1. Analyzing CM-Related Condition Reports
Sonja Myers / Mike Nordin
Nuclear Management Company
Fleet Design Engineering
June 11-14, Richmond, VA

2. Analyzing CM Condition Reports
Understand What your Corrective Action Program is Indicating
Work through 2 examples to compare where the issues are in the 3-Ball Diagram
Bin the issues in both the 3-ball diagram and in your own Human Performance tools
Process improvements to place barriers to prevent recurrence of issues

3. CM Related Issues
In-Process Errors committed during preparation of Engineering Products can be subtle:
Latent Errors go undetected for years
Errors caught in reviews may not get into CRs
Limits the feedback and course correction

4. Look at the issues and bin them to the 3-Ball Diagram.
How to do this
Look at the issues and bin them to the 3-Ball Diagram.
Determine where the issue caused an unbalance
Take this information and apply your station’s Human Performance tools

5. CM Model Functions #1 Protect the Design Basis #2 Modify the Plant #3
Design Basis Configuration #2
Modify the Plant
Engineering Change Control #3
Operate the Plant
Operational Configuration Control #4
Maintain the Plant
Configuration of SSCs not in service #5
Test the Plant
Plant Design Validation 25

6. NMC Picture Of Excellence Tools
Qualified Workers
Job Planning and Preparation
Procedure/Work Instructions
Verification and Validation
Supervisor Oversight
Worker Practices

7. Protect the Design Basis
Example 1
Protect the Design Basis
Instrument Air Compressor Room Temperature
Compressor Room Temperature was limited to 100 F
Intake Air for the Compressor was limited to 85 F
Intake Air was drawn from inside the Compressor room.
Station monitored the room temperature and assured the temperature did not exceed 100F

8. Upsets in the 3-Ball Diagram
Upsets Between Design Requirements & Facility Configuration Information
What went wrong
Design characteristics and bounding parameters needed for the design to work
The design had assumed the compressor intake air came from outside air.
The intake actually came from inside the room.
The limit was selected on other parameters for the compressor.
Must be verified or monitored to confirm that design is valid
Operator rounds recorded the temperature, but had the wrong limit.

9. NMC Tools Procedure/Work Instructions Verification and Validation
Procedures at the time allowed assumptions to be made without justification for why they were valid.
Verification and Validation
Assumption was made in the analysis and not verified
Worker Practices
Preparer thought intake was from the outside and incorrectly assessed the equipment requirements
Reviewer did not identify this.

10. Operate the Plant
Objective: Assure that alignment of in-service equipment is consistent with approved design through use of approved technical procedures.

11. Operate the plant Example 2
Recurring T-mod to allow testing of Safety-Related Batteries in Modes 5 and 6
Temporary cable to allow the battery loads to be supplied by a smaller sized batteries
HELB pressure boundaries need to be maintained

12. Upsets in 3-Ball Diagram
Upsets Between Physical Configuration & Facility Configuration Information
What went wrong
HELB boundary requires a special permit and engineering review to assure analysis assumptions and technical requirements are met
Temporary procedure did not have a verification the permit was obtained

13. Procedure/Work Instructions
NMC tools
Procedure/Work Instructions
Procedures for installation did not have a step to assure the HELB boundary permit was obtained
Procedure for T-mods did not include a review of the recurring T-mod procedure to assure all critical aspects were included
Verification and Validation
T-mod assumption was that the installation procedure had the permit, engineer did not verify this was included.
Procedure verification did not identify this issue

14. Conclusions
Although many issues in CM are found a long time after the error was made, the barriers to prevent an error from entering the plant, may still be the same.
Look at the processes and where the issues entered the plant to strengthen your CM program
Focus on the tools.

15. Questions?