REPORT OF THE OSART (OPERATIONAL SAFETY REVIEW TEAM) MISSION TO THE LOVIISA NUCLEAR POWER PLANT FINLAND March 2007 AND FOLLOW UP VISIT

Transcription

1 NSNI/OSART/08/139F ORIGINAL: English REPORT OF THE OSART (OPERATIONAL SAFETY REVIEW TEAM) MISSION TO THE LOVIISA NUCLEAR POWER PLANT FINLAND 5-21 March 2007 AND FOLLOW UP VISIT July 2008 DIVISION OF NUCLEAR INSTALLATION SAFETY

2 PREAMBLE This report presents the results of the IAEA Operational Safety Review Team (OSART) review of Loviisa Nuclear Power Plant, Finland. It includes recommendations for improvements affecting operational safety for consideration by the responsible Finland organizations and identifies good practices for consideration by other nuclear power plants. This report also includes the results of the IAEA s OSART follow-up visit which took place 16 months later. The purpose of the follow-up visit was to determine the status of all proposals for improvement, to comment on the appropriateness of the actions taken and to make judgements on the degree of progress achieved. Any use of or reference to this report that may be made by the competent Finnish organizations is solely their responsibility. DIVISION OF NUCLEAR INSTALLATION SAFETY OPERATIONAL SAFETY REVIEW MISSION IAEA-NSNI/OSART/08/139F

3 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 REFERENCES (Basis) TEAM COMPOSITION OF THE OSART MISSION TEAM COMPOSITION OF THE OSART FOLLOW-UP MISSION

4 INTRODUCTION AND MAIN CONCLUSIONS INTRODUCTION At the request of the Government of the Republic of Finland, an IAEA Operational Safety Review Team (OSART) of international experts visited Loviisa Nuclear Power Plant (NPP) from 3-21 March The Loviisa NPP is owned by Fortum utility. The plant operates two VVER-440 type units with pressurized water reactors. The capacity of the units has been uprated to 510 MW. Unit 1 started operation in 1977, unit 2 in The plant has applied for a 20 year license extension permit recently. 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; Radiation protection; Operating Experience, 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 Loviisa OSART mission was the 139 th in the programme, which began in The team was composed of experts from Canada, Czech Republic, France, Hungary, Japan, the Netherlands, Russia, Slovakia, United Kingdom and the United States of America, together with the IAEA staff members and an observer from France. The collective nuclear power experience of the team was approximately 300 years. Before visiting the plant, the team studied information provided by the IAEA and the Loviisa 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. 1 INTRODUCTION AND MAIN CONCLUSIONS

5 MAIN CONCLUSIONS The OSART team concluded that the managers of Loviisa NPP are committed to improving the operational safety and reliability of their plant. The team found good areas of performance, including the following: The Fortum Corporation has demonstrated a long term commitment to ongoing investment in equipment and system upgrades that have significantly reduced overall plant risk for core damage and release of radioactivity. Fortum Nuclear Services has developed a high quality and comprehensive Probabilistic Safety Analysis with state-of-the-art methods and tools. The model is used by the plant in several areas. The plant uses an analysis programme, named SaTu to support the on and off-site emergency organizations to estimate accidental releases in advance and the recommendations for protective actions can be estimated based on averted dose. Direct information exchanges with other nuclear power plants, especially other VVER plants, has contributed for getting lessons learned improving plant operations. This has been an important way of sharing operating experience, through twinning and personnel exchange with other plants. A number of areas for improvements in operational safety were identified by the team. The most significant proposals include the following: The managers are not providing enough guidance relating to the required use by workers of error prevention techniques such as self verification, peer checking, pre-job briefs and procedure usage. A rigorous approach in operators' work practices, including field operators' shift turnover, control room conduct and field rounds is not always evident. Control of the modification process is not always comprehensive to ensure that all necessary steps are implemented. Managers are not consistently identifying and correcting some industrial safety practices and plant conditions which increase the risk of injury to personnel. Loviisa management expressed a determination to address the areas identified for improvement and indicated a willingness to invite a follow up visit in about eighteen months. 2 INTRODUCTION AND MAIN CONCLUSIONS

6 FOLLOW-UP MAIN CONCLUSIONS The management and staff of Loviisa NPP have made an effort to address the recommendations and suggestions proposed by the OSART team. Several initiatives have been launched which need continued effort to reach the desired results. The implementation status of the most significant issues is the following: In the area of using error prevention techniques, a new classification system for procedures concerning their use has been introduced. A new system of pre-job briefing with industrial safety focus is in use. An external network is utilized by the plant to find improvement solutions which will work efficiently in the given cultural environment. However some of the new initiatives are in the phase of trial application or are applied only by certain parts of the plant organization. Concerning the rigorous approach in operators work practices the requirements for shift turnover practices have been enlarged and the requirements for good communication practices have been further specified. However these corrective actions entered into force only recently, therefore more time is needed to ensure their full scope application. The plant has successfully resolved the issue related to the control of the modification process. The work of the modifications committee has been enhanced and improvement in the performance of modifications is evident. In the area of industrial safety visibility of focus on industrial safety issues has increased, more comprehensive accident analysis was developed and the plant has been certified against the Occupational Health and Safety Management System (OHSAS 18001) standard. 3 INTRODUCTION AND MAIN CONCLUSIONS

7 1. MANAGEMENT, ORGANIZATION AND ADMINISTRATION 1.1 ORGANIZATION AND ADMINISTRATION Loviisa power plant is a dual unit PWR of the VVER-440 type owned and operated by the Fortum Corporation based in Helsinki, Finland. Each unit has rated power approximately 510 MW electric. Loviisa is one of two nuclear sites in Finland. Over the approximately 30 years of operation, the corporation has committed significant resources to the plant on an ongoing basis, allowing extensive modifications to improve safety and reliability of the plant. The OSART team identified this as a good practice. In conjunction with regulatory and governmental support, the plant constructed, and in 1997, began operation of an underground permanent repository for low and intermediate level waste located adjacent to the plant. Very comprehensive administrative control procedures define the organizational structure, including interfaces with corporate support organizations. Major accountabilities and responsibility for all major organizational entities are comprehensively described. The responsibility for safe operation of the plant is statutorily assigned to the Plant Manager. Several corporate organizations, external to the site organization, provide required support functions to the plant. These functions include procurement of nuclear fuel, design engineering, major project implementation, government relations, high-level radioactive waste disposal, and human resources. The authority interfaces, responsibility, and governance are clearly described. The Plant Manager maintains oversight of these functions through membership on governance boards and committees for the corporate organizations providing plant support. It is encouraged that senior corporate executives maintain a broader view of global nuclear industry trends and standards for excellence outside of Scandinavia. Senior corporate executives provide effective structured oversight of nuclear safety through the use of diverse governance boards and committees. Once per year, the plant manager is required to present a detailed and critical status of plant safety to the CEO of the FORTUM Corporation. Independent perspective is provided from both the independent safety committee (LYTT) and a corporate quality manager whom spends the majority of his time independently overseeing quality functions at the plant. The independent safety committee (LYTT) is comprised of experts from other nuclear utilities, the Finnish State Research Institute and Finnish universities. The committee protocol is to review presentations of aspects of the operation of the plant as a means to discuss and assess various aspects of nuclear safety. The OSART team encourages the plant to broaden the review of activities accomplished by the LYTT to include committee solicitation of employee input through 3 MANAGEMENT, ORGANIZATION AND ADMINISTRATION

8 group discussion and plant tours to assess and trend material condition, cleanliness and housekeeping standards. The plant is effectively implementing a multi-year initiative to hire and train workers in advance of ongoing retirements. Staffing of operators, engineers, and craft over the approved complement occurred over the last several years and staffing plans exist for additional hiring in the future. For example, the plant is hiring approximately 30 employees in 2007 and expects to hire 20 employees in This hiring is designed to allow sustainability of the current staffing levels. A rigorous process, more comprehensive than is typically seen in the industry, is used for identification and ongoing development of managers, senior managers, and corporate leaders. Structured reviews of personnel are completed annually and a tiered approach is used to provide intensive leadership training. Additionally, the Finnish power companies, regulatory authorities, and Finnish universities jointly developed this training programme to ensure a continued pool of technical talent supporting the Finnish nuclear industry. Performance discussions are held between supervisors and employees on a yearly basis to assess progress towards accomplishment of agreed upon goals and objectives. The identification and assessment of required behaviours towards safety (nuclear, radiation protection) is not well defined. Wide latitude is given for each supervisor to determine what criteria are applied to provide feedback to employees. The plant is encouraged to formally identify required quality behaviours for employee classifications such as operators, maintenance personnel, engineers, and supervisors. Appropriate quality behaviours examples include adherence to industrial safety requirements, use of error reduction techniques, appropriate adherence to procedures, and maintenance of their work areas tidy. This could have a significant impact on the working behaviour of the new generation of workers. Discussions with the plant manager and the STUK resident indicated that it is well understood that the role of the plant is to operate safely and the role of the regulator is to validate compliance with regulations and provide independent assessment of safety. Routine discussions between the regulator (STUK) and plant management occur to ensure that regulatory concerns are properly addressed. Additionally, STUK officials and corporate executives meet annual to discuss and address mutual issues of concern. A very detailed annual communication plan ensures ongoing and effective interface with key stakeholders including the general public, local politicians, STUK, and local media. Numerous activities are completed to keep the public informed about activities at the plant 4 MANAGEMENT, ORGANIZATION AND ADMINISTRATION

9 and the commitment to safe operation. Stakeholders are formally solicited to provide feedback on the effectiveness of communications and their input is used for continuous improvement of the communication. The organizational structure has remained stable for the last several years. Minor organizational changes that have occurred were appropriately reviewed by the senior management team prior to implementation. 1.2 MANAGEMENT ACTIVITIES A structured process is used to develop and effectively communicate plant goals and objectives. Detailed actions plans necessary to attain established higher tier business plan goals and objectives are developed with designated management owners and expected due dates. These plans are reviewed by the senior managers to ensure appropriate coordination and collaboration. Progress against the goals are tracked and visibly displayed throughout the plant. Performance indicators are established to measure accomplishment of annual business plan objectives. These performance indicators provide the bases for bonus programmes and goals in employee performance appraisals applicable to all personnel. The goals have been used to drive improvement through more challenging targets year to year. This has been effective at driving improvements in industrial safety and collective radiation exposure. The OSART team did not observe safety reinforcement during routine meetings and displayed graphically through the plant is typical of what is seen in at other plants. The OSART team encourages the plant to establish improved visibility of their commitment to safety through effective addition of safety (nuclear, industrial, and radiological) into routine daily meetings and improved postings in common work areas at the plant. Other plants use items such as a weekly safety topic to review specific requirements of the safety manual at the beginning of shop briefings and daily production meetings. These meetings are also used to alert employees of important maintenance ongoing for safety related equipment, and to reinforce use of error prevention tools by workers. Employees are encouraged to bring up safety concerns to their supervision and to write deviation reports for identified safety concerns. Additionally, the OSART team observed a formal process titled Cooperation Day which provides a group of front line employees a chance to discuss issues of concern directly with a member of the senior leadership team. Other opportunities exist where employees have the ability to bring up concerns to management including off-site meetings twice per year and a computer based solicitation of comments. The OSART team encourages the plant to establish a formal mechanism for 5 MANAGEMENT, ORGANIZATION AND ADMINISTRATION

10 submittal of nuclear safety concerns with management commitment to independently investigate identified concerns. Nuclear industry practice is to provide provisions for anonymous reporting if the submitter does not feel comfortable. The plant has a structured administrative control procedure system which provides controls for safe operation based on the regulatory required quality manual. The Finnish regulations specifications for safe operation are contained within these administrative controls. 1.3 MANAGEMENT OF SAFETY A safety policy, FORTUM Policy Commitment to Quality in Nuclear Power Operation, signed by the Chief Executive Officer, describes the corporate commitment to constantly strive for higher levels of safety...and further develop nuclear know-how for the short and long term. This policy is visibly posted around the plant. The OSART team observed some workers exhibiting behaviours that increase the potential for error. More specific guidance and reinforcement relating to worker use of error prevention tools such as self-verification, pre-job briefs, and procedure usage is needed. A recommendation has been provided for this issue. An employee suggestion programme is implemented for plant personnel to identify improvements to processes and other aspects of the operation. These are reviewed against criteria and there is an incentive system that provides bonuses for ideas that save time or money. The OSART team encourages the plant to consider adding additional criteria for rewarding ideas that improve nuclear, radiological, environmental, and industrial safety as a way of reinforcing the company s commitment to safety. Self assessment of departmental activities is specified in accordance with administrative requirements. The OSART team review of completed self assessments found them generally critical and identifying meaningful issues to correct. However, implementation of departmental level self-assessment is at early stages in implementation. Corrective actions taken to improve identified shortfalls in worker behaviours have not been fully effective. The OSART team observed that some departmental level performance indicators typically seen at other plants are not tracked and reviewed by senior managers. The OSART team encourages the plant to develop and implement a standard set of departmental indicators and set up routine senior management reviews of departmental performance against the identified indicators. This will improve the ability of Loviisa senior managers to provide a clear picture 6 MANAGEMENT, ORGANIZATION AND ADMINISTRATION

11 of overall plant performance as well as identify and correct precursors to more significant safety issues. The OSART team recognizes that a strong safety culture is comprised of many attributes that collectively demonstrate the safety culture of an organization. The OSART team does not perform a comprehensive review of safety culture. However, during an OSART review, the team identifies many facts related to these attributes of safety culture that are provided to assist ongoing management efforts to strengthen safety culture at Loviisa. The following positive attributes of safety culture were identified by the team: Fortum corporate and Loviisa plant are committed to invest in large projects (operational and organizational changes) to improve the level of safety and to make significant progress in the safety of operation. A recent example is the LARA project which comprises a large scale of renovation of the operation control room using modern equipment and introduces state of the art solutions in the human-machine interface. As many nuclear plants worldwide, Loviisa plant is facing a change generation at worker level as well as at management level. The team was shown a multi-annual plan to anticipate specialist hiring and to prepare an extensive training programme for new operators. The team noticed that the plant is well prepared and that the arrangements are initiated. Loviisa plant took the lead to initiate exchange of operating experience with other sister plants operating the same VVER-440 design. All these plants share their safety improvements, which Loviisa is often the first to introduce in practice, this way providing support to others. The OSART team noticed also that plant management, plant counterparts, escorts and interviewed workers are open minded and eager to learn. This evident learning attitude is a good sign that new generation of worker will benefit to develop a spirit of continuous improvement. The Fortum Company and the Loviisa plant also apply a performance indicator on working climate and evaluate it periodically when management meets staff representatives. This initiative is well received at all working level of the hierarchy and contributes to the safe atmosphere, which is manifest when touring the plant. The following represent attributes which could be strengthened to improve the overall safety culture: Looking at the main plant results during these past years, the OSART team has no doubt that the personnel operating the plant have extensive skill, knowledge, competence and 7 MANAGEMENT, ORGANIZATION AND ADMINISTRATION

12 experience. However more rigorous use of procedures, drawings and other supportive documents in operation and maintenance activities is encouraged. This together with transfer of knowledge would support new generation to adopt safety oriented attitudes. The plant managers could use more opportunities to set-up, show and promote their expectations on high standards. Walkdown of work sites could be an excellent occasion to challenge inappropriate or incomplete work practices and employee behavior. At a more minor level the OSART team also encourages the plant to further consider: The pragmatic approach to efficiently operate the plant results in optimized human resources. Continued review of required resources by managers is important to ensure that there is not a lack of attention to details in some areas. The OSART team observed acceptance of low visible material condition in some systems not related to safety, which should be brought to the attention of the workers through more systematic caution by the managers. 1.4 QUALITY ASSURANCE PROGRAMME The accountabilities, authority, structure, and independence of the Quality Assurance function are clearly described in the FORTUM corporate quality policy. The policy requirements are comprehensively translated to plant administrative procedures. Audits of safety related activities and processes are scheduled and completed in accordance with regulatory and administrative requirements. OSART team review of a sample of completed Quality Assurance assessments found them to be comprehensive and critical. Regulatory requirements were validated as well as worker adherence to procedure and management expectations. Critical findings were observed in areas including worker adherence to procedures, industrial safety rules, and the adequacy of procedures and instructions. Assessment procedures require that corrective action completion and effectiveness reviews are completed for previously identified assessment findings. Additionally, a common cause review is completed annually to determine repetitive themes across the population of completed assessments. The results of this review are reported to senior managers on an annual basis and include statistical breakdown of findings and comparison to the statistical breakdowns from previous three years. Direct feedback to managers is provided for quality assurance audits in their areas. Corrective actions are tracked to completion. In some cases, corrective actions to correct quality assurance identified shortfalls in worker adherence to requirements were not effectively used 8 MANAGEMENT, ORGANIZATION AND ADMINISTRATION

13 to improve worker performance. 1.5 INDUSTRIAL SAFETY PROGRAMME Clear policies and programmes are in place to describe and implement the industrial safety programme. A government programme specifies specific minimum safety requirements and covers contractors and plant workers through issuance of an Industrial Safety Card. A multi-year corporate initiative to reduce injuries is ongoing. In 2005 and 2006, all employees, supervisors, and managers attended an internationally recognized training course pertaining to industrial safety. Formalized industrial safety inspections by managers is required and tracked to ensure completion. A safety handbook was developed and distributed to employees to provide description of safety requirements. These efforts have resulted in a declining trend of injuries to plant and contracted workers over the last several years. While improvements have occurred, the OSART team observed workers placing themselves at risk to injury and also observed examples of hazards in the plant that also increase the potential for injury. Managers are not consistently identifying and correcting these worker behaviours on the spot. A recommendation has been provided for this issue. The OSART team observed the safety postings in the plant and reviewed the material provided in site indoctrination material. The OSART team encourages the plant to ensure consistent safety signage in the plant able to be understood by international workers. Review of the signage should be covered in initial indoctrination training given to new employees and contracted workers. 1.6 DOCUMENT AND RECORDS MANAGEMENT An upper tier administrative control procedure required by the Quality Manual describes the document control system and requirements for the plant. A well designed computer programme accessible provides easy access to plant documents by employees. Only appropriately reviewed and currently approved procedures are electronically accessible to workers. The process for review and approval is comprehensive. Document preparation status is tracked using the computer system. 9 MANAGEMENT, ORGANIZATION AND ADMINISTRATION

14 Administrative requirements exist requiring validation of latest revisions to procedures prior to use. Important locations, such as the control room are provided with hard copy procedures. Administrative controls are in place to ensure that these locations are updated when the associated procedures are revised. LOVIISA NPP FOLLOW-UP SELF ASSESSMENT The area and issues are recognized and fully accepted as improvement areas. The cultural nature of some of the issues makes it difficult to assess the progress in a very quantitative way. The responses in the Fortum Sound personnel survey show a recent strong commitment by the line managers and staff towards safety. Generally, the discussion and communication in the area has been showing growing maturity. STATUS AT OSART FOLLOW-UP VISIT The plant has launched several initiatives to improve the industrial safety situation and the use of error reduction techniques. Some of them are in the phase of trial application or are applied only by certain parts of the plant organization. Some of the new initiatives utilize methods having company wide application or represent joint programmes with other nuclear plants and installations. The effort has to be continued in the future as some experience will be gained by the plant. Given the nature of these issues and the need of their plant wide implementation it is normal that a longer implementation period is needed to achieve the desired results. 10 MANAGEMENT, ORGANIZATION AND ADMINISTRATION

15 DETAILED MANAGEMENT, ORGANIZATION AND ADMINISTRATION FINDINGS 1.1 ORGANIZATION AND ADMINISTRATION 1.1(a) Good Practice: Permanent safety upgrades to reduce overall plant risk. The FORTUM Corporation has demonstrated a long term commitment to ongoing investment in equipment and system upgrades that have significantly reduced overall plant risk for core damage and release of radioactivity. Several extensive modifications were completed to improve availability of the ultimate heat sink following internal and external events, including: Improved design and added additional redundancy for the residual heat removal system, including electrical separation. Providing redundant cooling water supply to emergency diesel generators Several extensive modifications have been completed to reduce the likelihood of radioactive release post-accident including: Addition of automatic isolation of primary coolant purification system when pressurizer pressure decreases. Relocation of the reactor coolant pump emergency seal water suction line. Addition of automatic isolation of reactor coolant pump seal water heat exchangers based on high pressure. 11 MANAGEMENT, ORGANIZATION AND ADMINISTRATION

16 1.3 MANAGEMENT OF SAFETY 1.3(1) Issue: The managers are not providing specific guidance relating to worker required use of error prevention techniques such as self verification, peer checking, pre-job briefs and procedure usage. During OSART team observation of plant activities workers infrequently used error reduction techniques. For example, during performance of a surveillance test, an instrument technician aligning the reactor protection system manipulated several switches without use of a procedure or self-verification techniques. For many of the evolutions observed by the OSART team, pre-job briefs were not accomplished for activities typically seen as requiring pre-job briefs in the industry. Examples included an operations test of safety injection pumps, and maintenance activities of a fire protection valve. The plant has developed and communicated the use of a pre-job briefing checklist but further reinforcement is needed to ensure consistent use. The OSART team observed workers exhibiting behaviors that increased the probability of error and in some cases caused errors. Ineffective self-verification and independent review during preparation of a modification package contributed to an incorrect fire protection valve being isolated. A portion of the fire protection system was isolated without appropriate compensatory actions and as a result of the error, an inadvertent actuation of the sprinkler system was actuated causing water to discharge into a safety related room. The OSART team observed control room operators, maintenance technicians, and field operators infrequently using self-checking and peer checking to verify that the correct equipment is manipulated. Managers have not established expectations for when procedures are to be used and whether the procedures should be in-hand or available at the jobsite. The OSART team observed several safety related evolutions being accomplished without using a procedure, including resetting of the reactor trip system following testing. Required worker behaviors relating to error reduction techniques and procedure use have not be specified or communicated. The quality assurance organization identified multiple procedure use deficiencies within numerous quality assurance reports and the 2004 and 2005 annual quality report. Corrective actions taken to date have been ineffective at anchoring use of desired error reduction techniques and standards for procedure usage. The current guidance relating to required use of error prevention techniques such 12 MANAGEMENT, ORGANIZATION AND ADMINISTRATION

17 as self-verification, peer checking, procedure usage, and pre-job briefs leaves workers wide latitude in determining requirements. Infrequent and inconsistent use of error reduction tools by workers increases the risk of operational transients and potentially challenges operability of safety equipment. Recommendation: Managers should provide more specific guidance for worker use of error reduction techniques, including procedure usage. Other plants have successfully raised worker usage of error reduction techniques, including procedure usage through focused alignment of management observations, coaching, training, rewards and recognition, performance management, communication, and assessments to provide continuous reinforcement of desired behaviors and identification and correction of deviations. IAEA Basis: GS-G-3.1 (2.21): "Work should be accomplished using technical standards, instructions, procedures and other appropriate documents." DS347: "(4.30) Operators should adhere strictly to plant policies with regard to... methods in place to minimize human errors. Operations management and supervisors should be aware of operator behaviour in this regard and should ensure that high standards of performance are continually enforced." "(5.25) Self assessment and error prevention techniques, such as the STAR principle (Stop, Think, Act and Review) and peer checking, should be used during reactivity manipulations or activities directly affecting the removal of residual heat." "(4.43) In order to reduce the likelihood of errors during verbal communications, both on the plant and in control rooms, the use of three way communications between the sender and recipient should be trained and used as widely as is practical, especially in abnormal situations." Plant Response/Action: The plant has recognized and understood the background of the related findings and fully agrees with the recommendation. Since the review the plant has been active in the area as follows: 13 MANAGEMENT, ORGANIZATION AND ADMINISTRATION

18 New classification of procedures has been planned and introduced, the classification more clearly states how the instruction/procedure is to be used More systematic pre-job briefing approach has been taken in test use New module introduced in EHSQ induction training package related to Safety Culture New resources and competences introduced for training in HP area Human Performance related training introduced in spring 2008 for operations and maintenance workers Modified approach for safety matters in some standing meetings (weekly, monthly) More comprehensive quality metering and related bonus awarding introduced in some areas Off-site co-operation and networking increased in the area (several cases) New Code of Conduct established in the company Area recognized and communicated as focus area in business planning for A new plant manager nominated in 2008 IAEA comments: The new classification system for procedures applies three categories concerning their use: continuous use, informative use and reference use. The classification system entered into force in April 2008 and each procedure will be assigned a category during the next revision, which means at least in 4 years from now. The new system of pre-job briefing is a FORTUM-wide approach without nuclear plant specific features. It focuses on industrial safety and it is in trial application to decide with what changes it could be applied on a permanent basis at the plant. 14 MANAGEMENT, ORGANIZATION AND ADMINISTRATION

19 The Human Performance and Safety Culture (HUSC) network of the Nordic nuclear facilities is utilized by the plant to find improvement solutions which will work efficiently in the given cultural environment. Conclusion: Satisfactory progress to date 15 MANAGEMENT, ORGANIZATION AND ADMINISTRATION

20 1.5 INDUSTRIAL SAFETY PROGRAMME 1.5(1) Issue: Managers are not consistently identifying and correcting some industrial safety practices and plant conditions. The OSART team observed several occurrences of inappropriate worker practices. Some workers were observed not wearing appropriate hearing protection and hard hats in areas of the plant clearly marked as requiring hearing protection and hardhats. In some cases, supervisors or managers who were present did not coach the workers. Additionally, a painter was observed sitting on a pipe while painting the ceiling of a room containing operable safety equipment. A shift manager did not immediately challenge the painter being in near proximity to a safety injection valve. Subsequently, the same valve did not initially pass surveillance testing due to the impact of the painter s weight causing the valve operation to be restricted. The OSART team observed some workers using inappropriate practices that placed themselves at risk of injury including routine use of tools to assist valve operation. Use of these devices increases opportunity of valve damage as exposes workers to risk of injury. The OSART team also observed a worker using a portable grinder without wearing a face shield as required. A foreman did not correct the situation when it was noted to him by the OSART team member. The OSART team observed examples of plant conditions that exposed workers to the risk of injury including un-terminated electrical cables secured to the metal stairway leading to a Primary Coolant Pump (PCP) platform, hot pipes and components with missing insulation, and temporary ladders inappropriately secured to plant components, and elevated permanent ladders without safety chains. The OSART team also noted initial training of plant workers and contractors does not include clear descriptions of safety postings used in plant areas to alert workers of industrial hazards and special instructions or requirements. While managers are completing numerous management observations per month, they are not consistently identifying or correcting issues that were readily observable by the OSART team. Managers' inconsistent identification and correction of some industrial safety practices and plant conditions place workers at risk to injury. Recommendation: Managers should improve identification and correction of worker adherence to industrial safety requirements, elimination of at risk behaviors and 16 MANAGEMENT, ORGANIZATION AND ADMINISTRATION

21 prompt identification and correction of industrial safety deficiencies. Other plants have successfully raised worker adherence to standards and expectations through focused alignment of management observations, coaching, training, rewards and recognition, performance management, communication, and assessments to provide continuous reinforcement of desired standards and identification and correction of deviations. IAEA Basis: NS G 2.4, Para 6.56, An Industrial Safety program should be established and implemented to ensure that all risks to personnel involved in plant activities are kept as low as reasonably achievable. INSAG , "Minimizing latent shortcomings in working practices and plant conditions is therefore vital in avoiding serious events..failure to challenge, especially by managers and supervisors, not only fails to eliminate the specific shortcoming in performance which has been observed, but also creates a culture in which failures, oversights, and shortfalls become the norm." Plant Response/Action: The plant has recognized and understood the background of the related findings and fully agrees with the recommendation. Since the review the plant has been active in the area as follows: Visibility and transparency of safety matters has been widely increased (visually and verbally) Safety management training for new managers recognized and actioned More consistent approach to pre-job briefings introduced More comprehensive accident and injury analysis established Quality metering taken in use more widely More efficient use of deficiency reporting system 17 MANAGEMENT, ORGANIZATION AND ADMINISTRATION

22 A companywide Fortum Safety Award established New Code of Conduct established in the company A new plant manager with fresh and extensive experience from UK safety practices introduced in 2008 IAEA comments: The plant was certified as part of Fortum Generation Business unit against the Occupational Health and Safety Management System (OHSAS 18001) standard in December Visibility of focus on industrial safety issues was increased through introduction of an industrial safety indicator display board in the lobby of the administrative building. An image of worker has been installed in the same location to allow eye catching indication of recent injuries and relevant safety messages. More comprehensive industrial safety events analysis was applied to injuries caused by slippery conditions in the beginning of 2008, however this improved analysis method has not been approved yet and has not been applied to analyze other recent industrial safety events. The new system of pre-job briefing is a FORTUM-wide approach and it is in trial application to decide with what changes it could be applied on a permanent basis at the plant. There is a summary safety performance indicator which includes also industrial safety data. It is being calculated and reported, however at present it does not influence the bonus system. The deficiency reports were analyzed in the middle of 2008 to see how this existing system could be used more efficiently to identify focus areas for improving performance. A plant employee has been recently awarded in the frame of the Fortum-wide Safety Award for industrial safety awareness (stopping unsafe work etc). However some industrial safety related deficiencies were observed during the plant tours: 18 MANAGEMENT, ORGANIZATION AND ADMINISTRATION

23 Unit 1 reactor building +3 m level: 5 constructor staff not wearing hard hat De-aerator room 2A1704: safety chain of the staircase not fastened Fresh fuel storage room 1A1284: 2 out of 3 loudspeakers plugged A lifting sling (LO.1130) at a work site near the spent fuel pool had a green tag while the valid tag for 2008 is orange. Conclusion: Satisfactory progress to date. 19 MANAGEMENT, ORGANIZATION AND ADMINISTRATION

24 2. TRAINING AND QUALIFICATIONS 2.1. TRAINING POLICY AND ORGANIZATION General training and qualification requirements are described by the plant quality assurance manual and quality assurance procedure. While basic qualification requirements and main elements of training system (initial training, continuous training, training records, ) are well defined there is no clear requirement in the plant quality assurance documentation to apply systematic approach to training (SAT) techniques as a tool for assuring quality of training and training material. As a consequence, structured task-based and/or competence based training needs analysis, learning objectives/ performance criteria definition, etc. have not been systematically applied when developing existing plant training programmes. The plant is aware of the problem and a pilot SAT project for a position of primary circuit field operator was included into the plant 2007 budget. However e.g. currently developed training programmes for Loviisa 1 and 2 automation renewal (LARA project) are not fully based on SAT principles. The OSART team has developed a recommendation in this area. Nuclear safety topics and ALARA principles are generally included in the standard initial training programmes. There is no specific initial training topic related to safety culture. However, safety culture topics are included in different initial and continuous training modules. Significant nuclear industry events are discussed in the training courses, but case studies and lessons learned from significant nuclear industry events like Three Mile Island or Chernobyl are not systematically included into initial training programmes. According to the plant policy, line managers are fully responsible for proper training and qualification of their subordinates. Individual training programmes (list of training topics) are agreed between the line manager, the trainee and a training department instructor based on current trainee s qualification. However this process is not well structured and does not fully meet SAT requirements. The main database for keeping personnel training records is Hermes. For specific competences and licenses, there are also other personnel training record databases e.g. Henri (General employee training (GET), special competences, etc.) or databases managed by line organizational units. Current existence of several parallel personnel records databases may not always be effective and unambiguous. The "Hermes" database software is administered at the corporate level which ensures a unified approach and software quality assurance throughout the FORTUM company. The database is well structured and there are sufficient functions for searching and screening the required information that supports effective data processing. Currently only a limited number 20 TRAINING AND QUALIFICATIONS

25 of persons from training department and human resources department have an access to this database on the plant network. This does not fully support declared responsibility of line managers for proper training and qualification of their subordinates. The plant is preparing an access to the main personnel training records database for the line managers and other plant staff members in 2007, after they have completed relevant familiarization training. Current personnel resources are not fully sufficient to meet existing training needs. Understaffing of training personnel was also mentioned as a significant risk of the Loviisa automation renewal (LARA) project in the STUK inspection report TRAINING FACILITIES, EQUIPMENT AND MATERIAL Two classrooms in the training unit building are equipped with data projectors white boards and other infrastructure. To a limited extent, the visitors center meeting room can be used for training purposes. However, the current number of classrooms is not sufficient to meet all plant training needs. There are no rooms available and adapted to effective self-study. Training materials supporting classroom training and self-study, including instructional audio/video records are available in the classrooms and on the plant intranet network. Standard training materials, e.g. general plant knowledge, nuclear engineering, reactor physics, plant components etc. are of very good technical quality with color photos, detailed drawings and diagrams which support effective lecturing and/or self-study. The OSART team considers it as a good performance. The plant took active part in a project of national training course on nuclear safety. The aim of the course is transfer of nuclear knowledge to a new generation of nuclear experts. This is especially important from perspective of in-coming change of generation at the plant. The OSART team recognized it as a good practice. Practical training of the plant personnel (maintenance, technical support personnel, I&C, electricians, radiation protection etc.) is generally performed as on-the-job training on real plant equipment. Except for some welder training and the plant full-scope simulator, there are no special training mock-ups, models and/or practical training laboratories available for systematic practical training. The OSART team developed a suggestion in this area. The LARA project modification of the simulator control room is done in timely manner, before implementing in the reference control room of Loviisa unit 1. However, simulator configuration management does not provide proper tracking of differences between the simulator and the reference unit. The OSART team developed a recommendation in simulator configuration management area. 21 TRAINING AND QUALIFICATIONS

26 Annual refresher simulator training programme is agreed with the operational department. The programme contains list of topics to be included into simulator training. However, no detailed training objectives, conditions and performance evaluation criteria are developed for such training topics. Observed performance of the control room crew while getting reactor critical on simulator did not fully comply with declared plant expectations and these expectations were not reinforced during the post simulator session critique. Formally validated and approved simulator scenarios are not generally used for the control room operator simulator training. The OSART team developed a suggestion in this area. 2.3 QUALITY OF THE TRAINING PROGRAMMES Training programmes for non-licensed personnel do not contain detailed lesson plans with reference to relevant supporting training materials. The training programmes are generally represented by a list of topics with referring operational procedures. Learning objectives / performance criteria are not specified in the existing training programmes. For continuous simulator training some topics selected based on the results of probabilistic safety analysis (PSA) are regularly included into annual training plan. Quality of in-house training programmes is not periodically evaluated by line managers and/ or training group. Quality of training provided by external instructors is evaluated by the participants by means of questionnaire feedback. Based on such evaluation, an external instructor was changed in past. Formal evaluation after completing individual initial training programmes is performed for the shift personnel (licensed control room operator, field operator). Evaluation of the unit electrician consists of written test only and does not include practical examination or plant walk-down. There is no formal evaluation after completion of initial training of non-shift personnel like maintenance personnel, technical and/or engineering personnel. Periodical evaluation/re-examination is done for the licensed control room personnel. There are also regular examinations for job positions (e.g. welders) and special qualifications (the Hot work license "blue card" and the Industrial safety license "green card" ) that are required by the law and/or regulatory authority, ("responsible plant managers", emergency preparedness engineer, nuclear material safeguards). End tests are also part of periodical general employee training. 22 TRAINING AND QUALIFICATIONS

27 2.4 TRAINING PROGRAMMES FOR CONTROL ROOM OPERATORS AND SHIFT SUPERVISORS Required minimal entry level education of control room operator candidate is a technician, for a shift supervisor position it is a technical university bachelor of science (B.Sc.) degree. Optimal control room candidate profile as defined by the plant is a young engineer with some industrial experience. Also internal plant employees with proper background can apply for control room operator position. External psychological tests and interview by operational managers are part of the recruitment procedure. This recruitment practice is in compliance with the good industry standards. Control room operator initial training process is well described in the structured process management software tool available on the plant network. Total duration of control room operator initial training is about 3.5 years. The training programme includes theoretical training, simulator training, on-the-job training and internal examination at certain points. Part of on-the-job training is working in the position of non-license shift technician. This approach provides a candidate with adequate knowledge about plant system layout and operation. The license exams consist of three stages: written exams with so called "trainee license" allowing the candidate some manipulation under licensed operator supervision, simulator practical exams and final oral exams. All three levels of the license examination are supervised by STUK. This process provides sufficiently comprehensive evaluation of the control room operator candidate s competence and is fully in compliance with international industry practice. For the shift supervisor position there is a requirement of experience at turbine operator and reactor operator positions. The shift supervisor license exams consists of simulator exams and oral exams. A holder of fresh shift supervisor license works several months under supervision of experienced shift supervisor. This process ensures proper on-the-job evaluation of the candidate performance. Control room operator and shift supervisor licenses have to be periodically renewed by simulator and oral license exams supervised by STUK. Control room operator continuous training includes so-called training days (6 days a year), refresher simulator training (8 days a year), self-study and general employee training (environment, health&safety; fire prevention, radiation protection etc.). 23 TRAINING AND QUALIFICATIONS