1. 1 RIC 2009 Reactor Oversight Process Initiatives Michael Cheok Session Chair Deputy Director Division of Inspection & Regional Support Office of Nuclear Reactor Regulation March 10, 2009

2. 2 General Session Information Badges and Identification – Please remember to visibly display name badges throughout the duration of the RIC. Cell Phones and Pagers – At this time, please turn off or silence cell phones and pagers. Presentation Materials – All provided electronic presentation materials will be posted on the U.S. NRC RIC website at www.nrc.gov, keyword: RIC. Evaluations – Please provide us with your valuable input via the Session Evaluation Form or e-mail comments directly to RICHelpDesk@nrc.gov.

3. 3 Presenters Doug Dalbey –Deputy Director, Flight Standards Service, Federal Aviation Administration Mont Smith –Director of Safety, Air Transport Association of America William Noll –Site Vice President, Three Mile Island Unit 1 Frederick Brown –Director, Division of Inspection & Regional Support, NRR

4. By: Mr. Doug Dalbey Deputy Director, Flight Standards Service Date: March 10, 2009 Federal Aviation Administration Beyond the Regulations: A look inside the safety culture of the FAA and those we regulate

5. 5 Federal Aviation Administration Nuclear Regulatory Commission Briefing March 10, 2009 5 AGENDA The Perfect StormThe Perfect Storm Mixed SignalsMixed Signals Beyond The RegulationsBeyond The Regulations IRT RecommendationsIRT Recommendations Risk Groups & IndicatorsRisk Groups & Indicators Continuous ImprovementContinuous Improvement Conclusion- “Conclusion- “The FAA’s Voluntary Disclosure Programs are vitally important to the future of aviation safety, and should be retained.”“ The FAA’s Voluntary Disclosure Programs are vitally important to the future of aviation safety, and should be retained.”

6. 6 Federal Aviation Administration Nuclear Regulatory Commission Briefing March 10, 2009 6 The Perfect Storm – April 2008 FAA’s Reality TV Show A Tale Of Two Airlines & Two Airworthiness Directives

7. 7 Federal Aviation Administration Nuclear Regulatory Commission Briefing March 10, 2009 7 Mixed Signals Media Public FAA Congress –Too cozy –Too nitpicking Dept. of Transportation White House

8. 8 Federal Aviation Administration Nuclear Regulatory Commission Briefing March 10, 2009 8 Area 4 Incorrect – No wrap on Back shell of connector and no tie tape Correct – Wrap on connector and tie tape

9. 9 Federal Aviation Administration Nuclear Regulatory Commission Briefing March 10, 2009 9 Miscellaneous Pictures Taken During FAA Follow-up Audit Chaffing

10. 10 Federal Aviation Administration Nuclear Regulatory Commission Briefing March 10, 2009 10 Beyond The Regulations “Voluntary Programs Under Fire” Voluntary Disclosure Reporting Program (VDRP) Flight Operational Quality Assurance Program (FOQA) Aviation Safety Action Program (ASAP)

11. 11 Federal Aviation Administration Nuclear Regulatory Commission Briefing March 10, 2009 11 Independent Review Team Recommendations The FAA should retain the right to ground any plane not in compliance with an applicable AD. The FAA should provide timely information about new AD requirements, in advance of compliance dates, to all relevant FAA field offices. The FAA’s Voluntary Disclosure Programs are vitally important to the future of aviation safety, and should be retained.

12. 12 Federal Aviation Administration Nuclear Regulatory Commission Briefing March 10, 2009 12 Risk Groups and Indicators

13. 13 Federal Aviation Administration Nuclear Regulatory Commission Briefing March 10, 2009 13 Continuous Improvement Air Transportation Oversight System ISO Registration AVS Overview Course Safety Issues Reporting System Partnership with Industry Lessons Learned Web Site Flight Standards Information Management System Internal Assistance Capability Aviation Safety Information Analysis and Sharing (ASIAS)Aviation Safety Information Analysis and Sharing (ASIAS)

14. 14 Federal Aviation Administration Nuclear Regulatory Commission Briefing March 10, 2009 14

15. 15 Federal Aviation Administration Nuclear Regulatory Commission Briefing March 10, 2009 15 Conclusion Strike A Balance Continually Analyze Risk Trust But Verify Listen To Your Workforce Take Swift Action When Necessary

16. 16 SMS and Aviation Safety Oversight Reactor Oversight Process Initiatives Mont J. Smith Director, Safety – Air Transport Association of America, Inc. March 10 th, 2009

17. 17 How are Unsafe Conditions Addressed? Air Carrier discovers problem not anticipated by manufacturer Air Carrier Engineering Order (EO) Air Carrier reports to FAA via SDR – Service Difficulty Report FAA Certification Offices – e.g., Seattle ACO, Engine ECOs OEM reports to ACO & develop Service Bulletin if Airworthiness issue (optional if safety “enhancement”) If unsafe condition exists, under 14 USC39 ACO initiates an Airworthiness Directive (AD) “Lead Airline Coordination Process” - ATA Spec 111 ACO issues Notice of Proposed Rulemaking Air Carrier reports to Original Equipment Manufacturer AD or, Immediate Adopted Rule Public comments to NPRM

18. 18 Why Did the April 2008 Process Go Wrong? Air Carrier and FAA Certificate Management Office did not follow AD process to the letter Non-compliance was assessed based on failure to strictly adhere to Service Bulletin instructions beyond achievement of the safety objective – “ prevent wiring bundle chafing ” Service Bulletins and some EOs did not depict variations in as-delivered wiring bundle configurations Licensed mechanics made “ on the spot ” judgments to prevent chafing FAA Inspector guidance allows determination of “ non- compliance ” in the strictest sense without judgment of safety assurance

19. 19 Compliance vs. Safety Is there a difference? Should regulatory compliance be based on explicit instructions to the lowest level of detail or should standard practices and judgment be assumed at certain levels? Can you be “ in compliance ” but still “ unsafe? ” Is it possible to assess risk (probability of occurrence vs. severity) and manage expectations accordingly? Task for operators – adopt SMS Task for regulator – ensure SMS is working!

20. 20 What are Emerging Airline Safety Initiatives? Air Carrier - Voluntary Safety Reporting Systems –Aviation Safety Action Program (ASAP) –Flight Operations Quality Assurance (FOQA) –Internal Evaluation Program –Maintenance Reliability Review Board (MRB) –Continuing Airworthiness Surveillance (CAS) –Voluntary Disclosure Reporting Program (VDRP) –Safety Management System (SMS) Regulator – Air Transportation Oversight Program (ATOS) –Safety Management System (SMS)

21. 21 Aviation Safety Information & Analysis System A collaborative Government-Industry initiative on data sharing & analysis to proactively discover safety concerns before accidents or incidents occur, leading to timely mitigation and prevention What is ASIAS … ?

22. 22 Aviation Safety Information & Analysis System Safety Reports Runway Incursion Surface Incident Operational Error / Operational Deviation Pilot Deviation Vehicle or Pedestrian Deviation National Transportation Safety Board Accident/Incident Data System Service Difficulty Reports De-Identified FOQA Data De-Identified ASAP Data Aviation Safety Reporting System En route Terminal Airport Surveillance Data Traffic Management Reroutes and Delays Airport Configuration and Operations Sector and Route Structure Procedures ATC Information Bureau of Transportation Statistics Weather / Winds Manufacturer Data Avionics Data Worldwide Accident Data Other Information

23. 23 Aviation Safety Information & Analysis System ASIAS Participants at Major US Airports

24. 24 Aviation Safety Information & Analysis System Protective Airspace Ground Proximity Warnings Oakland Airport Arrival Flight Tracks

25. 25 Aviation Safety Information & Analysis System Typical ASAP Narrative During a right base leg for a visual approach, Air Traffic Control switched us to a new runway with our concurrence. Both pilots switched to the appropriate Instrument Landing System frequency as a backup for the visual approach. The localizer signal was confirmed, but no glide slope signal was obtained. We had already started the landing configuration sequence and were configured with flaps 15 degrees and landing gear down on a normal descent path. As pilot monitoring, I was attempting to discern why the glide slope was unavailable for the pilot flying. The 1000 foot call was made with an airspeed of 150 knots. V-target was 141 knots. Shortly thereafter, at 500 feet above ground level, we received the warning “too low, flaps.” The pilot flying called for flaps 30 degrees and the Before Landing Checklist. I complied but I should have directed a go around. The landing was completed without incident, and the taxi to the gate was uneventful. In an attempt to offer support to the pilot flying, I had allowed myself to become distracted during a critical phase of flight with an unnecessary piece of approach guidance for the type of approach being flown. Proper prioritization and application of pilot monitoring duties would certainly have prevented this. Pilot monitoring is also flying, just not necessarily “hands on.” Whether pilot flying or pilot monitoring, one should aviate first and avoid/contain unnecessary distractions through correct identification and prioritization of perceived problems.

26. 26 Aviation Safety Information & Analysis System Digital Data Provides Insight about Flights: e.g., Unstable Approaches

27. 27 Safety Management Systems Operational performance Baseline performance Organization Predictive Highly efficient System Analysis Design Assessment Very efficient Proactive Surveys Audits Performance Assessment Efficient Reactive ASRS SDR Insufficient Reactive Accident and incident reports Desirable management levels High Middle Low Safety management levels “Practical drift”

28. 28 Safety Management Systems “Carelessness and overconfidence are more dangerous than deliberately accepted risk”…Wilbur Wright, 1901 Wilbur Wright gliding, 1901 Photographs: Library of Congress

29. 29 The Safety Continuum William G. Noll Site Vice President Three Mile Island And the Role of Oversight

30. 30 Three Mile Island January 15, 1979

31. 31 “The Front Fell Off”

32. 32 “The Front Fell Off” 1. Design 2. Construction Material 3. Staffing 4. Risk Assessment 5. The Environment “Tanker Safety”

33. 33 “The Front Fell Off”

34. 34 The Auto Industry In the 1970’s it was all mpg

35. 35 The Auto Industry In the 1990’s it was all about

36. 36 The Auto Industry Now it is all about being

37. 37 Our children will enjoy in their homes electrical energy too cheap to meter... Lewis L. Strauss Chairman of the U.S. Atomic Energy Commission Speech to the National Association of Science Writers September 16th, 1954 Too Cheap to Meter ?

38. 38 TMINovember1968TMINovember1968

39. 39 Adhering to the Nuclear Safety Principles in goal setting, work execution, business decisions and day- to-day activities ensures the proper focus and balance in operational execution

40. 40 Nuclear Energy Is Green

41. 41 Why Regulate the Nuclear Industry or Any Industry Public Trust and Confidence Complex Technology and Design Potential to Impact the Environment

42. 42 Public Trust and Confidence

43. 43 Why Regulate the Nuclear Industry or Any Industry Public Trust and Confidence Complex Technology and Design Potential to Impact the Environment

44. 44 Complex Technology and Design

45. 45 Why Regulate the Nuclear Industry or Any Industry Public Trust and Confidence Complex Technology and Design Potential to Impact the Environment

46. 46 Environmental Stewardship A requirement for Nuclear Operations

47. 47 Safety Culture Principle # 5 Nuclear technology is recognized as special and unique.

48. 48 Safety Culture Principle # 8 Nuclear Safety Undergoes Constant Examination

49. 49 CORNERSTONE CHART PUBLIC HEALTH & SAFETY AS A RESULT OF CIVILIAN NUCLEAR REACTOR OPERATION NRC’s Overall Safety Mission Strategic Performance Areas Reactor SafetyRadiation SafetySafeguards INITIATING EVENTS MITIGATION SYSTEMS BARRIER INTEGRITY EMERGENCY PREPAREDNESS Crosscutting Areas HUMAN PERFORMANCE SAFETY CONSCIOUS WORK ENVIRONMENT PROBLEM IDENTIFICATION AND RESOLUTION PHYSICAL PROTECTION OCCUPATIONALPUBLIC Self Policing Identifying Problems Behaviors

50. 50

51. 51 The Applicability of Air Safety Lessons-Learned to NRC Programs March 10, 2009 Fred Brown, Director Division of Inspection & Regional Support Office of Nuclear Reactor Regulation (NRR)

52. 52 Regulatory Environment Relative Risk Perceptions Performance Feedback Loop Effect of Public Opinion

53. 53 Licensee’s Programs vs Independent Verification Baseline and Appendix C Inspections Temporary Instructions Role and Influence of the Residents

54. 54 Minimum Standards and Beyond Design Approval and Maintenance ROP – Inspection Findings vs Performance Indicators INPO’s Excellence Standards

55. 55 Safety Management Systems Operational performance Baseline performance Organization Predictive Highly efficient System Analysis Design Assessment Very efficient Proactive Surveys Audits Performance Assessment Efficient Reactive ASRS SDR Insufficient Reactive Accident and incident reports Desirable management levels High Middle Low Safety management levels “Practical drift”

56. 56 Applied Insights Clear Standards, Rigorously Enforced Lowest Common Denominator The “Garrison Keillor” Conundrum

57. 57 Federal Aviation Administration Nuclear Regulatory Commission Briefing March 10, 2009 57 Risk Groups and Indicators

58. 58 Applied Insights Clear Standards, Rigorously Enforced Lowest Common Denominator The “Garrison Keillor” Conundrum

59. 59 Question & Answer Period