BULATOM Conference June, 2006 The OSART PROSPER EXPERIENCE Miroslav Lipr Head, Operational Safety Se

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BULATOM Conference June, 2006 The OSART /
PROSPER EXPERIENCEMiroslav LipárHead,
Operational Safety Section
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Content of the presentation

• Operational Safety Services-OSART/PROSPER
• Lessons learned-Issues
• Lessons learned-Good practices
• OSS present and future activities

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OSART PROGRAMME 1983-2005 December
134 OSART missions Western Europe 42 Central
Europe 21 Eastern Europe 25 Asia 25 North
America 12 South America 6 Africa 3
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OSART PROGRAMME 2005 Schedule
OSART Cernavoda, Romania Jan-Feb 129th Follow-up
Paks, Hungary Feb OSART Qinshan 3,
China Mar 130th OSART Blayais,
France May 131th OSART Brunswick,
USA May 132th Follow-up Rovno,
Ukraine June Follow-up Angra 1,
Brazil July Follow-up Pickering A4,
Canada Sept OSART Volgodonsk, Russia
Oct 133th Follow-up Krsko, Slovenia Nov Follo
w-up Tianwan, China Nov OSART Borselle,
Netherlands Nov-Dec 134th
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OSART PROGRAMME 2006 Schedule
FO Chashma, Pakistan January FO Zaporozhe
NPP, Ukraine May FO Philippsburg 2,
Germany November FO Kashiwasaki Kariwa,
Japan May FO Penly, France May O Ignalina,
Lithuania June FO Cernavoda,
Romania November O Mochovc
e, Slovakia September O South Ukraine, Ukraine
October FO Qinshan 3, China
November FO Blayais,
France
November FO Brunswick, USA
December O St. Laurent, France
Nov.-Dec.
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OSART PROGRAMME 2006 Schedule Preparatory visits
and seminars

• Tihange Belgium - February
• Metsamor Armenia - March
• Yonggwang Republic of Korea - April
• Khmelnitsky Ukraine September
• Chinon France October
• Neckarwestheim Germany November
• Bushehr Iran December ?

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PROSPER PROGRAMME

• 2003 Metsamor Armenia
• 2004 EDF Corporate
• 2005 Santa Maria de Garona Spain, Metsamor FU
• 2006 KANUPP Pakistan,
• EDF FU

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Lessons learned - Issues

• Staffing
• The company has not yet completed a study on its
  needs for critical positions, and of the risk of
  loss of knowledge, and it has not yet defined its
  policy and strategy to fulfil the human resources
  needed in the long term
• The plant should more clearly define their
  long-term staffing programme, reduce the reliance
  on contractors, and ensure that vital plant
  knowledge is transmitted to new staff

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Lessons learned - Issues

• Human performance
• The plants safety goals are essentially
  technical and do not cover all aspects, such as
  human aspects of safety. In addition, they are
  not communicated enough
• The current simulator training arrangements are
  not providing NPP staff with sufficient
  opportunities to continually improve their
  performance
• Deficiencies exist in human performance
  evaluation
• Operations management expectations to improve
  human performance in the MCR and in the field
  needs to be improved

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Lessons learned-Issues

• Management expectations
• In some cases there is insufficient operations
  management oversight
• Management expectations are not always met by the
  real behaviour of personnel or the status of the
  plant
• Effective communication of expectations do not
  always ensure that field operators identify and
  report all deficiencies in the field
• Although comprehensive management programs have
  been established at the plant, there remains a
  gap between some declared expectations of
  managers and results observed in the field.

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Lessons learned-Issues

• Contractors
• Monitoring of contractors work execution needs
  improvement. There have been some events in the
  past and also some noted deficiencies during
  field inspections
• NPP management interface arrangements between
  itself and its contractors and subcontractors
  have some weaknesses and should be strengthened
  in some areas

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Lessons learned - Issues

• Surveillance testing
• The surveillance implementation, review and
  monitoring programme does not always assure that
  surveillance testing of safety related systems is
  comprehensively and periodically conducted
• System surveillance reporting via system
  condition evaluation reports are not prepared
  for all systems
• Some practices in performance of the surveillance
  tests and evaluation of their results require
  improvement to ensure the required systems
  availability and reliability
•  

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Lessons learned - Issues

• Surveillance testing cont
• The surveillance test programme lacks a
  systematic approach to deal with deviations
  observed during the surveillance tests
• Surveillance test checklists for the safety
  related equipments are not specific to each
  particular safety system or component
• Trend analyses for the surveillance programme
  test results, with very few exceptions, are not
  performed within and outside accepted bands of
  the operational limits
•  

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Lessons learned - Issues

• Temporary modifications
• Long standing equipment problems and a large
  number of temporary installations, present a
  situations where operators are often required to
  take special precautions in operating plant
  equipment
• There are still many temporary modifications in
  place on the station, some of which have been in
  place for a long period of time. The
  implementation of some of the temporary
  modifications is not to the appropriate standard

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Lessons learned - Issues

• Temporary modifications cont.
• The plants temporary modification programme is
  not comprehensive regarding identification,
  impact analysis, limited initiation, marking and
  timely termination
• The system for controlling the temporary
  modifications (Jumpers) is overused. Operations
  do not perform a regular review of all jumpers
  for the aggregate operational impact on the
  plant, in particular prior to unit restarts

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Lessons learned - Issues

• Temporary modifications cont.
• Some temporary modifications remain in the field
  for long periods. Safety related modifications
  are not formally categorized by their safety
  significance and the plant lacks a systematic
  policy to periodically review the validity of
  safety justifications for long standing temporary
  modifications
• The control of temporary modifications does not
  ensure that they are clearly identified and that
  their number is kept to a minimum

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Lessons learned - Issues

• Low level events, near misses
• Near misses and low level events are not
  routinely reported. Events involving the failure
  of equipment are more likely to be reported than
  issues involving human performance shortfalls
• The plant expectations on near miss reporting are
  not sufficiently communicated to the plant
  personnel and not fully implemented in the field

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Lessons learned - Issues

• Low level events, near misses cont
• Systematic program and procedures for analysis of
  low-level events and near misses are not in place
  to capture human factors related issues
• Low level events and near misses are not
  reported, analysed and effectively trended to
  identify developing issues in a systematic and
  consistent manner
• The plant OE procedures does not include a
  function where low level issues, events and
  near misses (other than equipment defects) are
  collected together where they can be periodically
  evaluated and trended

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Lessons learned - Issues

• Use of operating experience
• Event investigations have incomplete assessment
  of the factors that contribute to the occurrence
  of degraded human performance. Events are
  considered as isolated events with little
  analysis of patterns of occurrence or of whether
  multiple events are showing common root cause.
  Trending of the occurrence of repeat events is
  not used
• The plant does not apply a fully consistent and
  integral approach to all-available internal OE
  information for comprehensive summary reviews to
  identify the generic issues

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Lessons learned - Issues

• Use of operating experience cont.
• The Plant personnel, as well as contractors do
  not always properly understand and apply the
  Abnormal Condition Report initiating criteria
• External international operating experience is
  not sufficiently considered
• Dedicated departments representatives have
  limited knowledge and insufficient experience in
  applying the event analysis techniques

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Lessons learned - Issues

• Use of operating experience cont
• Self-assessment programme and management
  indicators to evaluate the effectiveness of the
  operating experience feedback process are not
  systematically implemented
• There are no qualification criteria and training
  requirements for personnel performing activities
  to review operating experience at the plant
• The treatment of all available in-house and
  external operating experience and consequent use
  of results and dissemination of lessons learned
  in order to prevent events can be improved

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Lessons learned - Issues

• Use of operating experience cont
• Local Events reports are not receiving the
  necessary attention warranted by their importance
  and significance
• The existing process control on lessons learned
  from Significant Events does not ensure that all
  technical professionals from different
  departments receive the required safety related
  information
• The effectiveness of the corrective actions taken
  to address the causes of the events is not
  regularly assessed

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Lessons learned-Issues

• Computer applications
• Validation of local computer application
  important to safety is not monitored and reviewed
  systematically
• The installation of non-safety related computer
  systems and low energy cables associated with
  non-intrusive plant communication services has
  some shortfalls
• Requirements for some category 4 off-line
  computer applications used by the different
  groups of the plant and contractors such as fuel
  handling, surveillance tests management and
  chemical management have to be reinforced

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Lessons learned - Issues

• Fire protection
• There are weaknesses in the storage and handling
  of flammable and hazardous material, and the
  measures taken to mitigate risk of fires or
  accidents involving these materials
• The control of combustible materials or fire
  loading in stores, workshops, laboratories,
  administrative and other plant areas outside
  auxiliary building and RCA are not effective.

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Lessons learned - Issues

• Fire protection cont.
• Organization of fire protection, fire trainings,
  control of combustible material and fire barriers
  needs improvement
• The inspection program for the fire protection
  systems is not sufficiently robust to ensure the
  systems adequately perform their intended
  functions
• There are many false automatic fire alarms, which
  can cause unnecessary delays in response of the
  plant staff to fight a fire

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Lessons learned - Good practices

• Staffing/Contractors
• Operations management has implemented a
  comprehensive staffing and succession plan for
  all operations staff for the next 10 years
• The plant has very effectively implemented the
  system of supervision of contractors

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Lessons learned - Good practices

• Blame free culture
• Plant management has implemented a Blame free
  culture that is open and transparent at all
  levels of the organization. Staff at all levels
  are willing to discuss events at the plant, how
  they recognize the need for improvement in some
  areas, and they are open to suggestions for
  improvement.

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Lessons learned - Good practices

• Communication actions
• The NPP team utilizes multiple communication
  actions to ensure all personnel are informed and
  current on critical plant and company activities.
  These include general communications efforts to
  provide big picture information to employees
  and specific up to the minute technical
  information

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Lessons learned - Good practices

• Teamwork
• Management efforts have been effective in
  fostering a culture that promotes good teamwork,
  focuses the staff on the operational needs of the
  station, and fosters a healthy work environment.
  All levels of the organization have a low
  tolerance for behaviors that do not support team
  efforts

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Lessons learned - Good practices

• Self assessment
• The plant has developed a comprehensive and
  intrusive self-assessment program within the
  organization that has lead to improvements in the
  quality of work across all plant disciplines

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Lessons learned - Good practices

• Corrective action programme
• The methods used in the NPP monitor the quality
  of Corrective Action Program activities are
  unique and effective. Significant Adverse
  Condition Investigations and root cause analyses
  are critically reviewed and given a score based
  on quality of the analysis by the Self Evaluation
  Unit. Specific criteria are evaluated using a
  Quality Review Sheet

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Lessons learned - Good practices

• Risk assessment
• Effective risk assessment methodology of
  maintenance activities has been developed and
  implemented by the plant. This methodology is
  based on software application of questioning
  approach to encompassing the areas of nuclear
  safety, radiation protection, industrial safety,
  plant availability and environmental protection

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Results of OSARTs
Status of Issues at Follow-up Visits
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OSART 2003-2005Results
MANAGEMENT, ORGANIZATION And ADMINISTRATION
MOA 1management expectations/requirements
MOA 2 local industrial safety
MOA 3 corporate knowledge /specialist
MOA 4 consideration of human performance
TECHNICAL SUPPORT
MOA 5 internal and external interfaces
MOA 6 performance Indicators
TS 3 reactor engineering
TS 1 temporary modification programme
TS 2 systematic analysis of surveillance results
TRAINING And QUALIFICATION
OPERATING EXPERIENCE FEEDBACK
TQ 3 maintaining of the training facilities and
materials
TQ 1 Process of training evaluation
TQ 2 training of the instructors
TQ 4 systematic approach to Training
OE 1 Near miss and Low level events
OE 2 oversight process awareness
OPERATIONS
OPS 1 policy for conduct of the MCR activities
OPS 2 operations in the field
OPS 3 control of the access and authorization
OPS 4 equipment and system labeling
RADIATION PROTECTION
OPS 5 proper handling of operator aids
OPS 6 training scenario and tolls for fire and
rescue drills
RP 1 effective contamination control
RP 2 personnel exposure limitation measures
RP 3 solid radioactive waste management
RP 4 RP support during emergency
MAINTENANCE
CHEMISTRY
MA 1 maintenance inspection of the fire
protection system
MA 2 control of the plant fire risk
MA 3 predictive maintenance programs
MA 4 Foreign Materials Exclusion program
CH 1 labeling and storage
CH 2 chemistry control programmes
CH 3 laboratory QC systems
RP 4 chemistry operation history
MA 5 material conditions
MA 6 condition of maintenance equipment
MA 7 organization of maintenance
MA 9 work control
MA 8 outage management technique
EMERGENCY PLANING and PREPAREDNESS
EPP 1 evacuation procedures
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OSS Actions

• PROSPER Guidelines-Self assessment
• OSART Operating Experience Module
• Effective Corrective Actions to enhance
  operational safety of nuclear installations
  TECDOC published
• Best practices in Identifying, Reporting and
  Screening issuesTECDOC under preparation

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OSS Actions

• Best practices in Utilisation and Dissemination
  of operating experience TECDOC under
  preparation
• Trending of low level events and near misses to
  enhance safety performance in nuclear power
  plants TECDOC published
• Strategies for Antecedents management program to
  enhance safety - TECDOC under preparation
• Proactive Management of Operational Safety
  TECDOC under preparation

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OSART Good Practices on the web
http//www-ns.iaea.org/reviews/good-practices.htm
OSART Highlights
OSART Guidelines
OSART Pamphlet
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Operational Experience Feedback
Trending of Low Level Events and Near Misses to
Enhance Safety Performance in Nuclear Power
Plants
Effective Corrective Actions to Enhance
Operational Safety of Nuclear Installations
PROSPER Guidelines
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OSMIR Database

• OSART Mission Results Database
• Contains results from 66 OSART missions and 45
  follow-up visits from 1991 (Continually being
  updated)
• 2483 Recommendations, 1528 Suggestions and 647
  Good Practices
• Distributed in CD-ROM