Predecisional Enforcement Conference Apparent Violation – Criticality Warning System (CWS) Signal Delay NRC Region II Atlanta, GA April 4, 2012
Predecisional Enforcement Conference Apparent Violation – Criticality Warning System (CWS) Signal Delay NRC Region II Atlanta, GA April 4, 2012
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• Background and Facts (Holmes)
• Apparent Violation and GNF-A Response (Murray)
• Safety Significance (Murray)
• Event Investigation & Actions (Holmes)
−Technical
−Organizational
• Excellence Plan (Holmes)
• Conclusion (Walsh)
Agenda
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Criticality Warning System Functional Diagram
DAM # 1
Detector
Detector
Detector
Detector
Detector
Detector
Detector
Detector
Detector
DAM # 2
DAM # N
Secondary Tones and Amplifiers
Primary Relay Panel
Monitor and Maintenance
Detect Decide Protect
RP ECC Local Panel
RP – Radiation Protection ECC – Emergency Control Center DAM – Data Acquisition Module
Horns
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Simplified Timeline
CWS MORT Root Cause Investigation
Report Issued
Operational Self Assessment
and Readiness Reviews Complete
Fuel
Manufacturing Operations
Authorized to Resume
CWS Requalification
Testing Complete
Full Personnel
Access Granted
Limited Personnel Allowed to Perform
Authorized Activities
CWS Comprehensive System Tests
Complete
Independent Root Cause Team
Initiated Investigation
CWS re-testing to confirm inaudible horn corrected. Management
informed of delay in signal actuation
Fuel
Manufacturing Operations
Suspended – Personnel Evacuated
Initiating Event
Inaudible CWS
Evacuation Signal in
Chemet Lab Discovered
.
CWS Horn Activation System
Component Failure
Identified and Repaired
CWS
Evacuation Signal Delay
Recognized by Radiation Protection Technician
.
CWS Evacuation
Signal Delay Recognized by
Radiation Protection Technician
.
*NRC event notifications
Restricted Access
Employee Training
Week of July 29
Discovered during Extent of Condition Investigation
NRC Apparent Violation • Delay in CWS alarm signal activation
• Failure to meet license requirement that the system initiates immediate evacuation of the facility
GNF-A concurs.
The delay in the CWS signal activation resulted in a failure to meet the license requirement.
GNF-A Response
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Actual Significance
• No events occurred that would have resulted in actuation of the CWS.
• No plant upset condition or elevated radiation levels existed.
• Nuclear safety controls remained intact.
• Double contingency was maintained at all times.
Potential Significance
• In the event of a criticality, the automatic evacuation signal would have been delayed ... the manual evacuation signal was available.
Safety Significance
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Immediate Corrective Actions • Fuel manufacturing operations were suspended –
restricted access to the Controlled Access Area (CAA).
• Component failure was diagnosed and repaired.
• Extensive CWS requalification tests performed.
• CWS procedure was upgraded.
• Weekly verification testing was added and area audibility testing was augmented.
Initial actions taken as part of phased restart
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Event Investigation and Actions - Technical
Added parallel alarm monitoring Added weekly test of system Enhanced monthly system testing:
– Verification of detector response and calibration – Expanded audibility testing participation – System alarm response time monitoring
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• Independent, cross-functional team used Management Oversight and Risk Tree (MORT) methodology to perform root cause analysis (RCA).
• RCA identified four root causes and four contributing factors.
Event Investigation and Actions - Organizational
• Nuclear safety culture • Nuclear safety policy and program
implementation • Controls of equipment and
processes • Policies, programs, and controls
implementation
• Work practices
• Corrective action program
• Standards for procedures
• Oversight
Root Causes Contributing Factors
Nuclear Improvement Strategy
• Executive ownership
• Weekly rhythm
• Two-year plan
• Industry excellence • Process excellence • Regulatory excellence • Safety & Security excellence
• Significant event & RCA actions including: Sinter Test Grinder & Criticality Warning System
• Strengthen procedures, training and oversight
• Focused on fuel mfg operations
Raise the bar on nuclear safety and regulatory compliance … #1 focus
Excellence Plan
RCA Action Plan
Raise the Bar
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Raise the Bar (RTB)
Implement compensatory measures
Complete commitments for STG/CWS
Enhance problem identification and resolution
Simplify procedures and improve flow-down
Strengthen process surveillance + HU observations
Improve training program
Engage employees to assure organizational learning
Communicate internally and externally
• RCA actions … 80%+ in ‘12, complete in ‘13
• Problem Identification & Resolution – New CAP system user testing underway – “Go live” in second quarter
• Procedures – Requirements flow-down – Simplified procedure format
• Surveillance program – Staffed program – Completed 60+ surveillances
• Training – Implementing SAT-based program – OJT trainer/evaluator qualification program
• Employee engagement – Completed 2-day employee team feedback session – Employee teams engaged in procedures and training
• Communication – “I am relied on for safety” campaign – Nuclear Safety & Security traits and behaviors
8 Missions Status Update
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• Adopted industry model from NEI … piloted in 2011
• Institutionalized business commitment with policy and procedure … roles and responsibilities at all levels
• Monitoring safety culture traits for trends
• Performing quarterly review meetings with senior leadership team
• Monitoring performance through Nuclear Safety and Security Council
Monitoring our Nuclear Safety Culture
Drive better leading indicators for proactive improvements … monitor and measure culture
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Conclusion
Nuclear safety is #1 priority
• CWS is fully operable with robust surveillance process
• GNF-A continues to address programmatic issues through multi-year Raise the Bar plan with focus on culture, procedures, training and oversight
• Continued focus on nuclear safety culture and behaviors is fundamental to business success
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