REPORT OF THE OSART (OPERATIONAL SAFETY REVIEW TEAM) MISSION TO THE

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1 NSNI/OSART/09/151F ORIGINAL: English REPORT OF THE OSART (OPERATIONAL SAFETY REVIEW TEAM) MISSION TO THE OSKARSHAMN NUCLEAR POWER PLANT SWEDEN 16 February 5 March 2009 and OSART FOLLOW UP VISIT 30 November 3 December 2010 DIVISION OF NUCLEAR INSTALLATION SAFETY OPERATIONAL SAFETY REVIEW TEAM MISSION IAEA-NSNI/OSART/09/151F

2 CONTENT INTRODUCTION AND MAIN CONCLUSIONS MANAGEMENT, ORGANIZATION AND ADMINISTRATION TRAINING AND QUALIFICATIONS OPERATIONS MAINTENANCE TECHNICAL SUPPORT OPERATING EXPERIENCE FEEDBACK RADIATION PROTECTION CHEMISTRY EMERGENCY PLANNING AND PREPAREDNESS DEFINITIONS LIST OF IAEA REFERENCES (BASIS) TEAM COMPOSITION OF THE OSART MISSION TEAM COMPOSITION OSART FOLLOW UP MISSION

3 INTRODUCTION AND MAIN CONCLUSIONS INTRODUCTION At the request of the government of Sweden, an IAEA Operational Safety Review Team (OSART) of international experts visited Oskarshamn Nuclear Power Plant from 17 February to 5 March The purpose of the mission was to review operating practices in the areas of Management organization and administration; Training and qualification; Operations; Maintenance; Technical support; Operating experience feedback, Radiation protection; Chemistry; and Emergency planning and preparedness. In addition, an exchange of technical experience and knowledge took place between the experts and their plant counterparts on how the common goal of excellence in operational safety could be further pursued. The OKG Nuclear Power Plant is situated on the Swedish east coast about 30 Km north of Oskarshamn. The company is part of business area Electricity Generation within E.ON Market Unit Nordic and is a subsidiary company to E.ON Kärnkraft Sverige AB. OKG is owned by E.ON at 54,5 %. The remaining 45,5 % of the shares is owned by Swedish subsidiaries to the Finnish energy group Fortum. The plant operates three BWR units. Unit 1 has 440 MW rated power and started commercial operation in 1972, unit 2 has 590 MW rated power and started commercial operation in 1974, unit 3 has 1060 MW rated power and started commercial operation in The OSART mission concentrated on unit 2 and common site systems. OKG has 950 employees and about 300 long term contractors. The Oskarshamn OSART mission was the 151st in the programme, which began in The team was composed of experts from Armenia, Czech Republic, Finland, France, Germany, Slovak Republic, South Africa, South Korea, Spain and the USA, together with the IAEA staff members and one observer from Sweden. The collective nuclear power experience of the team was approximately 250 years. Before visiting the plant, the team studied information provided by the IAEA and the Oskarshamn plant to familiarize themselves with the plant's main features and operating performance, staff organization and responsibilities, and important programmes and procedures. During the mission, the team reviewed many of the plant's programmes and procedures in depth, examined indicators of the plant's performance, observed work in progress, and held in-depth discussions with plant personnel. Throughout the review, the exchange of information between the OSART experts and plant personnel was very open, professional and productive. Emphasis was placed on assessing the effectiveness of operational safety rather than simply the content of programmes. The conclusions of the OSART team were based on the plant's performance compared with IAEA safety standards and good international practices. An IAEA Operational Safety Review Followup Team visited Oskarshamn from 30 November to 3 December

4 MAIN CONCLUSIONS The OSART team concluded that the managers of Oskarshamn NPP are committed to improving the operational safety and reliability of their plant. The team found good areas of performance, including the following: An integrated management system which includes communication, quality structures and documentation links. All employees receive training on how the management system works and thereby gain easy access to documentation and indicators. The provision of effective and creative hands-on training such as those at the Barseback facility. A comprehensive In-Service Inspection (ISI) programme which includes a database for all ISI activities and also welding data. The use of an effective decontamination method for plant systems during outages has contributed to significant occupational exposure reductions in the past few years. A number of areas where improvements could be made in operational safety were offered by the team. The most significant include the following: A consistent system for monitoring and screening corrective actions, according to their impact on safety, and then tracking them until their effective implementation, is not in place. Although the plant has procedures in place for the isolation and tagging of equipment, those procedures and their implementation are, in some cases, not sufficient. A system for modification categorization, in accordance with the safety significance of the modification, has not been established. The reporting, analysis and trending of low level events and near misses is not sufficient to allow the systematic and consistent identification of event precursors. Oskarshamn management expressed a determination to address the areas identified for improvement and indicated a willingness to accept a follow up visit in about eighteen months. OSKARSHAMN FOLLOW-UP MAIN CONCLUSIONS (Self Assessment) At the request of the Government of Sweden, an IAEA Operational Safety Review Team (OSART) of international experts visited the Oskarshamn Nuclear Power Plant (OKG) and reviewed unit 2 from February 17 to March 5, Previous experience of international reviews had taught us how important the preparation phase is. This was underlined at the IAEA preparatory visit in January The preparations started with a comprehensive study of the IAEA requirements and guidelines and a comparison with OKG procedures and routines in order to identify and implement corrective actions. The main lessons learned from this activity were the importance of benchmarking and learning from best international practice. Another result is a much broader understanding among the staff of the IAEA requirements and guidelines. As a part of the preparations for the review and the follow up we have conducted our own reviews. The review team consisted of personnel with experience from international reviews as well as personnel without any review experiences. The aim of conducting our own reviews has been to establish the progress with the measures taken, and to spread knowledge and experiences regarding reviews and the IAEA requirements and guidelines within OKG. 2

5 Activities to remedy issues have included use of the OSMIR database as well as experiences from other OSART missions and also from co-operation with other utilities. In general, corrective actions have started in unit 2 and have subsequently been, or will be, introduced at units 1 and 3. By this approach lessons learned from the implementation at unit 2 can be effectively utilized during the implementation at the other two units. The overall conclusion is that the OSART mission has been very beneficial for OKG. The result was very encouraging and has inspired the organisation to further explore and implement best international practice. OSART TEAM FOLLOW-UP MAIN CONCLUSIONS There is clear evidence that the NPP management has gained significant benefit from the OSART process. The IAEA Safety Standards and benchmarking activities with other nuclear power plants were used during the preparation and implementation of the corrective action programme. The plant analyzed the OSART recommendations and suggestions and developed appropriate corrective action plans. The willingness and motivation of plant management to use benchmarking, consider new ideas and implement a comprehensive safety improvement programme was evident and is a clear indicator of the potential for further improvement of the operational safety of the NPP. Of the 17 issues identified at the OSART mission, it was evaluated by the follow up team that 9 of these issues had been resolved and resolution of 8 issues had reached satisfactory progress. The following provides an overview of the issues where some degree of further work is necessary. The plant undertook an analysis of the issue relating to management assessment of work activities and determined that, inter alia, (1) there was no clear procedural expectation of what was required of managers while in the field and (2) that there was no performance indicator to allow an overview of their findings and determine the appropriate corrective measures. Checklists and training for field observations have been developed and a performance indicator has been devised to reflect the activities in this area. These initiatives are commendable but are recognised by the plant to be at an early stage of development and further work is necessary to fully implement them. In the recommendation regarding improvement of the performance of the field operator rounds, the plant has made satisfactory progress to date. A number of improvements have been made but there are still some deficiencies which could be found on plant tours during the follow-up. Also, the shift supervisors do not yet perform field observations compared to the plant s own expectations and there is still space for improvement in this area. The plant significantly improved the practices of controlling temporary modifications. All temporary modifications are now registered in the database. Those which are not related to operators actions are marked in the field with a specific tag. The subject of temporary modifications is discussed in the daily and weekly meetings with the aim of keeping their number limited to the necessary minimum. However there is no trending or target value established for the number of temporary modifications being active at any moment in time. When reviewing the database, it was concluded that in the long term the overall number of 3

6 temporary modifications is rather stable, 41 at present. The procedure for temporary modifications states that the duration can be authorized to a maximum until the next refueling outage. However, when checking the database, 16 of them have been authorized for 2 years or longer with the longest being 9 years. Two randomly selected facts supporting the issue in the OSART report were checked: the control room indications for the reactor level measurement for accident conditions and the associated function of accumulated alarms disconnected. The physical status of the devices is still the same. Their final removal from operation was approved and it is planned for the 2013 outage. The resolution of the suggestion concerning the surveillance test procedures and analysis of test results has reached satisfactory progress to date. The plant decided to revise the surveillance test procedures in order to introduce: guideline value, acceptance value (criteria) and system requirement value for each parameter to be checked; requirement to perform trend analysis; requirement to issue a fault report or to consult maintenance department in certain cases; independent verification (approval) by the shift supervisor. However the procedure revision with the new requirements on performing the tests and the procedure revision with the new requirements on performing trend analysis were released only recently. At the moment about 30 of the 80 test procedures have been released for use and 50 are in various stages of quality control or approval. Satisfactory progress has been made to date for the three issues in the area of Operating Experience. The plant has set, as one of its top strategic objectives, becoming a learning organization and a Continuous Improvement Long-Term Plan has recently been issued and approved. This plan incorporates a clear vision and it is the result of international benchmarking and external evaluations, as well as a comprehensive self-assessment performed by the plant. In order to facilitate its implementation, a gradual approach is defined, organizational changes are planned and resources have been allocated. The plan is structured in five phases and its full implementation will be by 2015, although the critical necessary aspects to resolve the issues identified by the OSART team are planned for The first stages of this plan are being led by a project team and a gradual transfer to the line is foreseen in the short-term. Within the scope of the plan, a Corrective Action Programme based on international best practices is being implemented. The desired reporting threshold for observations to be reported has been defined and will be gradually implemented and communicated to the plant workforce during the next two years. These observations will be screened using a risk matrix to assess their impact on safety. Regarding emergency planning and preparedness, the plant has installed contamination monitors at the entrance to both the command centre and the alternate command centre. Instructions on their use have been updated. Activation of the alternate command centre in field conditions involving radiation exposures and contamination spread has not yet been exercised but it is considered that this issue has made satisfactory progress to date. 4

7 1 MANAGEMENT, ORGANIZATION AND ADMINISTRATION 1.1 ORGANIZATION AND ADMINISTRATION The organization of the company (corporate and plant) is clearly defined and documented. All the documents concerning the organization can be accessed by people working on the plant in a very efficient way via the internal internet called Kärnan. However, this communication tool requires a voluntary action from the reader; therefore some rules are not known and not applied. The main goals of the plant are discussed and approved annually by the OKG Board held at the corporate level and reviewed in a regular manner inside the plant organization. High priority is given to six goal areas including safety, production, environment, financial, human resources and plant development. These priorities can only be changed by the President. Concerning the staffing, a formal analysis is conducted from the need expressed by the departments and is combined at the plant level. The review process of the expressed needs comprises two review meetings in March and in September in order to validate the decisions. Furthermore, the plant has a long term succession plan for managers and specialists in order to secure knowledge. The team considers this as a good performance. With the actual projects (Plex = Safety upgrade and ageing replacement at unit 2, Nyans = New physical protection at OKG, Puls = Safety upgrade and ageing replacement at unit 3), the staffing will rise for several years until This staffing policy includes a very efficient succession plan which is established for managers, specialists and coordinators and was recognised by the team as a good performance. 1.2 MANAGEMENT ACTIVITIES The plant uses 10 year and 3 year plans and an annual vision is done to identify the main working periods. This vision is shared with the departments in a review meeting. The main goals of the plant are then divided amongst the organization; every manager knows its own objectives and contribution to the results of the plant. All the indicators are available in a very visible manner via the intranet site so that personnel are informed. External and internal surveys are performed to monitor the efficiency of the organisation. For example, the WANO indicators and the internal E.ON indicators are used to compare the trends with other plants. In addition, about 25 internal audits are performed each year by the safety department of OKG and further audits are conducted by E.ON. Concerning the human factors management, a survey is made every two or three years in order to define what is to be done. A manager on the field program has been started, and will be reinforced in the next years. This will be the mechanism to reinforce the managers expectations concerning the staff behaviour on the field. Prejob briefings presently are recommended in some areas but are not yet a mandatory approach across the whole plant. The plant intends to improve this, in coherency with the identification of safety related activities. The team has made a suggestion concerning better management assessment of work activities. 5 MANAGEMENT, ORGANIZATION AND ADMINISTRATION

8 The plant has a very effective organisation concerning the welfare of staff (including health facilities and an efficient drug policy) and has also a very effective welcoming organisation, for the many contractors that are arriving for the three main projects Puls, Plex and Nyans. 1.3 MANAGEMENT OF SAFETY A safety policy is reviewed and approved at E.ON level by E.ON Nuclear Safety Council and is very well known at the plant level. In this policy, the highest priority is given to safety and in several cases a questioning attitude was applied. In these cases, the plant was placed in conservative conditions. The identification of safety related activities is under the responsibility of operating personnel, but there is no complete pre-identification of safety activities (for example, for recurrent activities); this identification could be improved in order to simplify the workload analysis during the preparation of activities. Concerning the use of deviation, the plant has shown several ways of using them to progress. Some corrective actions are not followed. Several good signs of safety culture were observed by the team during the review: The corporate level managing director and the OKG president visibly support and regard safety as a very high priority. Since 2004 OKG has used Safety Culture ambassadors to develop and implement activities to improve safety culture. Part of their working time is dedicated to the task of consistently improving safety culture. They know the organization and add credibility to the training events and seminars. The team was reassured that the safe operation of the reactor has the highest priority, and if the situation is unclear the reactor will be brought to a safe condition. In the past on several occasions, there was a decision not to operate the plant in case of a doubt concerning the safety functions, e.g. after the grid event in Forsmark 1 and when traces of explosives were found at the entrance of the site. The team was able to sense an excellent work environment and stress-free atmosphere at the plant. Openness and transparency are highly regarded values. All of this results in a situation where staff are open and interested in their work. In order to achieve and sustain this, surveys and walk-downs are organized to assess and improve work environment. There is an effort to decrease stress as much as possible. Well-designed offices, an obvious effort of preserving the environment and historical buildings near the plant contribute to this situation. The plant has established a Welfare office for welcoming contractors to support their orientation after arriving at the site. Good housekeeping and material condition are evident throughout the plant which is even more commendable if we consider that unit 2 has been in operation since As an example, the reactor hall is kept in good order and clean, equipment is appropriately stored. This definitely contributes to a safe work environment. 6 MANAGEMENT, ORGANIZATION AND ADMINISTRATION

9 The plant has a systematic approach concerning safety culture. This approach includes regular surveys, formal analysis and training. For example, the plant organizes training before and during outages. The training scope was selected based on analysing past outage experience for safety culture weaknesses. OKG conducted 6 one day training events followed by about 40 days of individual coaching in 2007 for more than 80 team leaders and managers. At the Barseback training facility, plant staff is additionally trained on safety culture and human performance in the frame of practical exercises by performing real tasks to see whether safety culture is embedded in their activities and whether a questioning attitude is present in their practices. At the same time there are other signs indicating that the effort to improve safety culture should be maintained: In the team s opinion, roles regarding improper behaviour are somewhat unclear in the sense that managers and supervisors are reluctant to remind staff about the necessity to follow rules. The following examples support this opinion: during training, the trainees did not form groups to discuss items of training as requested by the trainer; fire door of work permit office of unit 1 is part of fire cell just adjacent to the entrance to unit 2 main control room, nevertheless it remained open for extensive periods when no one was inside. Staff is overly relying on experience without regard for current documentation. It is probably also associated with the practice that some requirements are not exactly written down or communicated. For example: it is accepted that everyone is responsible for tracking completion of his/her tasks; to decide about the scope of surveillance test result, judgment is up to the person who performs the analysis; competence requirements for some job positions are not defined; for scaffolding and industrial safety protective equipment, documented requirements exist but staff does not know about them and therefore does not apply them. The self-assessment process is not sufficiently effective at all levels of the organization, partly due to lack of appropriate indicators and the evaluation process. For example: performance indicators sometimes do not correspond to goals; there is no effectiveness review of implemented corrective actions. Safety is discussed in many meetings at the plant, but it is not always explicitly the first topic discussed in the agenda. This is valid for example for the monthly Departments management meeting. The first point in the agenda are production issues, and this might convey the impression that safety is not receiving priority attention. In the last organizational survey in 2007, only 52 per cent of OKG s personnel agreed with the statement I feel encouraged to report new ideas or improvements, while 33 per cent were not sure and 15 per cent did not agree with the statement. 1.4 QUALITY ASSURANCE PROGRAMME The plant has developed a very effective organization concerning the quality assurance. It is supported by the Kärnan tool. The main roles and responsibilities are documented and this helps to hold line managers accountable for the quality of performance in the areas for which they are responsible. The team has recognised it as a good practice. An effective QA monitoring system is implemented at the plant. It is based on a yearly discussion between managers and is managed at weekly meetings which review the main objectives or indicators of the plant. 7 MANAGEMENT, ORGANIZATION AND ADMINISTRATION

10 1.5 INDUSTRIAL SAFETY PROGRAMME The organisation for industrial safety is clear and well documented. The team has noticed that the knowledge of the rules to be applied is not sufficiently shared among the staff. Therefore, several rules are not applied; this could impair industrial safety and therefore safety during projects when many contractors are working at the plant or during normal operation of the plant. The team has made a suggestion in this area. 8 MANAGEMENT, ORGANIZATION AND ADMINISTRATION

11 DETAILED MANAGEMENT, ORGANIZATION AND ADMINISTRATION FINDINGS 1.2 MANAGEMENT ACTIVITIES 1.2(1) Issue: Management assessment of work activities and correction of inadequate behaviour are not consistently applied. There are a number of management initiatives in this area, but the following were observed by the team: - Managers presence in the field is limited and insufficiently recorded (e.g. outcomes, findings, etc.). - A unique tool (QAF database) is not used for each field visit. It is therefore difficult to get an overview. - Out-dated documents were observed to be being used by workers on several occasions (EPP, operating procedures, and documents related to modifications). - Tolerance to inadequate behaviour such as: staff not respecting the walk way limitations, staff crossing open gates when it is clearly indicated to wait, staff not wearing cards in a visible manner, many ladders not stored in a adequate way, cars driving too fast. - Some additional facts are listed in issues 3.4(2), 3.5(1), 4.5(1). Lack of management assessment can lead to unsafe practices being adopted, while remaining unknown from the management. Suggestion: The plant should consider enhancing the application of management assessment practices and correction of inadequate behaviour at the plant. IAEA Basis NS-G The appropriate corrective actions should be identified and implemented as a result of the monitoring and review of safety performance. Arrangements should be in place to ensure that appropriate corrective actions in response to audit and review findings are identified and taken. Progress in taking proposed actions needs to be monitored to ensure that actions are completed within the appropriate time-scales. The completed corrective actions should be reviewed to assess whether they have adequately addressed the issues identified in the audits and reviews. 9 MANAGEMENT, ORGANIZATION AND ADMINISTRATION

12 GS-G To avoid any decline in safety performance, senior management should remain vigilant and objectively self-critical. As a key to this, objective assessment activities should be established. The nature and types of assessment activity should be adjusted to suit the size and product of the organization, should reduce the dangers of complacency and should act as a counter to any tendency towards denial. In addition to the early detection of any deterioration, an assessment of weaknesses in the management system could also be used to identify potential enhancements of performance and safety and to learn from both internal and external experience. INSAG Although employees often concentrate initially on industrial safety and issues relating to plant conditions, involvement in and commitment to the improvement process is likely to lead to a wider appreciation of issues of nuclear safety and environmental issues, and to have broader benefits for the business in promoting a culture of active involvement and teamwork. INSAG (88) There is other more general measures of safety performance that, whilst providing more qualitative information, are an important adjunct to numerical indicators. For example, observations of the behaviour of plant personnel can give an indication of how safely they actually carry out work and comply with procedures and good practices. Observing plant personnel performing work in the field and their interactions with supervisors and managers can provide insight into the safety culture at a plant. Plant Response/Action: The result from the review was two suggestions within the area of MOA. We have reviewed and assessed these suggestions and tried to find out what the root cause might be. We have roughly established that there are three parts of the process that needs to be improved - Establish a standard both in a technical way and in forms of behavior. - Communicate the standard and create a sense of feeling in our wish to have a safe work place. - Managers need to perform more systematical task observations within their activity areas, as well as be confident enough to correct any misbehavior. In order to handle suggestion 1.2 (1), we have implemented a new routine managers in the field/task observation. This routine clarifies a number of areas that shall be observed, as well as directing how often the observation shall be performed. An indicator system for these observations has been developed. The indicator system is subsequently followed up by the corporate management at least every third month. To support the managers in their observations a specific training in Human Performance Tools and Task observation has been developed and performed. 10 MANAGEMENT, ORGANIZATION AND ADMINISTRATION

13 IAEA comments: The plant undertook an analysis of the issue and determined that, inter alia, (1) there was no clear procedural expectation of what was required of managers while in the field and (2) that there was no performance indicator to allow an overview of their findings and determine the appropriate corrective measures. Checklists have now been prepared and are used to record managers observations, which are undertaken 2-4 times per month. It is planned to collate these observations on a departmental half-yearly basis commencing December 2010 and for each department to then forward them to Human Resources for analysis regarding common areas of concern. Classroom training for field observations by managers commenced in August 2010 and special training has also been initiated for shift supervisors. Seventy six managers out of a total of ninety have undertaken training. A Performance Indicator has been devised which indicates the number of committed field observations undertaken as a percentage of those which should have been performed. This figure has improved from 16.9% in July 2010 to 57.5% (equivalent to 153 task observations) in October It is recognised by the plant that further development of this performance indicator needs to take place as variables such as leave periods and failure to record observations are not catered for. These initiatives are commendable but are recognised by the plant to be at an early stage of development and further work is necessary to fully implement them. Conclusion: Satisfactory progress to date. 11 MANAGEMENT, ORGANIZATION AND ADMINISTRATION

14 1.4 QUALITY ASSURANCE PROGRAMME 1.4(a) Good practice: The plant has developed an integrated management system which includes communication, quality structures and documentation links. The management system for the plant is organised in a simple and easily understood manner in a computer based structure. This structure describes the plant s operations from business data through the requirements and description of tasks to the specific instructions for practice. The management system ensures that the possible factors which can affect the operation are taken into account in order to guarantee a high quality of work. The centre of this system is the Intranet Kärnan ; it is managed by an internal editorial group which has a combination of competences. Kärnan is designed from a structure corresponding to the main goal of the plant (called goal areas ). Each document and indicator relative to the areas can be accessed easily, also a compact vision is dedicated to communication. All employees receive training on how the management system works. At training the managers are involved by demonstrating and explaining what is most important for their section. This gives co-workers many different possibilities of finding what they need directly via a document number or via the structure of the organisation. Some examples of positive outcomes include: - Possibility for every worker to easily access the documentation. - Plant staff knowledge about the Kärnan structure. - A posting for indicators in coherence with the structure of the quality system. 12 MANAGEMENT, ORGANIZATION AND ADMINISTRATION

15 1.5 INDUSTRIAL SAFETY PROGRAMME 1.5(1) Issue: Plant management expectations with respect to industrial safety are not adequately implemented in the field. Although documentation relating to industrial safety work practices exist, the following facts were observed: - Inconsistent information is provided by plant personnel concerning the rules for the use of industrial safety equipment when questions were asked in the field. - Rules concerning the use of acetone were not known by people using it on the working area. - Rules concerning scaffolding verification are not clearly understood by staff and therefore not practiced. - Two scaffolding workers did not wear any safety harness while they were working at heights that could result in physical harm. Without a good understanding and appreciation of the industrial safety rules, safety could be affected. Suggestion: Plant management should consider taking further efforts to ensure that its expectations are implemented in the field with respect to industrial safety. IAEA Basis: INSAG Nearly all events, ranging from industrial and radiological accidents, incidents and near misses to failures affecting nuclear safety, start with an unintentionally unsafe act or an unacceptable plant condition or process. These have often been latent and have gone undetected or been treated as custom and practice and therefore been ignored. Then, in combination with another challenge to the system, a further more significant failure occurs. Minimizing existing latent shortcomings in working practices or plant conditions is therefore vital in avoiding more serious events. NS-G To ensure that there is a clear understanding of responsibilities and relationships between organizational units and between personnel within the operating organization, detailed job specifications should be defined. In particular, these relationships should be clearly defined for all activities having a direct or indirect bearing on safety. 13 MANAGEMENT, ORGANIZATION AND ADMINISTRATION

16 ILO-OSH Hazard prevention and control procedures or arrangements should be established and should:... (b) be reviewed and modified if necessary on a regular basis; (c) comply with national laws and regulations, and reflect good practice; and (d) consider the current state of knowledge, including information or reports from organizations, such as labour inspectorates, occupational safety and health. Plant Response/Action: The result from the review was two suggestions within the area of MOA. We have reviewed and assessed these suggestions and tried to find out what the root cause might be. We have roughly established that there are three parts of the process that we will improve: - Establish a standard both in a technical way and in forms of behavior. - Communicate the standard and create a sense of feeling in our wish to have a safe work place. - Managers need to perform more systematical task observations within their activity areas, as well as being confident enough to correct any misbehavior. In order to handle suggestion 1.5 (1), the actions required to handle 1.2 (1) are very significant in order to ensure that our regulations are complied with. We have clarified the requirements/standards regarding personal protective equipment, inspections of equipment, walk limitation etc. We have reinforced our information regarding our requirements/standards via such forums as meetings, the intranet, video screens etc. to call attention to our aim in having a safe work place. In the area Operational experience, OE, the progress of corrective actions is described, a significant part of the industrial safety work. A decision has been made that the area of work environment shall be implemented in the new system from January 1 st We have increased the interaction between the safety culture work and industrial safety. Extended interaction is taking place with the NPPs of E.ON in order to jointly improve the work environment. A joint target figure is set, LTIF<1,0 year In order to attain directed and continuous improvements within Industrial safety, we have decided to be certified in accordance with the industrial safety standard OSHAS MANAGEMENT, ORGANIZATION AND ADMINISTRATION

17 IAEA comments: It was determined by the plant that some industrial safety rules/instructions were previously unclear and that these had not been effectively communicated to the workforce, including contractors. Updated instructions were produced and issued for personal protective equipment, lifting slings and scaffolding. Training on these was also undertaken. Information packages, for both permanent staff and contractors, have been produced regarding expectations of a safe workplace and safety alerts are distributed on an ad hoc basis. Traffic and pedestrian signs have been made to clearly identify desired walkways and traffic flow. It has been recognised by the plant that there is a clear link between safety culture and industrial safety. The reporting of minor events regarding industrial safety has been delegated to the responsible manager aiding the amount of information captured in these reports. Over and above the actions emanating from the issue, the plant has also decided to initiate the process of being certified according to OHSAS Conclusion: Issue resolved. 15 MANAGEMENT, ORGANIZATION AND ADMINISTRATION

18 2 TRAINING AND QUALIFICATIONS 2.1 TRAINING POLICY AND ORGANIZATION The team made a recommendation concerning the manner in the use of feedback from actual plant performance. Unlike many other plants in the world, there is no linkage between the plant work management system and the training management system. It allows the potential for assigning personnel to a task when they are not task qualified. The plant compensates for this with strong line management knowledge and use of its learning management system. The interface and contract control with external training providers is strong. Attendance at scheduled training sessions is not as good as at many plants in the world. Nonattendance indicators for the period from 2006 to 2008 were between 12.5 % and 9.3 % (not including operator training). The training organization has recognized this problem and is taking actions to improve training attendance. The plant is encouraged to continue with improvement efforts in this area. 2.2 TRAINING FACILITIES, EQUIPMENT AND MATERIAL The team found two good practices in this area, the first dealing with the use of hands on training facilities at the plant and at other training locations, and the second dealing with the high quality of training materials. Plant modifications are always developed, implemented and trained in the simulator before implementation. This process verifies that operators receive timely information needed for plant operational needs. This is seen as a good performance. The plant s configuration and problems reporting systems are not the same as in use in the simulator (OKG and KSU). This was changed during the on-site portion of the team s activities; KSU (at Oskarshamn) now matches the plant configuration system. 2.3 QUALITY OF THE TRAINING PROGRAMME Training programs are supported by effective task analysis, job descriptions and training requirements; however, there were two approved job descriptions for operations plant engineers, plus portions of two others, that were found which contained knowledge and skills sections that were blank (incomplete). The plant is encouraged to review all job descriptions to ensure consistency and completeness. 2.7 TRAINING PROGRAMMES FOR TECHNICAL PLANT SUPPORT PERSONNEL Each new trainee is provided with a mentor (or sponsor) to conduct the trainee s initial orientation. The mentor is tasked with providing informal orientation training that assists in familiarizing the new person with the plan, information systems, and department-specific practices. This practice results in greater new employee understanding of the history and basis for the ways that operations and practices are conducted, as well as improved technical knowledge transfer. 16 TRAINING AND QUALIFICATION

19 2.8 TRAINING PROGRAMMES FOR MANAGEMENT AND SUPERVISORY PERSONNEL The use of the management development centre effectively screens new management candidates for the desired skills. Areas for emphasis are identified for suitable candidates and some candidates, not yet suited for management positions, are not placed in such positions. 2.9 TRAINING PROGRAMMES FOR TRAINING GROUP PERSONNEL The team noted some instances of weak instructor performances. In addition, on-the-job training (OJT) instructors (plant personnel) do not receive training on the expectations for conducting OJT or task performance evaluations (TPE). The plant is encouraged to seek improvements in the area of instructor skills, including instructor fostering of human performance behaviors GENERAL EMPLOYEE TRAINING Clean System foreign material exclusion training, required for plant access, for all plant personnel and contractors is a positive corrective action taken for instances of fuel damage that has occurred on the site. The team considers this as a good performance. Contractors have not been trained in the use of the recently implemented White Card program. This is included in Issue 6.2(1). The plant is implementing the first round of human performance training on-site, but there is no, as yet, periodic training in the use of human error prevention. The plant is encouraged to continue its efforts in this area. 17 TRAINING AND QUALIFICATION

20 DETAILED TRAINING AND QUALIFICATION FINDINGS 2.1 TRAINING POLICY AND ORGANIZATION 2.1(1) Issue: The plant is lacking several comprehensive review mechanisms that assist in continuously and routinely improving the quality of training. Examples noted include the following: - Training management has not been routinely represented at plant status meetings. At many stations, this occurs so that early identification of training shortfalls and needs occur. - Performance indicators used in the training organization are generally not performance based. In addition, goals for current performance indicators (such as training attendance) are not set so that more rapid improvement can occur. - There is no use of qualification boards for final qualification of shift supervisors. In addition, there is no integration of site interviews (by technical managers) into the shift supervisor qualification process. - When they occur, Management observations of training are rarely documented for systematic collection and identification of training shortfalls and strengths. - Manager observations of instructors by training and operations personnel are often not critical (identifying needs improvement areas) so that instructor performance improves. There is no metric in use that systematically measures instructor performance. On-the-job training (OJT) instructors (plant personnel) do not receive training on the expectations for conducting OJT or task performance evaluations (TPE). - Comprehensive self-assessments of training effectiveness are not used or do not include external reviews to evaluate training s impact on improving plant performance. - Student feedback forms could be better designed to seek trainee input on the quality of training provided and they are also long (6 pages). In addition, although there is a listing of trainee expectations, there is not such an expectation for students to provide feedback. - Operators do not critique the performance of the simulator model. The critique of the quality of the scenarios could be improved. As found evaluations of operator performance in the simulator are conducted, but are not used in a systematic manner to improve ongoing training. Critiques, conducted as part of simulator training, do not explicitly focus and track Whys? to determine the reasons for performance shortfalls and strengths. 18 TRAINING AND QUALIFICATION

21 - Only periodic (quarterly) operations training review committee meetings (DUR) collect and discuss the operations training program needs and completion. This meeting is generally not plant performance based. Similar training boards for the review of maintenance and technical programs are just starting. Failure to identify training shortfalls, and strong aspects, in order to improve worker knowledge and skills can result in recurrent human performance errors, rework, and poor worker safety behaviors. Recommendation: The plant should develop a more comprehensive review of the numerous performance-based evaluative inputs from the plant and worker performance in order to continuously and routinely improve the quality of training. IAEA Basis: NS-G A training plan should be prepared on the basis of the long term needs and goals of the plant. This plan should be evaluated periodically in order to ensure that it is consistent with current (and future) needs and goals. Factors which can change a training plan include: commissioning experience, operational experience and decommissioning experience at the plants of the operating organization; feedback of operational experience from other plants; significant modifications to the plant or to the operating organization; changes in regulatory requirements; and changes in the State s education system The training plan should be periodically reviewed and modified as necessary. The review should cover the adequacy and effectiveness of the training with respect to the actual performance of employees in their jobs. The review should also examine training needs, training programmes, training facilities and the training materials necessary to deal with changes to regulations, modifications to the facility and lessons learned from experience in the industry The internal review of training undertaken at the plant or by the operating organization should be an integral component of the on-site training system. The review should cover all stages of the training system, the analysis of training needs, and the design, development and implementation of the training programmes. Training records should also be reviewed. Such a review should be undertaken by persons other than those directly responsible for the training. Plant managers should be directly involved in the evaluation of training programmes. Close co-operation should be maintained in the training evaluation process between the plant management, individual departments and the training unit Activities and practices in operating and maintenance, and compliance with industrial and radiological safety standards, should be monitored to identify any problems due to incorrect or insufficient training On the basis of the results of evaluations, an action plan to improve and correct the training programmes should be developed and implemented. This may lead to improvements in the conduct of training or to changes in the training programmes. 19 TRAINING AND QUALIFICATION

22 5.44. An independent review of the plant s training plan should be carried out by external organizations. The external review should be considered complementary to the internal evaluation in giving a different perspective to the evaluation of training programmes. The results of the external review should be integrated with the results of the internal evaluation, to identify necessary changes and improvements in the training programmes. Plant Response/Action: After completed analysis of the recommendation and also our experience we found out that the TQ area is currently in significant change both regarding manning of the group working with competence area and also regarding the approach to training. The working team has recently grown and has a different professional background today than earlier. As a result of this a new approach to training and new forms of cooperation with other departments at OKG and other plants, nationally and internationally is developing. Thus many of the measures described below are still at an early stage in their progress, some perhaps too early to clearly state results. Working methods have been developed in the short term in order to ensure that lacks in competence identified as a result of experiences or events are handled. In the long term, these will be handled within the corrective action program that are under development. Development of the training boards has been done and new boards have been established. The boards have the same agenda and also discuss for example experiences from the organization important to training and are also used to spread information about training. The A-Dur meeting handles events in plant important to training and suggests changes to quarterly operations training meeting. Responsibilities in the competence assurance process have been clarified. An industry-adapted evaluation model for training is under development and is tested on a pilot group before being implemented. The model is jointly shared with KSU and both KSU and OKG are now working with developing the routines concerning evaluation. A more appropriate student feedback form has been developed to assure the quality of training. Also a feedback form for instructors has been developed. Observations of instructors have become more thorough and the new evaluation questionnaire provides the opportunity to measure and follow up instructors efforts, which previously was not possible. A two-day training programme for OJT-instructors has been developed and the first group is due to attend this programme in December A new routine has been developed for the evaluation of candidates for shift supervisor positions. 20 TRAINING AND QUALIFICATION

23 Indicators within the competence assurance process have been established. Indicators for a national follow-up will be determined this autumn jointly between KSU and the Swedish nuclear power plants. IAEA comments: Along with the existing one for Operations, Training Review Boards have been set up for Technical Support, Maintenance, Administration, Human Resources, Environment, Safety and Management. These boards have typically representatives from the line, the plant s management, the plant s training department and where needed from the contractor providing support for training services. The attendees of the plant ensure that all required competencies are represented at the board. These boards are responsible for identifying training needs or requirements coming out from different activities at the plant, updating the content and scope of training programmes, following them up and evaluating each training area so the fulfillment of the aims pursued with the program is assessed. Operating experience feedback is routinely provided to these boards so its appliance is evaluated and training programmes are updated if necessary. A senior training coordinator with former experience in operating the plant has been appointed for each of the plant units. A new routine for the qualification of shift supervisors has been implemented. This routine includes a formal assessment of the candidate s technical capabilities, a personality test and a final interview with the Operations Manager and Human Resources. The conclusions are presented to the Management Team Meeting and, if validated, the final decision lies on the Operations Manager. The meetings between instructors and shift personnel have been formalized and its traceability has been addressed. Students feedback forms have been redesigned to seek trainee input on the quality of training provided and the critiques on the quality of scenarios in the simulator have been improved to track Whys? to determine the reasons for performance shortfalls and strengths. Observations of the training activities are carried out and the plant has planned establishing periodical seminars to share the conclusions of these observations with the instructors so their performance can be improved. A systematic process to assess the effectiveness of training at the plant has recently been defined. This process incorporates a set of key performance indicators that have started being calculated and tracked. Conclusion: Issue resolved. 21 TRAINING AND QUALIFICATION

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