware) and Design
Organization and Resources
Labour Relations

In addition to developing recommendations for the six fundamental problem areas listed above, the IIPA also:

Tested the effectiveness of the current OHN Strategic Plan for Excellence in Operations including the Nuclear Recovery Plan);
provided additional data needed to make the transition to an authoritative and accountable managerial leadership system, sustained with requisite managerial leadership practices;
provided insights that enhance the pursuit of excellence;
developed a database (compatible with existing and/or planned information management systems) that captures the IIPA baseline data and facilitates continual, on-line measuring and monitoring of overall performance.

The IIPA team addressed all of these issues with either generic or site-specific recommendations. As a whole, these recommendations form an essential part of the information needed to develop a strategically integrated and comprehensive Business Plan.

Urgent action is required in many areas to address the IIPA identified deficiencies. These deficiencies represent departures from the “defense-in-depth” concept that forms the cornerstone of the nuclear industry. They result in unacceptable erosions of the margin of safety afforded the public and employees. However, the design of the CANDU plant is robust, and in NPAG’s judgment the remaining safety margins are sufficient to protect station workers, the general public and the environment at each OHN site.

Summary of IIPA Results at a Glance

	Total OHN	Corporate Support	Bruce	Darlington	Pickering
Operations	Minimally Acceptable	Not Applicable	Minimally Acceptable	Minimally Acceptable	Minimally Acceptable
Maintenance	Minimally Acceptable	Not Applicable	Minimally Acceptable	Minimally Acceptable	Minimally Acceptable
Training	Minimally Acceptable	Not Applicable	Below Standard	Minimally Acceptable	Minimally Acceptable
Engineering	Minimally Acceptable	Minimally Acceptable	Minimally Acceptable	Minimally Acceptable	Minimally Acceptable
Quality	Minimally Acceptable	Minimally Acceptable	Minimally Acceptable	Minimally Acceptable	Minimally Acceptable
Radiation Protection	Minimally Acceptable	Below Standard	Minimally Acceptable	Below Standard	Minimally Acceptable
Chemistry	Minimally Acceptable	Below Standard	Below Standard	Below Standard	Minimally Acceptable
Emergency Preparedness	Below Standard	Below Standard	Below Standard	Below Standard	Below Standard
Security	(Confidential)	(Confidential)	(Confidential)	(Confidential)	(Confidential)
Organizational Effectiveness	Minimally Acceptable	Minimally Acceptable	Minimally Acceptable	Minimally Acceptable	Minimally Acceptable
Regulatory Affairs	Not Applicable	Unrated	Not Applicable	Not Applicable	Not Applicable

Full explanation of meaning of ratings is presented below.

The performance rating code definitions are:

Excellent – Performance exceeds industry standards (world class) and generally produces exceptional results. Current level of management attention is sufficient to sustain performance.

Satisfactory – Performance meets most industry standards and generally produces the desired results. Some additional management attention is needed to improve or sustain performance.

Below Standard – Performance is below industry standards and generally produces the desired results. Increased management attention is needed to improve performance.

Minimally Acceptable – Performance is substantially below industry standards, but produces minimally acceptable results. Immediate management attention is required to improve performance.

Unacceptable – Performance is not acceptable and nuclear safety is compromised. Immediate management action is required to return to an acceptable level of nuclear safety or to justify continued operation until performance is improved.

Unrated – Insufficient data available or collected to permit assigning a rating.

Industry Standard generally means a comparison to the key parameters used by INPO/WANO in their performance monitoring program to measure the proficiency of the nuclear industry. It is a combination of the nuclear safety, production and environmental aspects of nuclear power generation without regard to cost. In this document, however, “Industry Standard” is defined herein to include not only the nuclear safety aspects of the INPO/WANO indicators, but also cost competitiveness. It has been demonstrated that the generating units with the best overall INPO performance index are also the ones with the best (upper quartile) cost-of-generation results (non-fuel OM&A).

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FINDINGS AND RECOMMENDATIONS

Managerial LeadershipOver several decades, Ontario Hydro has not maintained a consistent, long-term vision of how its nuclear assets should be maintained and operated. OHN, in turn, has not provided an authoritative and accountable managerial leadership system for use by all OHN managers.

No sense of urgency exists to drive immediate change. Many managers are content with the rate at which the organization is changing. Some even actively resist change. The IIPA, however, found that there is ample opportunity to hasten the pace for increasing the standards of performance and changing the culture, the processes, the organizational structure and the procedural hierarchy. Every employee has to recognize the need to move quickly ahead with required changes.

There are significant numbers of managers at all levels of the nuclear organization who lack the basic management and leadership skills to be successful. They lack a fundamental understanding of the need for and value of a consistent, integrated managerial system.

Ontario Hydro has many highly motivated and experienced employees in managerial roles. However, their ability to provide adequate managerial leadership has been undermined by:

Organizational structures with inconsistently defined functions and poorly defined or missing functions and roles;

inadequately specified accountabilities and authorities not only for vertical organizational relationships, but also lateral working relationships;

lack of consistent and proven requisite (required) managerial leadership practices;

inadequate training and development programs for managers at all levels;

unclear or frequently changing direction on the goals and standards for OHN and specific sites;

lack of a well-managed performance indicator system;

lessons learned and best practices are neither shared nor required to be shared between sites, work units and central support services;

frequently changing application of the collective agreement.

Key Deficiencies

Inadequate Definition of Employee Accountabilities

Significant numbers of managers at all levels have not communicated to subordinates the need for understanding the vision and goals of OHN and the manner by which they are to be translated into defined tasks with clear individual and managerial accountabilities for performance. For example, it is easy to find employees at all levels who are assigned tasks with no completion dates, with accountability but no or limited authority, and no awareness of how their work supports OHN or site-specific goals.

It is also relatively easy to find employees in what are assumed to be first line managerial roles, such as Shift Maintenance Supervisors (SMS), who are convinced that they are not accountable for the results of their subordinates and in fact have little or no authority in their role. Worse still, some of the managers of the SMSs don’t even know what their shift maintenance subordinates are doing.

Poorly Defined Lateral Working Relationships

There were several instances of missing or poorly defined functions. For example, the IIPA team expected that Nuclear Technology Services (NTS) would be responsible for developing recommended engineering standards for OHN-wide application. However, no such function had been assigned to NTS, and NTS management did not exhibit the leadership needed to propose that it be given such an assignment. As a result, prior to action by the CNO in early 1997, there was no expectation that all sites would operate to the same standards. NTS did not meet the performance expectations of the IIPA; it did however adequately fulfill the functions assigned by previous OHN management.

The practice of offering critical services, such as training and engineering, on a “fee for service” basis has created an attitude that the groups providing the service are not a part of the team. This lack of teamwork hinders performance of the service organizations and causes unclear lines of authority and accountability between the operating stations and corporate support services.

Inadequate Managerial Practices

Some managers at all levels have not established the effective lines of communication required to obtain and clearly understand direction, gather important information, and listen and respond to concerns from employees. As a result, there is a gap between management’s perception of performance and actual performance. In fact, many managers were surprised by the negative findings of the IIPA team.

Managers do not routinely attach to assigned tasks clear expectations in terms of quality standards, timeliness or resource limitations. There is little expectation of excellent performance, either by management or employees, and little incentive to deliver excellent performance (financial incentives for example). Failure to perform adequately or poor performance is routinely accepted by management, and many managers have similarly low expectations for themselves.

Station management does present performance plans, daily work plans and outage plans. However, it is either unwilling or unable to do anything about minimally acceptable performance or non-performance. This fact is underlined by the number of missed deadlines and commitments, and increasing backlogs in all areas. For example a high percentage of preventative maintenance activities are not completed each month. Several managers at various levels indicated that there are no consequences when key objectives are not met.

Failure to Support Lower Level Management

Senior station and senior corporate services management does not fully support lower line management. Both good ideas and problems tend to be suppressed due to senior management’s lack of support. As a result, “bad news” and effective solutions are not flowing up through the organization. Problems are often “solved” at a level too low to assure sustained performance improvement.

Ineffective Oversight

A characteristic of most superior performers in the nuclear power generation field is the enthusiastic acceptance of an intrusive internal program of self-assessment throughout the entire organization. This includes oversight from respected nuclear quality groups comprised of experienced personnel. These oversight groups consider themselves, and are considered by the staff, to be an integral part of the team. They conduct their evaluations on behalf of the Site Vice Presidents and the CNO utilizing standard policies and programs developed at the corporate level with monitoring by corporate to assure adherence and effectiveness across all sites. The IIPA team saw neither effective self-assessment nor oversight accountabilities and authorities at OHN.

Recommendations

Create organizational structures and alignment of functions that are clearly defined and provide for all required functions placed at the requisite organizational levels;

assign accountabilities and authorities both vertically and laterally as required;

hold managers individually accountable for ensuring that they and all employees under their direction are aware of and committed to achieving safe and reliable operations through quality performance of expected behaviors and practices;

train all managers in basic managerial leadership practices that ensure effective two-way feedback, coaching, promote communications between managers and their subordinates re: task assignments, deadlines, quality, resources, employee concerns;

establish OHN corporate and site performance indicators that support the right behaviors for safe, reliable operations;

establish cross-functional and cross-site advisory roles for collecting and sharing lessons learned and best practices;

establish EVP directed self-assessment groups that will do in-depth honest assessments across all sites on a continual basis on behalf of the EVP;

create and fill new role of First Line Manager as first level of full managerial accountability and authority, accountable for ensuring timely, quality completion of all work assigned to non-management individual contributors on days and shifts;

establish on-site and off-site safety review capability reporting to the Site Vice President.

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Culture and Standards

Culture

Ontario Hydro has stated for years that “Our people are our most important resource.” In spite of this statement, OHN is not looking after its people very well. There are pronounced cultural problems that need to be addressed. The malaise is deep and wide and continues to worsen. It will not be quickly or easily corrected.

This culture is the result of long-standing managerial tolerance for cumbersome and ill- defined work processes that make it virtually impossible to get work done at the shop floor level and in the engineering office. In addition, this leadership has permitted the development of “organization walls” that discourage collateral working relationships and teamwork. Some of the behaviors that the team observed that supports this assessment are:

It’s acceptable to cut corners. It is not acceptable to make waves. Those who have made waves have been fired or sidelined. The messenger with bad news will be told to fix the problem. Attention to detail is not important as getting the job done. Not meeting commitments is the norm. One person can’t make a difference.

Non-performance is accepted — or even expected — because senior management has neither set nor enforced standards for employees nor have they assigned specific accountabilities and authorities to managers and individual contributors. As a result, few employees display all of the behaviors required to ensure that station operations remain within safety limits and that every task is completed down to the last detail.

This culture has a negative impact on productivity. More important, however, is the lack of commitment to the establishment and maintenance of a strong safety culture. The organization as a whole and employees as individuals must learn to consider safety an overriding priority, and safety issues must receive immediate and effective attention. The specific problems itemized below are examples of much larger generic issues for OHN:

Employees lack a questioning attitude; deficiencies with safety systems are tolerated at all levels of the organization; procedures are violated and management is tolerant; justifying that “that is OK”; managers, staff and suppliers are not accountable for timeliness or meeting quality and safety standards. Staff are in effect rewarded for poor performance; training in safety and job related accountabilities and authorities, procedures and tasks is insufficient or ineffective; training and development for managers is insufficient or ineffective for most, non-existent for others; there is insufficient training or preparation for managers in dealing with union-related matters .

Employees generally identify with their business unit, station, union affiliation or department, not Ontario Hydro or OHN, and generally do not work well with other groups. For example, training groups and line management do not exhibit a strong sense of working as colleagues with a common goal (See People and Performance). They are not always focused on the same goals and, at times, have conflicting goals that ultimately have a negative impact on OHN. The necessary cross-functional working relationships have not been established, monitored, and supported by senior managers.

Nonconservative Decision-Making

A lack of conservative decision-making is prevalent in OHN stations. Management is neither setting high standards for itself nor demanding the best from other departments, and personnel have not incorporated an adequate safety culture into their normal activities.

The IIPA observed a number of challenges to operations, indicating a lack of consideration of overall safety implications. For example, one challenge involved an alternate cooldown process that was modified and adopted without formal engineering review and appropriate analysis of the configuration.

Decisions are dominated by a production mentality and managers feel excessive pressure to continue planned evolutions. The production-dominated culture and its ultimate impact on long-term station performance was most apparent in management decisions regarding the start of the ten-year inspection at the Darlington vacuum building. This requires a full station outage. Although only about 60 percent of the scheduled outage jobs had received final planning, the decision was made to move forward with the outage on the original schedule, causing the remaining work plans to be issued during the outage when station resources were stretched to the limit.

Standards

Existing standards are, for the most part, not consistent with best industry practice, and are not consistently enforced across the entire organization. Lack of compliance is, in fact, commonplace because there is limited monitoring and assessment to identify and correct non-standard performance. The absence of common performance standards has led to a proliferation of varying and, at times, conflicting standards. Even within a single site, there are differences. For example, Bruce A and Bruce B have different managerial, operations and support structures, making it more difficult to implement positive changes across sites.

Recommendations

Require all managers to communicate immediately and support with their actions a firm commitment to a fully integrated OHN with common goals achieved using common structures, working relationships and managerial leadership practices;

upgrade operating and technical standards to meet the level established by top- performing nuclear operations and apply standards consistently across OHN;

establish training and development programs that fully inform all employees what will be required of them in their roles;

require managers at all levels to require their subordinates to think through the processes and procedures they are required to use and to bring issues, questions, ideas and recommendations of safety concerns, conflicting standards, and improvements to the manager for consideration and decision;

monitor adherence to OHN policies by all employees and consistently expect and require full compliance;

provide training for managers on the collective agreements and union relations;

provide experienced coaches coming from a stronger “conduct of” environment to accelerate the transition to a more self-critical culture.

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People and Performance

People

Poor work planning and scheduling has led to under-utilization of many workers within OHN. For example, maintenance crews are often unable to start work because materials, equipment or support is not available. In addition to draining productivity, this also undermines employee confidence in the managers who planned the work in the first place. There are also skill mismatches where the wrong people are assigned the wrong jobs, such as engineers preparing work packages and operations and maintenance procedures.

Serious shortages of key management, supervisory and some technical skills exist within OHN, particularly in plant and systems engineering, radiation protection, licensed operations personnel, and training. Too many gaps have been filled with temporary appointments, and there are inadequate plans in place to replace many key employees with specialized skills who are approaching retirement in the next five years. In addition, there is a lack of personnel with the special skills and experience needed for effective self-assessment and oversight.

Assignments often occur without proper regard to necessary requisite skills, particularly at the supervisory and management levels. For example, many employees at Bruce have been placed in front line supervisory positions with no understanding of their accountabilities and authorities. Worse still, after holding these positions for several years, many supervisors have still not received even the most basic training or coaching by their managers on how to manage, set priorities, and handle employee communication. In short, the mix of skills and assignments given are not in alignment with the work to be done. The solution is not to hire more employees, but to provide better training for those we already have.

Generally OHN employees, especially managers (who are charged with stating what work will be done, when, and how) are sufficiently acquainted with the differing standards and “conduct of” requirements in the nuclear industry. However, their attitude of “our technology is so different and superior that we really haven’t anything to learn from stations who use other technology” exhibits the kind of technical and managerial attitude that has contributed to the current state of station performance. This heavy reliance on past technical acclaim has set the tone of the current culture of a lack of urgency and inattention to disciplined “operations and maintenance” behaviors and attitudes at the stations.

Performance

Individual employee performance is being held back by the lack of managers who understand their accountability and authority for assigning specific work, tasks, expected results (See Managerial Leadership) and by serious and deepening deficiencies in training and development.

Most important, senior management has failed to give training the attention it requires to ensure that all employees are properly trained and qualified to perform their duties. Relations between station management and training support management are poor. They do not exhibit the trust and openness required to achieve excellence through early identification and correcting of problems. Training support is not able to meet station needs, while station management has not been sufficiently involved in the design and delivery of training programs. The training division is understaffed to ensure expected performance.

The most pressing problem in training is a severe shortage of resources. For example, the Western Nuclear Training Department (WNTD) lacks sufficient resources to support Bruce Nuclear Division (BND) operations, and achieve key training objectives in the Nuclear Recovery Plan (NRP) and Peer Improvement Plans. For example, a recent study by the Nuclear Energy Institute indicates that top performing nuclear stations conduct 240 hours of continuing training for control room staff; OHN does 80-120 hours.

Recommendations

Hold managers accountable for the outputs of their subordinates–what work is assigned, timely completion, maintenance of quality standards, etc.–and for coaching and training to correct deficiencies;

establish updated job descriptions including vertical and lateral working relationships and expected results for every position in the OHN organization;

ensure additions to the organizational structure meet station needs, industry standards, and requisite OHN policies organization principles;

establish new roles within required OHN standardization across sites;

standardize skill and knowledge sets across all sites;

create training programs that focus on individual effectiveness improvement, not training delivery, requiring Station Management to be involved in the design and delivery;

create required OHN training policies and enforce them;

upgrade content and delivery of training program to industry standards, developing a comprehensive initial training plan for each major job family;

require all managers be held accountable for ensuring that each subordinate is made available for required training;

enforce with managers the need to ensure that subordinates possess the required qualifications prior to beginning work;

establish formal on-the-job training/verification processes for all crafts;

ensure key personnel, such as station operators, are not overburdened by administrative duties;

continually monitor deviations from work plans, determine root cause of deviations, and correct with new policies, processes, standards, procedures, training, coaching, and disciplining as required;

develop innovative solutions, including the use of external sources, to clear the backlogs in training, engineering and other areas; increase productivity by:

forecasting manpower needs more accurately;

developing more accurate job estimates;

“walking down” more jobs prior to assignment; and

keeping employees fully deployed at all times;

monitor human performance problems;

assess impact on required resources due to attrition and demographic analysis and develop replacement staffing strategy as part of OHN business planning.

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Processes and Procedures

As the OHN workforce ages, the loss of more experienced personnel — those who constructed and commissioned the plants, is accelerating because of retirements, restructuring, etc. The loss of “corporate memory” can be devastating without comprehensive and accurate procedures and mature processes. OHN senior management have not set comprehensive standards for the plants. As a result, many processes and procedures are inadequate or are too outdated to be compatible with the current plant configurations. Often, major inconsistencies exist in the quality, extent, and use of processes and procedures between the various OHN sites.

At times, personnel cannot comply with the established processes or procedures — problems that have resulted in serious operating and safety issues. Many procedures can not be performed as written, and it typically takes months to get procedures revised and approved. Workers expressed the view that verbatim compliance with many procedures, as they are currently written, is impossible. For example, procedures are not always available for expected plant or system evolutions and Operating Memos are being used in many places instead of procedures or procedure revisions. Due to the extent of these problems, “bad practices” such as allowing shift superintendents to approve on-the-spot hand-written procedures have permeated the existing procedural control processes.

Procedural compliance policies are not consistent with good industry practice. For example, “follow as closely as possible” and “prepare hand-written procedures if necessary” are typical instructions provided for the procedure compliance process. The industry standard is to require strict (verbatim) compliance to procedures as written and approved and not to have the built-in workarounds. Workers become confused by inconsistent enforcement of procedural compliance requirements. Previously identified procedural problems are often not corrected and workers are still directed to continue work without making necessary changes.

Several vital processes are not sufficiently mature to determine how well they will work. For example, processes such as the new 13-week work control schedule are very recent and require time to grow and show improvements in performance. In the interim, lessons learned from their implementation must be shared between the various OHN sites and inconsistencies eliminated.

Procedures and established processes are the primary mechanism for maintaining the “corporate memory” of the workforce. Both require substantial improvement throughout OHN to reduce the probability and consequences of events and to maintain plant safety and reliability.

Inadequate Performance Monitoring

Key elements of an effective performance monitoring process exist within OHN. But they are not integrated to provide a full and accurate picture of plant performance. In general, key issues are not consistently identified, problem analysis is superficial, corrective actions are weak and not fully evaluated, receipt inspection does not exist in all areas, and in-process inspections are generally not required.

Managers have not been held accountable for establishing the performance measures required to identify problems, implement corrective actions, and assign accountability for results. For example, maintenance management at Bruce remains focused on day-to-day issues, not corrective actions that would lead to long-term improvements Moreover, maintenance management has been unable to correct increasing backlogs of maintenance work. As a result, the physical plant material condition is deteriorating and putting in jeopardy the value of OHN‘s primary assets — the operating stations.

Worker inefficiencies have not been evaluated and corrected. For example, many plant personnel change into radiation worker “Browns” when it is highly unlikely they will be assigned to work in a contaminated area. This inefficient practice is very costly to OHN and has very little, if any, payback in terms of worker safety.

Inadequate Procedural Compliance

Procedural compliance is not a standard expectation — a major reason for the excessive human error rate within Operations. Current procedures require assigning only specifically qualified personnel to certain job tasks. In practice, decisions regarding assignment of work are often based on who is available, rather than on existing individual qualification documentation, which is often out-of-date or incomplete.

Operations processes and procedures require improvement to maintain plant safety and reliability. Examples of present deficiencies include:

Procedures are not always available for expected plant or system evolutions. Examples are, integrated procedures for start-up and shutdown, heat sink change-over, and safe shutdown following loss of Class I power; operating memos are being used in place of procedure revisions because of the excessive time required to process revisions. Lack of timely revision discourages operators from identifying deficiencies. The backlog of pending revisions numbers about 350 for some plants with no plans for immediate, significant reduction; “Pickering Forms” are used as substitutes for operating procedures but do not receive the same level of review and approval as a procedure does; procedure adherence policy was observed not to be followed when human factor considerations prevented step-by-step adherence or when equipment deficiencies arose; shift superintendents are permitted to approve procedures prepared on-the-spot when no procedure is available. This approval does not require an assessment of potential effects on the safety envelope; periodic review to ensure long-term integrity of procedures is not being conducted.

Operations Procedures Groups have been established at two sites. However, they are not presently staffed to assume responsibility for managing the entire procedure maintenance process. A clear procedure format and content requirement has not been established by OHN for these groups to use. Based on future staffing projections, the group will not be fully functional for years.

Inadequate Quality Assurance

Quality Assurance is not assigned accountability or authority to monitor correction of deficiencies on behalf of the Site VP and to report when corrective actions are not within the expected time, quality, or quantity– a common requirement in high-performing nuclear operations.

Inadequate Work Protection

Errors made in work protection documents and work permits are placing workers at risk and inhibiting operators’ ability to control plant status. The existing code is unduly complex and is applied inconsistently. The current Work Protection Code is a major contributor to periods of worker idleness since these documents are required to be processed through the operations group where only a few operators are available to handle the large number of maintainers needing approval.

Root Causes Not Identified

Corrective action processes focus on superficial issues, not root causes, leading to excessive levels of repeat issues and rework. Identification of root cause and development of corrective actions and processes is not evident as a management value in OHN.

Security Program Needs

Although the OHN nuclear security program meets the minimum requirements of the Atomic Energy Control Act, it is questionable whether the assets of OHN are adequately protected against threats of sabotage, theft, or intruders. For example, the program doesn’t specifically allow security to inspect and search vehicles entering OHN facilities or to search personal belongings being brought on site by employees and visitors for contraband or other disallowed items. Additionally, there is no formal program that ensures personnel reporting to work are free of alcohol, and prohibited substances, or don’t exhibit aberrant behavior.

Incomplete or Flawed Processes

Some programs, such as the Hazardous Materials Management Program, the Emergency Preparedness Program, and the Station Calibration Program, are not working well and need attention. For example, the following processes within the Emergency Preparedness Program need attention: control of fire loading, training for radiological emergencies, use of operating memos for procedure revisions, backlog reduction, personnel accounting methods, and response to fire protection system design and equipment deficiencies.

Recommendations

Standardize processes and procedures throughout OHN;

initiate a procedure upgrade program that meets current industry standards.

establish and enforce a procedural compliance policy;

establish a standard definition and goals for controlling “operator workarounds” and monitor and control to within the goals;

establish a central operations support group to coordinate standardization improvements at all stations;

adopt a set of easily understood and implemented standard Work Protection Code procedures for the nuclear stations;

establish processes and procedures to identify root causes of events and track corrective actions;

develop a set of standards for “conduct of” type functions in each major OHN group;

restrict use of “Browns” to contamination areas or work areas with potential for contamination; see recommendations in “Managerial Leadership” section for QA initiatives;

establish a “fitness for duty” program for personnel having unescorted access to OHN facilities;

implement a personnel and vehicular search program to assure that prohibited items do not enter the plants.

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Plant (Hardware) and Design

The design of the CANDU plant is robust, and plant hardware (including equipment and materials), for the most part, is adequately reliable. However, several design and material condition issues incrementally erode the margin of safety afforded by the design. Although these issues are serious, they have not undermined the safety margins and safe operating envelope to an unacceptable level. Adequate safety margins remain to protect station workers, the general public, and the environment.

Design basis documentation is not accurately maintained. Vendor manuals are not current, and a large backlog of plant changes have yet to be incorporated into other design documentation. Updating design and vendor manuals is not a priority thereby necessitating the use of operating manuals as well as other available operating documents as alternatives (e.g., setpoints). It is not intended these documents be used for design information.

Compounding the issue of maintaining the design bases is the fundamental lack of appreciation for the impact of unauthorized changes on safe plant operations. In fact, the very definition of what constitutes a plant change from a design basis perspective is not fully understood by all elements of the organization. In some cases, changes were made without full consideration of the design intent and may have affected the integrity of special safety systems. For example, materials and parts substitutions have occurred without following the approved design change processes.

Station activities are not effectively managed to ensure that plant operation and configuration conform to design bases and remain within the bounds of analyzed conditions. Many surveillance and preventive maintenance activities have not been fully developed or are not being satisfactorily implemented to ensure long term availability and reliability. System and equipment performance is not optimized because of conflicting priority and resource management problems (e.g., living with condenser tube leaks for extended periods of time).

As a result, evidence of deteriorating materials and equipment are not difficult to find at each site. The IIPA found that each station had substandard equipment. Important equipment was out of service. Insufficient or improper maintenance resulted in leaks from mechanical joints, packing, seals, and equipment. Operators, engineers and station management accept low standards for equipment performance and condition. None of these groups insists on prompt repairs being made to prevent further deterioration.

In many cases, the implementation of preventive and predictive maintenance initiatives have been inadequate and insufficient to compensate for the normal aging of plant equipment. In general, OHN plants have been increasing the amount of preventative maintenance performed. However, the backlog of corrective maintenance is still increasing. In some extreme cases, preventative maintenance was not performed on station equipment because maintenance resources were completely consumed by more urgent tasks.

The deterioration of plant equipment as a result of ineffective and slow preventive maintenance is of particular concern. This issue has the potential of forcing unit shutdown or severely impacting the company asset and must be resolved as soon as possible.

Operability Determinations

The lack of a formal, documented process for performing technical assessments of equipment availability under degraded conditions, makes it difficult to declare with certainty when all of the requirements for operability of systems, structures, components and all attended appurtenances are met. Design and equipment issues with potential nuclear safety significance are not dealt with by the engineering organization in a rigorous and controlled manner. This results in answers that may not be correct or timely with respect to the immediate and long-term safety significance of the situation. A production imperative exists with the engineering staff at all stations. When the IIPA raised issues that had potential nuclear safety implications, the engineering staff responded by justifying the situation as being acceptable. In many cases, this justification was based on unsupported or undocumented engineering judgment or on an incomplete assessment of the intended design function of the equipment. The nuclear safety focus and questioning attitude of the engineering staff is lacking.

Design Basis Documentation & Change Control

The Design Basis Documentation is not maintained, understood, or appreciated by the System or Design Engineers. It is recognized that safety reports are deficient in some areas (e.g., not formally assessing the shutdown condition) but action has only recently been taken to address this in a limited way. Design Manuals are out of date and have not been revised to reflect plant modifications. Updates are generally not a priority, and there is a large backlog of plant changes that have not been incorporated into the design documentation. In addition, the Design Responsible Engineer’s input is not always sought when making permanent changes to the plant (e.g., in specifying substitute parts). These problems are best demonstrated in the difficulties encountered in resolving the excessive and at times improperly controlled use of jumpers (temporary modifications not receiving full engineering review).

Systems Engineering and Programs

Managers do not fully understand the function of system engineers and the role they play in assuring that plant design remains current and that critical equipment meets the highest standards of reliability. As a result, standards and expectations for systems engineering are not clearly defined and existing resources are not effectively managed. Managers do not understand the role of system engineering in maintaining the link between the design basis and the operating documentation, which provides the tools required to operate inside the defined safe operating envelope; therefore, they do not insist that this work be performed. As a result, engineering programs, when they exist, do not meet industry standards and monitor only degradation. They do not address long-term degradation prevention and performance improvement.

Safety System Functional Inspections Results

Six Safety System Functional Inspections (SSFI’s) identified several specific plant hardware and design deficiencies. These deficiencies represented additional examples of performance problems identified within this area. Each deficiency must be evaluated for potential generic applicability and impact across OHN stations. It is recommended that management consider performing additional SSFI type inspections to determine the extent of the types of deficiencies discovered during these six inspections.

Plant Status and Configuration Control

Indicators at all stations point to a lack of understanding and responsibility by the operations staff of the necessity to operate within the analyzed plant configuration. The use of jumpers, often approved at the shift superintendent level without engineering review, is extensive. Large backlogs exist with no concern about potential cumulative effects.

Operational flowsheets used to operate the plant and establish work protection code boundaries are outdated and maintained by operators with different station-to-station administrative controls designed to ensure the integrity of the flowsheet. At some plants, all valves on the flowsheets are shown in the open position, rather than the expected design configuration for the system in an operating state. The engineering drawings show the expected configuration.

Procedures generally do not establish valve lineups including manual valves and vent and drain valves but reflect only a change in valve positions from one state to another. Valving errors have occurred, resulting in spills. The position-assured-valve procedures were found to be less than effective. Shift Superintendents can approve on-the-spot procedures. Operations Managers can approve Operating Memos establishing unanalyzed configurations without a safety review. Special Safety Systems have been inappropriately removed from service by the Shift Superintendent.

Recommendations

Establish a process to accurately verify and status of system health;

establish design review and design verification expectations and address design deficiencies;

update design manuals on a prioritized basis;

establish and enforce rigorous configuration management and configuration control processes;

implement a rigorous change control procedure;

identify and repair degraded equipment;

establish reliability centered maintenance approach to conduct of maintenance;

ensure maintenance has sufficient resources to meet plant operational needs;

perform additional SSFI‘s as necessary to determine extent of deficiencies identified in SSFI‘s;

establish formal process to perform operability determinations and provide justifications for continued operation of structures, systems and components when technically degraded.

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GLOSSARY OF ACRONYMS

AC Alternating Current

AECB Atomic Energy Control Board

AIM Abnormal Incident Manual

ALARA As Low As Reasonably Achievable

ANO Authorized Nuclear Operator

AOV Air-Operated-Valve

CANDU CANadian Deuterium Uranium (reactor)

CDF Core Damage Frequency

CNO Chief Nuclear Officer

CPA Chestnut Park Accord

D₂O heavy water

DBA Design Basis Accident

DCN

DNGS Darlington Nuclear Generating Station

ECI Emergency Coolant Injection

ECN

EDS Electrical Distribution System

EDSFI Electrical Distribution System Functional Inspection

EP

EQ Environmental Qualification

EQA Environmental Qualification Assessment

EQL Environmental Qualification List

ERT Emergency Response Team

EVP Executive Vice-President

EWS Emergency Water System

FRF

H₂O ordinary (light) water

HPD Health Physics Department/TD>

IA Instrument Air

IIPA Independent Integrated Performance Assessment

IPAP

INPO Institute of Nuclear Power Operators

MG

MSLB

N₂ nitrogen (gas)

NRC U.S. Nuclear Regulatory Commission

NRP Nuclear Recovery Plan

NTS Nuclear Technology Services

NPAG Nuclear Performance Advisory Group

OH Ontario Hydro

OHN Ontario Hydro Nuclear

OM&A Operating, Maintenance and A—— (costs)

OP&Ps Operating Policies and Principles

PNGS Pickering Nuclear Generating Station

PRA Probabilistic Risk Assessment

PVC Polyvinyl Chloride (plastic)

PWU Power Workers’ Union

QA Quality Assurance

RANA Regulatory Affairs/Nuclear Assurance

RDF

RP Radiation Protection

RSS Responsible System Supervisor

SALP Systematic Assessment of Licensee Performance

SER Significant Event Report

SES Site Electrical Systems

SDS Shutdown System

SMS Shift Maintenance Supervisor

SR Safety Report

SSFI Safety System Functional Inspection

USNRC U.S. Nuclear Regulatory Commission

VP Vice President

WANO World Association of Nuclear Operations

WNTD Western Nuclear Training Department

Organization and Resources

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

Identify required requisite roles throughout OHN; establish the tasks, working relationships, and associated accountabilities and authorities; establish the requisite accountable authoritative managerial hierarchy;
fill roles with individuals who have the capability to handle the complexity of the role and the knowledge and skills necessary for making judgments about what must be done and who value the required behaviors in the role;
ensure that every employee has an immediate manager who is capable of handling the complexity of setting the context for the subordinate’s work, supplying sufficient resources for tasks assigned, setting realistic priorities, processes and procedures for tasks assigned and providing feedback, coaching and training as needed to ensure that each subordinate is increasing able to handle the full scope of work in the role;
create full First Line Manager roles in all organizations and staff the roles with fully qualified people;
continue the development of a common functional organization for all sites, e.g., common shift organization; and put in place programs to develop sufficient qualified resources to staff it;
establish a talent pool identification and development process to ensure an adequate supply of succession candidates for existing and future roles;
work with the AECB to establish an expedited means of qualifying ANO’s that reduces the total time to that required to license an operator in the USA;
ensure standards and expectations are defined for each role throughout OHN.

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Labour Relations

Certain provisions of the union contracts limit the effectiveness of management. Major issues include the following:

Collective Agreement restraints;
Purchased Services Agreement restrictions;
strike threat;
fitness for duty;
Chestnut Park Accord;
personnel and vehicular searches;
too many Union Officials on full-time release.

Collective Agreement Issues Affecting Performance

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

Aggressively pursue options that permanently eliminate the threat of strikes by the PWU and Society, such as a final and binding arbitration clause. This will most likely require a change in the Canada Labour Code;
petition for legislative changes endorsing a fitness-for-duty program featuring mandatory alcohol and drug testing, similar to the programs at most other North American nuclear utilities;
negotiate future collective bargaining agreements to enhance management’s ability to select the assignment of jurisdictional “Trades Work” at OHN facilities based on the overall needs of OHN. Consider such options as the General Presidents’ Maintenance Assist Agreement in a manner that is not disruptive to the base operations and maintenance functions of OHN facilities;
OHN should pursue changes to the physical security plan with the legislature and unions so that management can exercise more positive control over materials entering and exiting OHN facilities.
provide additional training on collective agreements and union relations for all managers and supervisors;
implement a personnel and vehicular search program to assure that prohibited items do not enter the plant;
establish OHN full-time union release policy that minimizes the impact on the organization while affording proper representation to union members and defining which roles are eligible for release from operating duties.

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Site Specific and Corporate Reviews

Bruce Generating Station

Overall rating: Minimally AcceptableRanking by Performance Area

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

Overall, the Bruce Station is rated “Minimally Acceptable”. Pockets of good performance were identified and several performance improvement initiatives were underway or planned. However, sufficient operating experience had not been logged to demonstrate sustained improvement in these areas. Several performance areas require immediate management attention to ensure that barriers to good performance are quickly removed and appropriate resources are dedicated to achieve rapid and lasting performance improvement.

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 design basis process and control;
the change control process; and
the long-term performance monitoring process.

The lack of a defined, current and understood design basis is a significant vulnerability for the station.

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.

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Darlington Generating Station

Overall rating: Minimally AcceptableRanking 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

Overall, the Darlington Station is rated “Minimally Acceptable”. Several performance areas require immediate management attention to ensure that barriers to good performance are quickly removed and appropriate resources are dedicated to achieve rapid and lasting performance improvement.

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.

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Pickering Generating Station

Overall rating: Minimally AcceptableRanking 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

Overall, the Pickering is rated as “Minimally Acceptable”. Several areas require immediate management attention to ensure that barriers to good performance are quickly removed and appropriate resources are dedicated to achieve rapid and lasting performance improvement.

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.

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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:

The lack of understanding, supporting analysis, and appropriate testing of valve timing for the H₂O injection and the gas tank valves and the effect of this timing on the H₂O/D₂O air gap are serious concerns. The likely consequences (severe waterhammer) make this a potentially significant issue requiring timely resolution.
many deficiencies exist in the station’s calibration program (methodology, procedures, and documentation) with adverse consequences for required testing, system maintenance and operations;
the corrective action program is not consistently effective in identifying and fully resolving problems. As a result, resolution of long-standing issues affecting the ECI system has not been timely;
design control and documentation for the ECI system lack sufficient formality and rigors eroding confidence in the reliability of the ECI system;
managers and staff are not consistently held accountable for high standards of performance. Mechanisms are not in place to define expectations, monitor performance routinely and hold individuals and organizations clearly accountable.
weaknesses exist in the quality of policies and procedures and inconsistent adherence to procedures is inconsistent.

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

There is a lack of a questioning attitude in identifying and documenting system deficiencies and a lack of aggressive action to resolve these deficiencies once they are identified. Managers do not aggressively use peer reviews, audits, and other assessments as a means to pursue real improvement in their organization.
The roles and responsibilities for some staff positions and the interfaces between some organizations have not been clearly defined and communicated. Although the personnel with whom the team interacted included many dedicated professionals, the quality of their performance was undermined by the lack of structure and direction in station policies and procedures.
A level of complacency and acceptance exists in some elements of the staff. This attitude may be a reflection of deficiencies in the quality of procedures and the corrective action program, along with the weaknesses in the definition of roles and responsibilities and in accountability. Personnel did not consistently demonstrate an understanding of the importance of strict adherence to procedures and complete and accurate documentation of safety-related matters.
More effort is required on the part of the line and training managers to assure the highest-priority training needs are met.

Bruce B SSFI Service Water Systems

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:

The Emergency Water System (EWS) has a number of deficiencies associated with design configuration and documentation, as-built conditions, maintenance, and the conduct of testing. Therefore, reasonable assurance that the system will function as intended following a seismic event or main steam line break design basis accident is not provided;
the corrective action program has been ineffective in implementing timely and complete corrective action. Consequently, long-standing problems with service water systems, some of which are urgent, have not been resolved;
operator rounds are not being performed to the standard that adequately monitors service water system components and functions. Service water system deficiencies are not being identified in a timely manner and causes a degradation in material condition;
poor quality of some procedures and inconsistent procedure adherence were observed. Most notable were deficiencies identified in controlled maintenance procedures for important equipment repair activities;
the Responsible System Supervisor (RSS) program is not effectively implemented. This significantly reduces the organization’s ability to make on-going improvements to the material condition of the service water systems;
design documentation for service water systems is not adequately controlled. This reduces the confidence in the operability of these systems;
the calibration program for instruments and indications associated with the service water systems does not adequately support proper calibration, set point determinations, calibration frequencies, safety system test performance, and operability of system components.

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:

The Class I batteries for Unit 5 are not capable of meeting OP&P requirements under the assumed loading for a loss of AC power;
the Class I 250 VDC switchgear for PNGS A is not rated to withstand the available fault current from the system. The switchgear is rated at 25,000 amps and the available fault current exceeds 33,000 amps;
the 250 KVA inverters for PNGS B do not meet stated requirement for fault clearing.

Design activities are not well controlled and are frequently performed in a less than rigorous manner. Controls for bus loading and cable separation were identified as deficient. Conservative decision making was not always evident. The station has recently implemented new policies for design basis control. Although these are conceptually sound, additional effort is needed to reinforce management expectations with regard to design control and configuration management.

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:

In conducting work activities and addressing issues, station personnel do not always view the issue or problem from the perspective of how if affects the ability of the system to perform its design safety function under design basis conditions. They did not always recognize that system performance could be undermined by design or maintenance activities that might not show up under normal operating conditions, but instead might only surface when the equipment was subjected to additional stresses or challenges imposed by accident conditions. Additional emphasis should be placed on this aspect of safety. It is crucial that all station activities reinforce the inherent design safety features that enable safety-related equipment to perform its safety function under accident conditions;
when impairments are identified, they are not always evaluated for immediate operability concerns. The station does not have a formal process that assures problems are screened for their potential impact on the ability of safety systems to perform their design basis function.

In-Service Environmental Qualification Program SSFI

The SSFI equivalent for the in-service Environmental Qualification (EQ) project determined or established the status of the following:

Accuracy of fundamental project bases;
accuracy in defining the scope of the project;
the value and quality of the products produced to date;
the effectiveness of project management;
to provide an assessment of “to go” tasks and costs.

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:

Establish a Stratum IV level EQ Program project manager to provide program oversight. The program oversight function should include the following areas:
- establish common processes and criteria for all sites;
- be responsible for ensuring that project implementation is consistent with the long-term vision of OHN‘s overall EQ program;
- establishing/defining the EQ design and licensing basis for each station;
- be responsible for ensuring EQ has proper priority and support at the Head Office and at the sites;
- facilitate the removal of unnecessary organizational and administrative barriers;
- ensure that the project is focused on meeting the commitment dates;
- be responsible for obtaining project funding authorizations;
- ensure that the processes and programs are in place to support long-term program implementation.
Refocus attention on near term project needs
- finalize Safety Requirement Matrices, Harsh Equipment Component List, Failure Mode and Effects Analysis, and EQL‘s for special safety and support systems;
- finalize all room conditions for Bruce and Pickering;
- install/complete in-progress work on risk significant EQ modifications;
- validate adequacy of EQ risk assessments for Bruce A and B;
- formally document the basis and assumptions used to establish Pickering’s EQ risk assessment;
- ensure cable qualification program provides timely support to the EQ Project.
Identify potential plant modifications up-front and ensure that the project schedules and cost estimates adequately reflect and account for all known issues that will or potentially could require significant plant modification or effort.
Qualification approaches and contingency plans need to be pro-actively developed for all currently known qualification issues (e.g., PVC cable qualification issues, electrical distribution system EQ related issues, hardening of the Bruce B Main Control Room to prevent adverse electrical interactions during MSLB, building or installing steam proof rooms/enclosures, qualification of the RDF at Pickering, equipment relocation, non-qualified motor rewinds, etc.);
- qualification issues that will or could have a significant effort associated with them should be addressed from an overall project and plant viability perspective, and not on a system-by-system basis;
- project schedules should reflect critical path activities, as well as defining which project activities are directly related to resolving AECB Action Items.
The focus needs to be on completing the EQ project and not on analysis or research

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:

proactive modifications to eliminate equipment/cables from the program;
simply replacing equipment when it is cheaper than the analysis;
providing the highest level of qualification that is consistent with the safety significance of the equipment;
taking advantage of the opportunity to improve the material condition of the plant.
Need to know that implementing EQ is a viable option at the sites

A near-term effort is needed to define the currently known EQ issues that have the potential to involve a significant amount of field work. Since the total scope of the project and specifically the scope and cost of required equipment and plant modifications is not fully defined, the current projected budget may be insufficient to implement the project fully. Implementing an EQ program at the in-service stations will involve significant “backfits” to the plants, and should in no way be considered an engineering exercise that will not involve significant modifications. The resolution path(s) for these types of issues needs to be known in the near-term in order to have some assurance that implementing EQ is viable at the stations.

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:

The OHN Fire Protection organization from a functional alignment, redundancy, overlap and accountability perspective;
applicable Fire Protection regulations at OHN‘s nuclear plants, including an evaluation of the current state of compliance;
the state of the Fire Protection program.

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:

A lack of understanding of the fire hazards;
insufficient or nonexistent plant implementation of corporate requirements;
a lack of defined standards and expectations;
undefined or insufficient training;
undefined role, tasks and cross-functional relationships;
undefined authorities.

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:

Where the OHN units are vulnerable to fire;
how fires in specific critical locations could adversely affect nuclear safety;
what the impacts of fire would be;
how the operator must respond to the specific fire scenarios. Post-fire operator actions have not been thought out, documented, and/or used for training scenarios;
the requirements that are placed on the Emergency Response Team (ERT) to contain and control the fire event and what steps are to be taken if the event escalates beyond the ERT response capabilities;
the extent to which the design basis fire scenario could excessively challenge the ERT’s, resulting in an uncontrolled and uncontrollable fire scenario;
where additional fixed detection and suppression systems are necessary for the reason that the design basis fire scenario has too high a probability of escalating beyond the control of the ERT.

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.

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Corporate IIPA

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:

Performance Area Ratings

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

In the case of Corporate Engineering, immediate management attention is required to improve performance. Chemistry and radiation services also require management attention to ensure that the obstacles precluding good performance are removed, and that appropriate actions are taken to achieve rapid and sustained improvement.

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.

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Organizational Effectiveness

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.

Standard setting and performance monitoring
Processes and procedures
Work organization
Resource utilization
Information technology
Materials management
Configuration management
Organizational systems

Examples of major deficiencies identified include:

Performance indicators are not consistently applied at all plants. Performance gaps are not aggressively resolved;
procedures are designed and implemented at each site independently;
inadequate management attention focused on the planning and coordination of work;
cost, financial, and performance reporting is not grounded in an approved business plan;
each site operates an independent computer technical infrastructure and possess many site-specific applications;
the specification of replacement parts to meet the end-use requirements is not under adequate control;
there is inadequate Configuration Management of the plant design documents, technical documents, and databases;
none of the major elements of Requisite Organization are in place and working effectively.

END OF REPORT

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