Report of the operational safety review team mission to the Forsmark ...

NSNI/OSART/08/145
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REPORT
of the
OPERATIONAL SAFETY REVIEW TEAM
(OSART)
MISSION
TO THE
FORSMARK
NUCLEAR POWER PLANT
SWEDEN
12 - 28 February 2008
DIVISION OF NUCLEAR INSTALLATION SAFETY
OPERATIONAL SAFETY REVIEW MISSION
IAEA-NSNI/OSART/08/145

PREAMBLE
This report presents the results of the IAEA Operational Safety Review Team (OSART) review
of the Forsmark Nuclear Power Plant, Sweden. It includes recommendations for improvements
affecting operational safety for consideration by the responsible Swedish authorities and
identifies good practices for consideration by other nuclear power plants. Each
recommendation, suggestion, and good practice is identified by a unique number to facilitate
communication and tracking.
Any use of or reference to this report that may be made by the competent Swedish organizations
is solely their responsibility.

FOREWORD
by the
Director General
The IAEA Operational Safety Review Team (OSART) programme assists Member States to
enhance safe operation of nuclear power plants. Although good design, manufacture and
construction are prerequisites, safety also depends on the ability of operating personnel and
their conscientiousness in discharging their responsibilities. Through the OSART programme,
the IAEA facilitates the exchange of knowledge and experience between team members who
are drawn from different Member States, and plant personnel. It is intended that such advice
and assistance should be used to enhance nuclear safety in all countries that operate nuclear
power plants.
An OSART mission, carried out only at the request of the relevant Member State, is directed
towards a review of items essential to operational safety. The mission can be tailored to the
particular needs of a plant. A full scope review would cover eight operational areas:
management, organization and administration; training and qualification; operations;
maintenance; technical support; radiation protection; chemistry; and emergency planning and
preparedness. Depending on individual needs, the OSART review can be directed to a few areas
of special interest or cover the full range of review topics.
Essential features of the work of the OSART team members and their plant counterparts are the
comparison of a plant's operational practices with best international practices and the joint
search for ways in which operational safety can be enhanced. The IAEA Safety Series
documents, including the Safety Standards and the Basic Safety Standards for Radiation
Protection, and the expertise of the OSART team members form the bases for the evaluation.
The OSART methods involve not only the examination of documents and the interviewing of
staff but also reviewing the quality of performance. It is recognized that different approaches are
available to an operating organization for achieving its safety objectives. Proposals for further
enhancement of operational safety may reflect good practices observed at other nuclear power
plants.
An important aspect of the OSART review is the identification of areas that should be improved
and the formulation of corresponding proposals. In developing its view, the OSART team
discusses its findings with the operating organization and considers additional comments made
by plant counterparts. Implementation of any recommendations or suggestions, after
consideration by the operating organization and adaptation to particular conditions, is entirely
discretionary.
An OSART mission is not a regulatory inspection to determine compliance with national safety
requirements nor is it a substitute for an exhaustive assessment of a plant's overall safety status,
a requirement normally placed on the respective power plant or utility by the regulatory body.
Each review starts with the expectation that the plant meets the safety requirements of the
country concerned. An OSART mission attempts neither to evaluate the overall safety of the
plant nor to rank its safety performance against that of other plants’ reviewed. The review
represents a `snapshot in time'; at any time after the completion of the mission care must be
exercised when considering the conclusions drawn since programmes at nuclear power plants
are constantly evolving and being enhanced. To infer judgments that were not intended would
be a misinterpretation of this report.

The report that follows presents the conclusions of the OSART review, including good practices
and proposals for enhanced operational safety, for consideration by the Member State and its
competent authorities.

CONTENT
INTRODUCTION AND MAIN CONCLUSIONS ...................................................................1
1. MANAGEMENT, ORGANIZATION AND ADMINISTRATION..................................4
2. TRAINING AND QUALIFICATIONS...........................................................................17
3. OPERATIONS.................................................................................................................27
4. MAINTENANCE ............................................................................................................39
5. TECHNICAL SUPPORT ................................................................................................49
6. OPERATING EXPERIENCE..........................................................................................57
7. RADIATION PROTECTION..........................................................................................79
8. CHEMISTRY ..................................................................................................................89
9. EMERGENCY PLANNING AND PREPAREDNESS ................................................103
DEFINITIONS.......................................................................................................................111
LIST OF IAEA REFERENCES (BASIS)..............................................................................113
ACKNOWLEDGEMENT .....................................................................................................116
TEAM COMPOSITION OSART MISSION.........................................................................117

INTRODUCTION AND MAIN CONCLUSIONS
INTRODUCTION
At the request of the Government of Sweden, an IAEA Operational Safety Review Team
(OSART) of international experts visited the site of the Forsmark Nuclear Power Plant and
concentrated its review on unit one from 12 February to 28 February 2008. Forsmark NPP
unit one is a part of the Forsmark site which hosts all together 3 units with a total gross
capacity of 3254MWe. The NPP is part of the Vattenfall Group and the site is situated on
the east coast of Sweden, approximately 140 Kilometers north of Stockholm.
Vattenfall AB is the majority stakeholder with 66% of the shares, making Forsmarks
Kraftgrupp AB (FKA) a subsidiary of Vattenfall AB. In addition, Mellansvensk
Kraftgrupp owns 25.5% and E.on Karnkraft owns 8.5%.
The purpose of the mission was to review operating practices in the areas of management
organization and administration; training and qualifications; operations; maintenance;
technical support (engineering); operating experience feedback including evaluation of the
25 July 2006 event; 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 Forsmark OSART mission was the 145 th in the programme, which began in 1982.
The team for Forsmark unit one OSART was composed of experts from Canada; Czech
Republic; Finland; France; Germany; Japan; Russian Federation; Slovakia; Switzerland;
United Kingdom, and the USA, together with the IAEA staff members and two observers
from Sweden and one observer from Slovakia. The collective nuclear power experience of
the team was approximately 390 years, including the observers.
Before visiting Forsmark unit one, the team studied information provided by the IAEA and
the Forsmark 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 performance of the plant compared
with IAEA Safety Standards and good international practices.
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INTRODUCTION AND MAIN CONCLUSIONS

MAIN CONCLUSIONS
The OSART team concluded that the managers and staff of Forsmark NPP are committed
to improving the operational safety and reliability of their plant. This was clearly
demonstrated by the fact that since the OSART preparatory meeting and seminar in June
2007, the plant has introduced or extended several programmes contributing to improved
operational safety. During this process, the plant has extensively used the OSART
methodology for self assessment and the IAEA Safety Standards to benchmark their
existing practices and to identify gaps and useful improvements. The team recognized that
Forsmark management and staff are dedicated and knowledgeable, with a very
professional attitude. The plant is benefiting from an excellent work environment with
open and interested staff. The management recently implemented several good
programmes and initiatives to further enhance operational safety including an operating
experience process and indicators to help drive improvements.
The team found good areas of performance, including the following:
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Very well structured management manual which supports communication of
management expectations and commitments.
To use the training simulator to describe complex events and to demonstrate the
work methods in the control room, following a disturbance, to the media and other
key groups.
Computerized monitoring of safety functions and operating status checks
Effective management of fire cells in order to prevent the spread of any fire and
associated fumes.
The TIGER procedure ensures that the Human-Machine-Interface design is
incorporated in modernization projects in an appropriate manner.
MATSTAB (a full 3-dimensional neutron model in combination with a thermal
hydraulic model) can provide information on core design for stability prediction
and stability optimization.
Structured cooperation with the original equipment manufacturer Westinghouse
Electric Sweden for operating experience dissemination for the improvement of
safety.
In the Chemistry area, the plant has optimized the oxygen content in the drain of
the pre-heaters by changing the ventilation from the pre-heaters to the condenser
together with installation of a bypass flow through some pre-heaters. In addition,
the plant has optimized the sulphate content in the coolant after the power upgrade.
A number of proposals for improvements in operational safety were offered by the team.
The most significant proposals include the following:
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The plant should review responsibilities for the operating staff, considering both
the individual unit and the combined site, to determine if transients or abnormal
conditions can be properly managed during both design basis and beyond design
basis events. In addition there should be always one person on site capable of
declaring an emergency and notifying the off-site authorities.
The organisation should implement an independent high level safety review with
responsibility to maintain safety accountability external to the operating
organization.
The plant should perform an analysis and, based on the result of the analysis, define
the size of the minimum shift staff complement taking into account abnormal
operation scenarios involving fire and accident conditions.
The plant should rigorously apply the control and review process of operational

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documentation, emergency preparedness procedures and operators aids.
The plant should establish and implement the appropriate control of fire loads
especially in the areas containing the safety systems.
The plant event reporting criteria should be clearly communicated to all staff and
contractors to ensure adequate reporting levels.
In the Operating Experience area, the plant should organize and implement a
system for regular training and retraining of personnel involved in event root cause
analysis and the Operating Experience Feedback process. It should provide clearly
defined criteria for reporting of events which are less significant than events to be
reported to the regulatory authority. Also the plant should develop and implement a
procedure for screening Operating Experience information.
The plant should improve the organization and work practices to cover all aspects
in order to limit the exposure of workers and the spread of any contamination.
In the Chemistry area, the plant should implement clear chemistry management
expectations for the chemistry department and implement appropriate chemistry
specifications.
The plant should create an emergency level “Alarm” that would apply to Unit
disturbances that trigger protective actions for Unit personnel.
Regarding the event on 25 July 2006:
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At the time of the event, there was a lack of an integrated operational experience
feedback programme and Corrective Action Programme at Forsmark. This was
coupled with the weak use of a systematic analysis methodology. While technical
issues were investigated in-depth utilising the expertise of experienced and
knowledgeable staff, underlying organisational issues took longer to recognise and
were latterly requested by the regulatory authority.
The event was communicated to international organizations in an open and timely
manner.
The corrective actions from the plant investigation and those required by the
regulatory authority were satisfactorily addressed.
Forsmark unit one NPP 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.

1. MANAGEMENT, ORGANIZATION AND ADMINISTRATION
1.1 ORGANIZATION AND ADMINISTRATION
Forsmark is a three unit power plant of Boiling Water Reactors. The original design was
ASEA, now supported by Westinghouse. The Forsmark organization functions as an
independent corporate organization with multiple owners. Majority ownership is held by
the Vattenfall corporation.
Units 1 and 2 are sister designs; however design fidelity has not been totally maintained
as each unit acted independently for many years. The organizational structure was
recently changed to place a single unit manager over both units. Efforts are underway to
standardize both the best practices and best design elements with the desire to improve
both units.
Unit 3 was commissioned in 1985, approximately five years after unit 1 and 2, and is a
newer design. This unit has a single operational organization overseen by a single unit
manager.
Support functions for all the units is provided by common maintenance and technical
services organizations. The organizational structure is clearly defined in the management
manual and well publicized.
The Final Safety Analysis Report (FSAR or SAR) is well maintained.
Organisational charts are provided in the Quality and Management handbook (LOK).
Support functions are included and well defined. Corporate reporting is shown on a
separate organizational chart.
Creation of a new Corporate Nuclear Group is in progress. While the functions of this
new group are not well defined, reporting assignments are known. Opportunities on how
best to use this group can be gained from benchmarking.
Some responsibilities and authority of chartered committees are well defined; however,
new committees are being formed and remain under development.
Staffing and resources are adequate; however, the organization is experiencing some
stress created by organizational improvement initiatives and major projects. As
indicated by safety culture surveys, the employees are concerned about resources and
have been since 2001. More discussion on this topic will be provided in subsequent
sections of this report.
A cautious approach is being used for the creation of a new Vattenfall corporate
oversight group to ensure site functions remain consistent with the overall responsibility
for safety. The plant has very defined lines of responsibility. This division of
responsibility is well understood.
The Shift Supervisors have the authority to take actions deemed necessary with the plant,
but are not responsible for emergency plan implementation. Call-out situations are
directed by the duty engineer when contacted by the applicable shift supervisor. Shift
supervisors direct control board and field activities from their station in the control room.
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MANAGEMENT, ORGANIZATION AND ADMINISTRATION

No plant personnel are on-site, at all times, with responsibility for oversight of a unit or
the entire site until the duty engineer arrives, following notification. The team made a
recommendation in this area.
Backlog activities were checked in various organizations and meetings. These activities
appear to be both understood and managed without impacting plant safety. The plant
continues to experience a low attrition rate each year and has increased staffing since
2003 by 16%. Staffing increases are expected to continue by an additional 11% until
2010. Site average age is currently 46 years of age with normal retirement occurring at
65. Loss of corporate knowledge is not a significant threat in the near or medium term.
A significant percentage of all promotions occur from internal candidates. Increasing the
number of external experienced recruits would benefit the organization with new ideas
and proven methods from previous experiences.
Temporary supervisors are used during high activity periods. When necessary, the plant
evaluates a candidate to perform these duties to determine if minimum requirements are
satisfied. Consideration of a more specific qualification process for temporary
replacements would better serve the plant while ensuring that all activities are performed
safely.
The plant has a fitness for duty programme to ensure all employees are capable of
performing their duties error free. The team has recognized a good performance in this
area.
As previously noted, no Vattenfall corporate nuclear operating organization exists at this
time. More Corporate Nuclear oversight is planned; however these plans are only in the
early development stages. A new position of Chief Nuclear Officer (CNO) has been
created. The CNO reports directly to the managing director of Vattenfall. In addition, a
new group has been formed within the Vattenfall production unit that will have nuclear
safety competence. The new group will assist the plants and the management on the
corporate level.
External challenge of the plants organization is an important element of avoiding
complacency. While an onsite safety committee review is currently in-place, an
additional high level committee is planned. However, current plans do not include use of
independent expertise which should be considered. A recommendation was made by the
team in this area.
Staff services are defined and clearly shown on the associated organizational charts.
Control structures are in place to ensure that contractors and staff services activities are
performed safely.
The Swedish Nuclear Power Inspectorate (SKI) and Swedish Radiation Protection
Institute (SSI) both have a frequent presence on site, but do not appear to intervene
directly in the management of safety which is in accordance with national practice.
The threshold for reporting events is high. A Corrective Action Programme (CAP) is
under development for full implementation later in 2008. As this programme develops,
it will be important for the plant to lower the reporting threshold to allow a more focused
examination of event precursors and worker behaviours. These efforts will permit
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MANAGEMENT, ORGANIZATION AND ADMINISTRATION

problem correction at low levels before events occur.
Significant public scrutiny has recently been experienced. The organization’s intent to
operate safely appears to have been reinforced with public statements from both
Forsmark and Vattenfall on a number of occasions. A Municipal Safety Information
Council is in place to improve communication with local officials and the public.
Meetings with the council are held every second month to communicate recent
developments. This forum provides plant management and the Swedish Nuclear Power
Inspectorate with a method to communicate safety and environmental issues.
Communication with local officials has helped establish strong acceptance and trust with
the public. The team recognised a good performance in this area.
The Plant Safety Committee is a chartered group tasked with reviewing and discussing
significant safety issues. It is chaired by the President with membership by the senior
management team.
Historically the plant appears to have had little trending of performance with only a
limited number of management goals focused on safety. Following a recent benchmark
effort, the plant has identified an additional 21 parameters to trend and monitor plant
performance. These indicators are being run on a trial basis but have not yet been widely
published. Action plans are provided in cases where goals are being exceeded; however,
the urgency being applied is questionable and needs more follow-up. The plant’s intent is
to use the Quality Indicators to help identify important safety issues. The team has made
a suggestion in this area.
Weekly meetings are conducted with the President, reviewing performance over the
previous week. These meetings do not provide senior management with an in-depth
view of the organization’s or equipment performance. As the corrective action
programme develops, opportunities will be available for management to monitor
behavioural level performance more closely. The plant is encouraged to continue this
objective as a focus and drive for full implementation of the CAP as quickly as possible.
The plant’s policy for managing change is focused towards organizational changes. A
change management policy governing lower level types of changes could help improve
the organizations ability to manage even relatively small changes. This improvement
also provides tools for managers and organizations implementing change to ensure all
appropriate actions are considered.
1.2 MANAGEMENT ACTIVITIES
The President’s policies, goals and objectives are clearly communicated down to the unit
managers. Expectations are then developed using the grandfather principle for each level
of the organization below the unit managers. The grandfather principle ensures
management at least one level of responsibility higher in the organization is involved as
expectations are developed through the organization.
Unit managers then respond with letters detailing how they will comply, forming a
contract between them and the President. However, the team identified that some goals
are not well understood by all employees.
The Safety and Environment Unit (FQ) is tasked with checking progress in this area. In
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MANAGEMENT, ORGANIZATION AND ADMINISTRATION

addition, weekly performance review meetings between line organizations and the
President are held to monitor performance and implementation of expectations.
A system is established and implemented to recognize and appreciate the contribution of
individuals or groups in the achievement of established goals and objectives. Specific
follow-up is provided during annual performance appraisals with individual contributors.
Several communication channels exist between management, including the President,
and employees. Scheduled meetings, intranet forums, employee surveys and published
articles are all used as methods of communication. The intranet reporting method was
developed to allow both questions and identification of anonymous concerns. The team
has recognized a good performance in this area.
A business plan does exist and contains actions that the plant has agreed to address. The
plant hierarchy of priorities is defined. However, an element of resource allocation
remains a topic. Employee survey results indicate that employees believe there is a
resource allocation concern that needs to be addressed. Additionally, there is a high
tolerance of late actions and open issues for the plant. For example, procedure reviews
are required biannually and several examples of procedures, not in compliance, are
known to exist. While plant staffing has increased, a gap between employee perceptions
about safety culture and recent hiring practices are inconsistent with management
initiatives being pursued. Plant management is encouraged to take more action to
understand why employees voice this concern and to ensure actions being taken are well
communicated. Adequate resources are available to support training.
Multiple systems are used to track commitments and corrective actions. The plant is
developing a more integrated, but still graded approach, but it is not fully implemented at
this time. Implementation of a common action tracking system would improve the
organizations ability to monitor actions and eliminate fragmentation that can lead to
performance concerns.
Organizational implementation of initiatives and tracking to goals is part of the agenda
for weekly review meetings between line organizations and the Senior Management
team. The Safety and Environment department is also tasked with checking compliance.
As previously noted, quality indicators are being developed. While this will provide an
improvement in monitoring capability, it will not provide a concise overview of plant
performance. When combined with the safety index, a better assessment is possible at
the management level, but not at the working level. The safety index is not well
understood by all employees. The team has made a suggestion in this area.
The quality indicators are updated three times per year which may not be frequent
enough to provide early indications of degrading performance. Action plans to correct
deficient performance are not always pursued urgently which may leave the plant staff
with the perception that the management is tolerant or satisfied with existing
performance.
The “no-blame culture” objective is thoroughly engrained and is benefiting safety
culture; however, it has eroded accountability. As discussed in other areas, more
oversight from senior management could help ensure accountability for performance is
maintained.
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No formal programme for human performance is currently in use at the plant. However,
many elements of a focus on human performance are visible. Human factors are
considered during plant modifications and the STAR process is widely used. Continued
focus in this area might warrant expansion of the various human performance tools, plus
education of how to identify human performance traps to benefit plant performance.
Work hours are controlled and limited to minimize the potential for fatigue. SKI is also
forceful in limiting work hour effects on the working environment of individuals.
Facilities are clean and organized. Work environments are good.
During backshift or off-hour operation, no formal process for assessing personnel
performance currently exists. Industry experience indicates such a programme is
important and the plant is encouraged to review this practice to determine how
management can be more aware of how activities are conducted when management is
not present.
Fault indications are being entered into databases to provide further input to the
Probabilistic Safety Analysis (PSA). The PSA is also used to determine the significance
of plant safety issues when a Licence Event Report (LER) is warranted or when
determined appropriate by the unit manager.
Periodic safety reviews are routinely conducted to verify assumptions in the PSA are
consistent with actual plant performance. Equipment failure information is updated for
the plant and provided to the other Nordic Plants for their use in PSA.
However, PSA is not used for proactive reviews. As discussed, it is used reactively,
looking back in history. Use of the PSA in a more live time manner as a management
tool could enhance decision making. The plant states that compliance with Technical
Specifications is adequate. Continued use of existing deterministic reviews, combined
with more use of the probabilistic tools would provide an even higher level of confidence
that activities will not degrade safety. The plant is encouraged to consider the proactive
use of PSA to complete a more thorough evaluation of plant activities.
In addition to an extensive regulatory body driven safety modernisation program, a
company reactor safety programme is utilised to address both technical and
organisational action items. This is recognised by the team as a good performance.
1.3 MANAGEMENT OF SAFETY
The plant has a high level safety policy visible via a number of documents and it is well
accepted by the plant staff. Goals and objective are published in a management manual.
All eleven organizational units give their replies on how they meet the quality
requirements stipulated. The replies are given on a free format, where applicable
instructions, procedures, etc., are referenced in order to facilitate providing more detailed
information when required. Each reply must respond to all requirements placed on the
organizational unit and the reply is used in internal audits to ensure that all
responsibilities are taken care of. Internal audits are performed to ensure field
observations are consistent with the commitments made. Overall personal commitment,
at least within the management chain, is improved by this structured approach. The team
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ecognized a good performance in this area.
The plant establishes goals based on improvements from the past and has made
indicators consistent with WANO indicators. Vattenfall has reinforced their
expectations of a strong nuclear safety policy. Vattenfall endorses and supports
employee health improvements.
The quality assurance organization is relied upon to ensure each organization at the plant
is complying with their commitments to the management manual. Other reviews and
audits are routinely performed; however, they are primarily focused on compliance with
little emphasis towards performance or sustainability. Industry peers and external
experts are not frequently used. To prevent stagnation of the organizations improvement
initiatives, further development in this area is encouraged.
The plant workers have historically been insulated from external organizations. While
some limited benchmarking has recently occurred, future plans are not well documented.
The sites involvement in owners’ group activities is good, so future initiatives with
benchmarking are encouraged to focus towards improvements in less technical areas,
such as processes, human and organizational performance.
The plant may not always be aware of activities occurring in the switchyard. Without
this awareness, nuclear safety implications for the activity or timing of the activity can
not be evaluated by the plant. Interface between the plant and Svenska Kraftnät
(Switchyard Operator) should be controlled, consistent with industry operating
experience, should be based on pre-established protocols. The team made a suggestion
in this area.
Root cause analysis techniques have been infrequently used in the past. While more are
being performed in 2008, more management attention will improve the plants ability to
prevent recurrence of undesired conditions and behaviours. Root cause analysis for a
foreign material exclusion (FME) performance deficiency was determined to be
necessary in December 2007 with a scheduled completion by April 2008. Delay in
performing the analysis does not promote timely feedback or correction. While a
number of process improvements have been implemented, the plant continues to have
problems with control of FME.
The plant safety committee reviews corrective actions in some important areas like
Significant Operating Experience Reports (SOER’s). A comprehensive CAP will also
improve performance in this area. The plant, consistent with the SKI regulations, has
embarked on a number of plant modernization programs. The team has recognized a
good performance in this area.
During the review period, the team captured what they believe to be those characteristics,
practices and attitudes that indicate the level of safety culture at the plant. To assist with
the ongoing management efforts regarding safety culture at the plant, the team identified
some facts which are related to safety culture.
With respect to the positive aspects of safety culture, the team determined that the plant
staff were very open in their discussions with the team. This openness was evident in all
areas and is conducive to a good management/workforce relationship as well as their
willingness to improve. A high degree of professionalism was also apparent within the
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shift staff along with a prudent and interrogative attitude.
The staff expressed a high degree of satisfaction with the managerial approach adopted at
the plant. Teamwork was considered to be very good with many opportunities for
interactions between the staff and management.
There were also some comments made with respect to the less positive aspects of safety
culture which were observed by the team during the review. It was felt that there was an
underlying belief that experience and length of service took precedence over a more
formalized work ethic at the plant. Although experience is considered a vital component
of work within the nuclear industry, it is encouraged to be complemented by the
appropriate documentation and work practices.
Gaining associated international experience is vital in the continuing development of a
company and its staff. It was considered that more staff exposure to international forums
would be beneficial to the plant. This would then allow additional benchmarking to take
place and ensure that the plant is kept up-to-date with international practices and
developments.
It was observed that, in a number of instances, there is no clear comprehension regarding
what safety culture means to the workforce. Nuclear safety is the responsibility of all
plant staff and this message is encouraged to be reinforced at every opportunity. Many
safety culture initiatives and seminars have already taken place but these need to be
supported in the workplace by continual managerial repetition and publications.
Performance indicators are an industry norm to inform the workforce and management
on how well they are achieving their objectives. Nuclear safety indicators are available
at the plant but they are sometimes unnecessarily complicated – simple indicators are an
ideal way of relaying safety information to the staff and can give them an indication on
how to improve with respect to safety culture. The plant is encouraged to make the
indicators easily retrievable on the intranet and widely publicized on the plant.
1.4 QUALITY ASSURANCE PROGRAMME
The plant has a high reliance on the independence provided by the Safety and
Environment Unit. This approach does assure an independent view of technical issues,
but does not appear to provide external input to challenge the organization to ever
improving standards. The quality assurance (QA) group is a small organization within
the Safety and Environment Unit, consisting of a manager and two plant employees.
Since these individuals are not currently qualified to perform their responsibilities
independently, the group is supplemented with a full time long-term consultant and a
part-time long-term consultant. The organizations commitment to quality assurance is
improved with the assignment of staff; however, the impression created could allow the
conclusion that quality assurance activities are not considered important by the
organization.
An audit programme is established and the Quality Assurance Manager holds the
organization accountable to complete actions by agreed due dates. The plant can rely on
QA involvement for compliance oversight. However, opportunities to use the QA
organization for performance based insights are missed.
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1.5 INDUSTRIAL SAFETY PROGRAMME
Industrial safety is structured with a focus on employee health improvement and
compliance with industrial safety rules. Regular meetings are conducted to keep senior
management informed and to maintain a good relationship with the industrial safety
trade union delegates. These delegates have a number of responsibilities including
monitoring for adherence with safety rules during field activities. There are currently 28
delegates, one of which fills the role of senior delegate. The senior delegate coordinates
the oversight of the other delegates and acts as the primary interface with management.
This individual is also very involved with providing the plant with information shared
with other Swedish Nuclear Plants and the trade unions.
Management support for correcting identified safety concerns is improving. Safety
delegates believe their concerns consistently get management support and are confident
in their ability to stop work when conditions warrant. Middle management is held
accountable to correct concerns.
1.6 DOCUMENT AND RECORDS MANAGEMENT
Records retention is consistent with the regulations and well organized. Procedure
controls are in place and compliance with the requirements is not a concern. Record
vaults are organized and tidy with no concern identified. The Safety Analysis Report is
maintained as a living document with significant recent focus to ensure accuracy.
Some issues were noted by the team with the control of operator aids and controlled
document maintenance in the field. More discussion is provided in the Operations
section of this report. In addition, a structured approach for end-users to validate use of
the most recent revision is not well controlled. Benchmarking of how other nuclear
organizations deal with this situation could help eliminate the potential for future
problems in this area.
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DETAILED MANAGEMENT, ORGANIZATION AND ADMINISTRATION FINDINGS
1.1 ORGANIZATION AND ADMINISTRATION
1.1(1) Issue: No off hours on-site supervisory position is present to determine if transients
or abnormal conditions are properly managed considering both design basis and
beyond design basis events and to declare an emergency.
Shift supervisors are responsible for direct response of the operating crew when
abnormal conditions exist at Forsmark. Each operating unit is staffed with one
supervisor on the operating crew. His primary responsibility is to implement the
emergency operating procedures. This staffing arrangement does not leave adequate
supervisory presence to provide oversight. In addition;
• Emergency plan implementation or consideration for conditions affecting
multiple units can distract the shift supervisor from this primary command and
control function without the assistance of a unit supervisor to direct crew
activities.
• The shift supervisor is responsible for addressing issues on a unit and to make
contact with the duty engineer, who may not be on-site. Implementation of the
emergency plan is not in the scope of authority of the shift supervisor.
• The FSAR Chapter 2 clearly defines the shift supervisor as not in the operational
management.
• The process for declaring an emergency and notifying off-site authorities may
result in unnecessary delays in the implementation of protective actions.
Failure by an operating crew to identify parameters that are not expected to be affected
by the event or the transient operational state could be neglected. Failure to declare an
emergency in a timely manner could result in unnecessary overexposure following an
accident.
Recommendation: The plant should review responsibilities for the operating staff,
considering both the individual unit and the combined site, to determine if transients
or abnormal conditions can be properly managed during both design basis and beyond
design basis events. In addition there should be always one person on site capable of
declaring an emergency and notifying the off-site authorities.
Basis: GS-R-2; 4.23: “Each facility or practice in threat category I, II, III or IV shall
have a person on the site at all times with the authority and responsibilities: to classify
a nuclear or radiological emergency and upon classification promptly and without
consultation to initiate an appropriate on-site response; to notify the appropriate offsite
notification point (see para. 4.22); and to provide sufficient information for an
effective off-site response. This person shall be provided with a suitable means of
alerting on-site response personnel and notifying the off-site notification point.”
NS-R-2; 2.32: “The operating organization shall establish the necessary organizational
structure and shall assign responsibilities for managing emergencies. This shall
include arrangements for: prompt recognition of emergencies; timely notification and
alerting of response personnel; and provision of the necessary information to the
authorities, including timely notification and subsequent provision of information as
required.”
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GS-G-2.1; Appendix VI – Response Time Objectives, Threat Category I, Facility
Level: “Identifying, notifying and activation (the objective is timed from the time at
which conditions indicating that emergency conditions are detected): Classify the
emergency: < 15 min, Notify local authorities (PAZ and UPZ) after classification: <
30 min.”
Basis: NS-G-2.14 sec 3.1. “The shift supervisor should manage plant operations on
each shift and should be responsible for the overall safety at the plant, protection and
safety of personnel, coordination of plant activities ad performance for the assigned
shift. The responsibilities typically should include supervision of the shift personnel
and direct control of plant operations in accordance with the operational limits and
conditions and operating procedures. In addition, the responsibilities of the shift
supervisor should normally include the following:
• During off-hours, to assume the authority of the plant manager. The shift
supervisor should be given the authority to resolve any problem that may affect the
safe operation of the plant.”
NS-G-2.14 sec 3.2. “In multi-unit power plants, where one shift supervisor may be
responsible for all units, other persons, designated as unit supervisors, should be made
responsible to the shift supervisor for the operation of each unit.
1.1(2) Issue: While internal safety committees provide a high level of confidence in the safe
operation of the plant, no independent safety review is provided by a periodic external
review.
Information relative to this issue includes:
• A Vattenfall corporate nuclear operating organization is currently being formed
with the objective of providing independent review of plant safety. However, this
organization is being developed and is not assisting with this function today.
• A high level independent safety review committee is planned but is in the early
stages of development. No external membership is currently known to exist on
this committee.
• An on-site safety review committee does exist and functions to oversee plant
safety; however, this committee consists of many senior managers assigned to the
site with no external membership.
Without a formal and fully implemented process to ensure safety accountability is
supported by arrangements that are independent of the pressures of plant operation,
operational pressures can limit senior managements ability to detect early indications
of performance degradation.
Recommendation: The organisation should implement an independent high level
safety review with responsibility to maintain safety accountability external to the
operating organization membership.
Basis: NS-G-2.4 sec 5.18. “The operating organization should provide a means for
independent safety review. The key to this process is the establishment of an
objective internal self-evaluation programme supported by periodic external reviews
conducted by experienced industry peers using well established and proven processes.
The principal objective is to ensure that, in those matters that are important to safety,
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MANAGEMENT, ORGANIZATION AND ADMINISTRATION

safety accountability is supported by arrangements that are independent of the
pressures of plant operation. The safety review should be independent of plant
operation, and should be conducted on a continuing basis to verify that plant
management establishes verified and authorized practices and implements changes as
required. The reports resulting from this activity should be formal and should be
provided directly to the top management of the operating organization. Particular
attention should be paid to the feedback from experience.”
1.1(3) Issue: Only a limited number of management goals are focused on operational safety
performance. Monitoring methods can also be improved to ensure the plant is aware
of progress towards meeting established goals.
The monitoring and reporting on the performance of process’s can be improved with
implementation of the Quality Indicators currently being developed as trial measures.
The plant has started work to provide indicators as a tool to help drive improvement;
however, the team found the following facts during review.
• Following a benchmarking effort, the plant identified 21 parameters to trend and
monitor plant performance. While several of these indicators have been
developed on a trial basis, the full implementation is not scheduled until May.
• Based on the trial development of these Quality Indicators, several undesired
performance areas were identified. In December 2007, it was determined
appropriate to perform a root cause in one area. This root cause analysis is not
scheduled to complete until April of 2008 due to other priorities.
• The 21 quality indicators were created in October, published in November with
the next update scheduled in May. Currently, 5 have no data, 2 are green, 4
yellow and 11 are red. The thought process was to make them challenging. These
are very new and are a good idea; however, updates only 3 times per year may not
drive the improvements desired. Some specific data from individual indicators is
provided:
o Fuel leaks at Forsmark are most frequently caused by debris fretting. This
combined with the results of the FME quality indicator where 25% of all
FME inspections discover foreign material indicates problems with FME
continue to exist.
o Each unit as a large number of temporary modifications, some approaching
five years in age. The December indicator shows approximately 110. This
is a current focus area for the plant and progress has been made in recent
months.
o 60% of maintenance procedures did not satisfy the requirement to review
every 2 years.
Goals and strategic targets set for the operating crews have just two of nine focused on
operational safety issues. The remainder are more focused on business oriented
objectives. The team observed the following facts during the review:
• One of the operational safety focused goals is to avoid INES 2 and higher events,
which is not a challenging goal.
• A second one is to reach safety index higher than 3, however, plant personnel are
not sufficiently familiar with the safety index to understand how their actions can
influence the goal.
• Operational staff during interviews referred mainly to the general plant vision to
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safely operate the plant and to safety as an overriding priority. They were rarely
aware of any specific goals.
Untimely monitoring and a delayed response to process indicators can lead to
degradation of plant performance. A full understanding of the entire work force of
how they can help the station achieve safety goals is also necessary.
Suggestion: The plant should consider expanding the number of management goals
and the monitoring methods used for improving the focus on operational safety
performance.
Basis: GS-R-3 sec 3.11. “Senior management shall ensure that the implementation
of the plans is regularly reviewed against these objectives and that actions are taken to
address deviations from the plans where necessary.”
1.1(a) Good Practice: Structuring the management manual in such a way that the
requirements for each unit are described in one chapter of the management manual.
Responses by the units on how they will meet these requirements are described in an
adjacent chapter. This structure aids in communicating expectations and commitments
to the plant staff.
It is important to safety for the organization to be committed to the requirements.
Thereby, the personal engagement can be improved supporting fulfilment of the
expectations.
The plant has structure the management manual into four main chapters:
1. Management principles
a. Company structure
b. Vision and company mission
c. Management philosophy
d. Policies
e. Management expectations
2. Organization
a. Responsibilities
b. Definitions of management levels
c. Safety management principles
d. Delegation
e. Authorities
f. Organization charts
3. Quality requirements
4. Replies from the individual units on how they meet the quality
requirements.
In chapter 4, all eleven organizational units give their replies on how they meet the
quality requirements stipulated in chapter 3. The replies are given on a free format,
where applicable instructions, procedures, etc., are referenced in order to facilitate
more detailed information when required.
Each reply must respond to all requirements placed on the organizational unit and the
reply is used in internal audits to ensure that all responsibilities are taken care of.
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Internal audits are performed to ensure field observations are consistent with the
commitments made.
Overall personal commitment to the requirements set up by the company is
significantly improved by this structured approach.
1.3 MANAGEMENT OF SAFETY
1.3(1) Issue: Switchyard activities are not fully evaluated by plant personnel.
Switchyard maintenance and operations without appropriate review, controls and
communications have created a number of issues at nuclear power stations. Lessons
from these events demonstrate the need for close interface between nuclear units and
switchyard operators to ensure activities are adequately assessed for impact to nuclear
safety.
Other information relevant to this issue:
• SOER 99-01 was issued to notify nuclear plants of operating experience
related to operation and maintenance activities in electrical switchyards. The
recommendations from this document have been reviewed and open issues
identified.
• Multiple events have been encountered at the plant initiated by perturbations in
the switchyard resulting from operating activities.
Activities occurring in electrical switchyards and through the transmission system
have a potential, if errors or malfunctions occur, to impact safety of nuclear units.
Nuclear units are not only a supplier of electricity but also a vital customer.
Suggestion: The plant should consider establishing a structured evaluation process
for activities with the potential to impact electrical power transmission to or from the
plant.
Basis: NS-G-2.4 sec 3.1. “In establishing the structure of the operating organization,
consideration should be given to the management functions in the following areas:
• Operating functions, which include executive decision making and actions for
the operation of a plant, both in operational states and in accident conditions.
• Supporting functions, which include obtaining from both on-site and off-site
organizations the technical and administrative services and facilities necessary
to perform operating functions.”
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2. TRAINING AND QUALIFICATIONS
2.1 TRAINING POLICY AND ORGANIZATION
The Human Resources Department has a very important function for the training policy
and organization. It facilitates the process to confirm that each employee gets adequate
training to fulfill the requirements of the position. The Human Resources Department
supports the competence supply efforts in the plant. Methods and processes are well
developed to establish good relationships with contractors and the public education
system. Methods for initial and continuing training are suitably described in the Strategic
Competence Planning Process (STRAKO) and are reflected in the Systematic Approach
to Training (SAT) methodology. The plant process is based on the IAEA document
“Nuclear power Plant Personnel Training and its Evaluation Guidebook – TRS 380”.
The Human Resource Process was established in 2001. The process shows a skill
programme of high standard. Kärnkraftsäkerhet och Utbildning (KSU, contractor for
skill) training policies and programs are compatible with current practices at Forsmark.
All skill levels are individually defined in the STRAKO and annual assessments of the
qualifications are provided. This practice supports fairness and shows an adequate,
transparent policy. The training evaluation is formalized. A generic standard is
established for each occupation and if a specific position requires special skills,
additional training modules are provided. Training sessions are adequately planned and
recorded in a database (SAP). All documents are archived. SAP can produce various
statistics on the training courses as well as the output of historical training records.
However, the team observed that the results were not developed and published as
training indicators to confirm and assess the efficiency of the training. The team provided
a suggestion in this area.
All rules for goals, objectives and management oversight are adequately established in
the Human Resource Process. It also requires a debriefing after every training session.
The management thereby gains direct feedback on the quality and effectiveness of the
course.
The Human Resources Department has overall training process responsibilities. One
exception is the training process for operations management and engineers on duty (VHI)
which is handled by the Department for Safety and Environment. The responsibilities of
both departments are well supported.
NSMI (Nordic Generation Safety Management Institute) is the advanced safety
management programme intended for the operational management level 1, 2 and 3 and
for managers in certain functions. The purpose of the programme is to give the
participants a broad understanding for safety work to support their acting in unexpected
situations where they have to make decisions in operational and safety issues. The
programme has been completed for the President, unit managers and operation managers.
The plant has tutors, including contractors, who provide training for its employees. The
basic Radioprotection training at the plant was good. At the University of Uppsala, a
tutor enhanced the lesson with self-created interactive Excel-Spreadsheets.
Westinghouse, the contractor for maintenance, provided good training on mock-ups of
the plant, supported by learning objectives and theoretical lessons. The conduct of this
training is considered a good performance by the team.
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The Human Resources Department is well supported by management and allocates
sufficient resources to meet requirements. It performs an internal self assessment
regularly to improve the process. The team recognized that deviations from the annual
training goals are discussed and inputs from the other plant’s management or feedbacks
from the training courses are well implemented in new tasks.
The implementation of the administrative policy is guaranteed due to SAP and the
Competence Management Process. Responsibilities are suitably regulated in the Human
Resource process. Nevertheless, other departments participate in important decision
making processes. The needs of every plant department are adequately described in the
STRAKO process. Gap analysis was performed effectively before planning further work.
If the attendance of a worker at prescribed training is not evident, then the reasons will
be discussed in the annual assessment.
The Human Resources Department is responsible for the quality control of external
training. Sessions are supervised by random audits carried out by the plant person
responsible for the area.
2.2 TRAINING FACILITIES, EQUIPMENT AND MATERIAL
The team observed that numerous multifunctional training rooms were available. These
can be used for training purposes, classrooms or individual study, workshop training or
meeting rooms. Training rooms were well equipped.
The plant utilizes interactive training courses on actual plant equipment for industrial
safety training, fuel handling, foreign material exclusion and industrial safety on
electrical and mechanical work. A formalized programme for retraining staff on
laboratory instruments does not exist. However, the Chemistry Department possesses a
procedure to ensure well documented on-the-job-training on chemical instruments.
Workshops for the maintenance department are well equipped. For special tasks e.g. fuel
service work, Westinghouse transfers its own equipment to the plant.
Annually, the plant creates an inventory of needs for the full scope simulator. All
relevant changes and modifications on and for the plant are discussed between KSU and
the plant, four times a year. Modifications are implemented to keep the training facility
realistic. This process ensures that KSU have a constantly updated simulation-system.
Adequate testing phases for new LCD-Displays are performed to validate planned
changes before implementing them on site.
The full-scope simulator F1 for Forsmark Unit 1 and Unit 2 adequately supports a wide
range of training capabilities from abnormal up to emergency events. Unit 1 is the main
reference and shows practically no differences to Unit 2. The shutdown panel is used in
emergency scram situations when the main control room (MCR) is not available. On the
full-scope simulator, the shut down panel is not installed. In the basic training course, it
is well described. However, when on-the-job, no formal retraining exists on how and
when this panel should be used.
Training facilities in the full-scope simulator are enhanced by different instructor aids
e.g. video-system, audio recorder, computer based technical information and access to
KSU´s network. The team recognised a good practice with respect to the plant utilising
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the simulator to demonstrate work methods to the media and other key groups.
KSU provides well updated training programs. These are adequately recorded and allow
retrieval possibility. Furthermore, every programme is reviewed by the evaluation tool
“Delta Plus”. Quality control is performed for an adequate adult learning experience.
Real time walk-throughs for all lessons and reviews of student’s and tutor’s material are
satisfactorily established. Recently, a real time data viewer (RDV, a graphical debugging
tool), which was originally designed for development, was adapted as an aid for the
simulator instructors and their preparations. It has also been used in training courses.
2.3 QUALITY OF THE TRAINING PROGRAMMES
The Human Resource Competence Management uses a special process to qualify the
results of reviewing training programs. The Human Resource Process itself provides a
good basis for knowledge and skill.
The principal results of probabilistic safety assessment of the plant, showing the
importance of plant systems in preventing damage or severe accidents, are not included
in the shift supervisors training program.
Adequate independent qualifying reviews of the training plans and activities are given by
feedback from the attendees. The Human Resource Process provides an annual
assessment between management and the employees. In these audits, training activities
and qualifications are discussed and modifications are considered if needed. KSU
performs internal audits using its own instructors.
The adequacy of training programs for field operators is also assessed by KSU.
The team furthermore observed good systematic training approaches initiated by
Westinghouse for the maintenance personnel. The personnel practice on a mock-up of
the plant. This process ensures that the trainees have good practical experience.
Quality control, content and scope of simulator training are well covered by using two
methods. Firstly, before a training course is conducted with the shift group,
representatives from the plant and other instructors validate the program. The second
method is provided by the trained group itself. In the follow-up assessments after the
simulator training, the shift group is given the possibility to give feedback on the
training. With this method, quality is optimised.
Some training subjects in the basic training for all employees are required at regular
intervals e.g. fire protection every four years, respiratory protective equipment every two
years. Other requirements are included in the training program.
2.4 TRAINING PROGRAMS FOR CONTROL ROOM OPERATORS AND SHIFT
SUPERVISORS
The first step for the initial training programme for control room operators and shift
supervisors is an authorization exam for the field operator. The training programme for a
turbine operator contains training modules such as: thermo hydraulics, general plant
knowledge, plant dynamics, simulator training and On-Job-Training (OJT). Another
programme is required to get a reactor operator authorization. Starting with a
satisfactorily completed authority exam as a turbine operator, supplementary courses in
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technical specification documents, reactor physics, emergency preparedness, core theory
and intensive simulator training follow. To get a shift supervisor authorization,
additional courses are needed. Core requirements are: leadership training, emergency
procedures and simulator training. Again, an authority exam must be successfully
completed.
The retraining programme for control room operators provides a good mix of theoretical
training in the classroom and practical training on the simulator. In the classroom, plant
modifications, operating experience and observations from previous training are
considered in different ways, as lectures or team work presentations. On the simulator,
training subjects are based on abnormal and emergency accident management. KSU has
a spreadsheet with all recurring simulator training tasks (1-6 year cycle). Important
elements are retrained more frequently. The retraining covers plant systems as well as
overall fault instructions (ÖSI) unit fault instructions (ASI) and system-wide operating
instructions (SDI).
KSU provides training courses of a high quality standard. Training materials are
generally well prepared. These contain detailed information and are constructed in
accordance with adult learning standards. Reviewed papers were of good quality,
containing pictures, schematics, and diagrams. All documents are printed in color and
distributed to the trainees.
The exercise guide for the instructors describes all actions in each simulator training
scenario and is well documented. In the follow-up meeting after the retraining, the
simulator instructors and the shift team evaluate recognized weak areas in performance
as well as good practices. In an intensive dialogue, all occurrences are discussed to
ensure successful performance for assigned duties for the shift team. For MCR staff, the
training programme is improved in real time sessions (pilot course). The requirements to
pass retraining include passing a theory test with >80% score and attending for a
minimum of 80% of the time.
The team observed simulator retraining. The programme is well conducted on the full
scope simulator, with theory in the classroom. The actual scenario was adequate and well
managed by the participants. The shift group use the 3-way communication method and
the STAR principle is well established. A few areas for improvement were observed
during the training: the responsibility of an extra shift supervisor was not clear, however
corrective action was taken by the instructor.
2.5 TRAINING PROGRAMS FOR FIELD OPERATORS
Initial training for field operators is broken down into several tasks. It starts with a kickoff
group dynamic meeting with team-building exercises. The course includes five skill
areas for: administrative training, operating principles knowledge, technical training,
component training and finally, plant knowledge.
Under the conduct of the shift group and experienced field operators, each trainee passes
on-the-job training and walk-throughs. During these, the shift supervisor acts as a
mentor. KSU is responsible for on-the-job training of field operators and must ensure its
effectiveness. Also, the shadow training method is well established. After finishing the
training period and passing the final authority exam, the employee achieves field
operator status.
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A Graphic Simulator is a useful tool for operators. Only Unit 3 has direct access to such
a simulator. Another Graphic Simulator for Unit1/2 is placed in Studsvik (Headquarter
KSU) and is used only for development. The team encourages the plant to install a
graphic simulator for units 1 and 2 as this would improve training, safety culture and
familiarity with routine tasks.
2.6 TRAINING PROGRAMS FOR MAINTENANCE PERSONNEL
Individual training subjects for maintenance personnel are developed in the STRAKO
process that outlines all training requirements. All job related inputs are used for training
development and are supported by the line organization.
For specific knowledge, training is undertaken on a mock-up of the plant owned by
Westinghouse. This model offers a good learning environment for the development of
specific knowledge and skills. The mock-up allows sufficient training on most critical
work sequences, especially from the ALARA standpoint. Classroom training and
practical training are well balanced.
2.7 TRAINING PROGRAMS FOR TECHNICAL PLANT SUPPORT PERSONNEL
For employees, work specifics and the needs of every plant department are adequately
addressed in the STRAKO process. However, the SAT methodology for Technical
Support staff training is only currently under development.
Last year, the plant hired 18 trainees. During the eighteen month trainee program, these
young people are trained at the plant to meet the requirements of the following sections:
electrical systems, nuclear safety or project management. The programme activities are
mainly held at the plant but also at the Uppsala University.
Trainees are annually interviewed in assessments by management. Management validate
the satisfactory performance of the trainee. Job related inputs are compared with a
defined standard for the position. This systematic gap analysis of job requirements
ensures an adequate training development.
2.8 TRAINING PROGRAMS FOR MANAGEMENT AND SUPERVISORY
PERSONNEL
The team observed that the managers possess many well established skills. The
management planning process and the training programme are well described. The main
purpose of the Managing Planning Process is to secure the supply of future leaders at
different management levels. Furthermore the purpose is to promote safety and
assessment of potentials. These requirements are explained in the “Management’s
Expectations and our Leadership criteria” document.
Management profiles are satisfactorily handled with the STRAKO process. The
requirements are described in the plant document “The role of managers at FKA”. This
document deals with the role of the manager and leader, the required behaviours of
managers, safety thinking and general competences.
Fundamentals such as problem solving, decision making and leadership are adequately
addressed in the VCMP-Course (Vattenfall Core Management Program). Additional
management courses are provided for experienced managers e.g. “Management
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Development Programme for Potential upper Management”.
Key line managers participate in training. In special cases, the President is present and
speaks to the trainees.
The plant has ongoing activities divided into three modules. The first module,
Management Expectations is addressed to all managers and employees. The second
module is a self-made module “Strengthen the leadership”. This module begins with a
questionnaire taken before individual interviews. All managers are asked about safety
culture behaviours or setting goals for work. This evaluation highlights the present
situation in the plant. A third activity is the Safety Dialogue Seminar. The target groups
are all managers and employees. They build up cross functional groups in these seminars.
The first pilot project was successfully completed in January 2008. The overall goal is to
strengthen the safety culture. The team identified this area as a good performance.
2.9 TRAINING PROGRAMS FOR TRAINING GROUP PERSONNEL
Instructors at the plant are typically recruited on the basis of their technical knowledge
and experience at the actual working position. They usually act as on-the-job trainers. In
the Chemistry Department for example, the team observed that on-the-job training is
performed by an experienced employee. A policy for the training of external instructors
is currently under development.
Simulator instructors are employed by KSU. All instructors are mainly recruited from the
operational staff at the plant. Academic background is not a primary consideration. The
Competence Profile out of the STRAKO process defines the training requirement.
Every instructor comes with a long experience as a shift worker (mainly shift supervisor)
and good plant and technical knowledge. For external instructors and part time
instructors, KSU uses the same criteria as for its internal personnel to ensure high quality
teaching.
KSU attests that its instructors have a high proficiency, although no formal programme
for qualification exists. These instructors are evaluated on their performance in different
ways. During each retraining course, the instructor is observed by a manager of the
operation department. At the end of a retraining session, the instructor and the training
group discuss the training with each other in a follow-up assessment. Furthermore, KSU
has an advisory committee which is responsible for the quality control and good
performance of its instructors.
When weaknesses are detected in an instructor, the plant simulator manager or the
advisory board directly initiates corrective actions. If one area of competence is weak,
the instructor is required to take supplementary courses and improve his competence.
Furthermore in the annual assessment between the management and the instructor,
possible weaknesses or deviations from the expected standard are discussed.
2.10 GENERAL EMPLOYEE TRAINING
Several new employees have been hired due to retirements. To keep a high training
standard, a business strategy was developed in the Strategic Competence Planning
System. The plant supports a high school on site. The aim of this initiative is to get
highly educated students ready for future employment.
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The team observed that the Human Resource Process provides to all new employees,
high quality general and basic training education, covering knowledge about the
operation process, organization, industrial safety, radioprotection, environmental training
and fire protection. This basic course explains the plant administrative controls as well as
the approach for the performance of safer work. In addition, the regular retraining
ensures a comprehensive understanding of the requirements.
The plant provides training and retraining covering practical training in industrial safety
and radiation protection for each employee, all temporary personnel and contractors.
Furthermore, a special ALARA requirement for difficult work during the outage is a task
in a separate document. This document includes a full description of the analysis to
assess risks, hazards, safety culture aspects, working rules and eventually up to the
description of how to work on a mock-up.
The basic training for all employees includes training in first aid and rescue for accidents
as well as training on alarm rules.
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DETAILED TRAINING AND QUALIFICATIONS FINDINGS
2.1 TRAINING POLICY AND ORGANIZATION
2.1(1) Issue: Even though most training tools are of a fairly high quality, some training
documents, instructions, routines and analyses are incomplete.
• The HR department does not develop and publish training indicators to
confirm and assess efficiency of the training.
• SAT methodology for Technical support staff training is currently under
development.
• During the simulator training, responsibility of an extra shift supervisor was
not clear. However, corrective action was taken by the instructor.
• In the general training for Radiation Protection, a film was shown. However
some incorrect examples exist in the movie.
• Specific retraining how to restart manually UPS was not performed.
• Policy for the training of external instructors is currently under development
• The shutdown panel is well described in the basic training course, however
on the job, no formal practical retraining exists on how and when this panel
should be used.
• The principal results of probabilistic safety assessment of the plant, showing
the importance of plant systems in preventing damage or severe accidents, are
not included in the shift supervisors training programs.
Without complete and thorough training documents, instructions, routines and
publishing indicators, the plant cannot maintain the current high level of training.
Suggestion: The plant should consider completing all training documents,
instructions, routines and analyses to the required standards.
Basis: NS-G-2.8 Par 3.3, 5.27, 7.8(1), 5.5, 5.20, 4.3, 4.37, 4.36
Par. 3.3. “Before undertaking any safety related work, staff should demonstrate
the appropriate knowledge, skills and attitudes to ensure safety under a variety of
conditions relating to their duties. …”
Par. 5.27 “Personnel involved in chemistry, radiation protection, nuclear
engineering or other technical functions should undergo qualification and receive
training as appropriate to their jobs and responsibilities. Their training should be
determined by a systematic approach as described in paras 5.16–5.26 for operators
and maintenance personnel. ”
Par. 7.8(1) “The shift member(s) designated to directly supervise operation of the
plant or of the unit and who decides on safety related measures during normal
operation, incidents or accidents, gives commands to the shift and is responsible
for the safe performance of the unit (that is, the shift supervisor and the deputy
shift supervisor, who may take over these functions).
Par. 5.5 “All persons likely to be occupationally exposed to ionizing radiation —
that is, not only radiation protection staff — should receive suitable training in (a)
radiation risks and (b) the technical and administrative means of preventing undue
exposure and applying the ALARA (as low as reasonably achievable) principle.”
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Par. 5.20 “Field operators should receive training commensurate with their duties
and responsibilities. All personnel in this category should have detailed
knowledge of the operational features of the plant and hands-on experience. This
knowledge should cover both the control rooms and the plant as a whole”
Par. 4.3 “The training policy should be known, understood and supported by all
persons concerned. Plant department managers and the plant training manager
should be involved in developing the training policy and implementing
procedures, as a way of facilitating their acceptance of the policy”
Par. 4.37 “Plant emergency response using emergency operating procedures
(EOPs) should be practiced in the simulator, to provide operating personnel with
the necessary knowledge and skills to demonstrate competent emergency actions.
…”
Par. 4.36. “Supplementary training should be provided for those staff members
who are required to perform specialized duties in the event of an accident. For
example, topics such as nuclear safety analysis, applicable codes, standards and
regulations, information on evaluated safety margins of the plant, symptom
oriented procedures and accident management measures should be covered. The
principal results of any probabilistic safety assessment of the plant, showing the
importance of plant systems in preventing damage or severe accidents, should be
included in the training programs”
2.2 TRAINING FACILITIES, EQUIPMENT AND MATERIAL
2.2(a) Good practice: To use the training simulator to describe complex events and to
demonstrate the work methods in the control room following a disturbance, to the media
and other key groups.
A problem in communications in nuclear power is to be able to describe clearly complex
events and the design of the safety systems that manage the events to people outside the
nuclear power industry. Furthermore, it is difficult to present a picture of the orderly
work methods in the control room during a disturbance by merely describing them.
There is a full scope simulator at Forsmark which is used to conduct training and
refresher training for different categories of operations personnel. This simulator is an
identical copy of the Forsmark 1 control room. It has been on the site since 2001 and is
operated by KSU (Nuclear Training & Safety Center) at the Forsmark site.
After the July 25, 2006 event at Forsmark the media published and broadcast a number of
inaccurate descriptions of the situation in the control room during the disturbance and of
the impact of the disturbance on various surveillance systems.
The plant invited journalists in to the simulator to witness a simulation of the event,
providing them with a much clearer picture of the sequence of events, which surveillance
systems were affected and which were intact as well as the orderly work methods of the
control room personnel, which were in turn a result of the training and refresher training
on the same simulator. Furthermore, it was made clear how the safety systems are
designed, with redundant features and so forth. This effort contributed much to
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TRAINING AND QUALIFICATIONS

presenting a more balanced picture of the July 25 th event which had been described in the
media as a potential core meltdown.
Other groups have visited the simulator later to see the same run-through. Among others,
SKI, the local safety board, the county administrative board’s emergency preparedness
organization and many national politicians have seen the simulation. Their perception of
the July 25 th event has also become much more balanced.
A contributing factor in the success of presenting a more balanced picture is that the
personnel who work as instructors in the simulator are good teachers who are able to
describe clearly complicated situations and relationships to the layman.
This positive outcome has resulted in Forsmark including the simulator as a
communication resource in their emergency equipment.
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TRAINING AND QUALIFICATIONS

3. OPERATIONS
3.1 ORGANIZATION AND FUNCTIONS
The Operations organization and responsibilities are well defined in the procedure F12-I-
0001 “Assignment of responsibilities and distribution of work within F12” as well as
delegations in procedure F12-I-0002, “Delegation of authorities from F12”. They are
properly communicated and understood by the appropriate level of operation managers.
Goals and objectives are defined in the document F12-2007-0113 “Activity Plan for
2008-2010 at F12” which is then further defined in one document per Unit (e.g. F12-
2008-0102). Specific and measurable goals are set for the plant and operations
management level for short term and intermediate periods. However, the team
recommended further improvements in this area.
The Operations’ managers are frequently present in the field. They have open discussions
with the operational staff members and are recognized by their staff. Unit Managers take
responsibility for long term activities to relieve Shift Supervisors (SS) of this
administrative work. The Shift Supervisors recognized the presence of an additional
crew member with SS qualification as very effective help to reduce their administrative
tasks. They recognize the goal to increase the number of shift crew members as a very
positive step in this matter. Off shift operation personnel support the shift teams in
several fields like training, planning of activities related to surveillance testing and
modifications, personnel planning, management of keys and work authorization process.
In some periods of time the maximum authorized overtime limits are used, specifically
during outages periods.
The Shift Supervisor is not identified as having the authority of the plant manager during
off hours. He has to call the Engineer on duty or Operations manager for problems in
connection with safe operation. The authority allocated to the Shift Supervisor is not
commensurate with his responsibilities. In the Safety Analysis Report (SAR) Chapter 2
he is not identified as being in the operational management and consequently there is no
continuous oversight of the units. However, though he has authority to solve problems
that may impair the safe operation of the unit, off hours, no one on site has an oversight
of the safety of the whole site.
The Operations Department initiated regular self assessment sessions for each shift crew
as the closing part of their seven week shift cycle at F1 and F2 units at the end of 2007
and at F3 unit earlier in 2007. Some shift crews have not conducted this activity yet.
Once effectively implemented, this activity is a very positive step towards improving
Operations performance.
Units at the plant are independent by design and also by the operational organization, so
there should not be any effects on other units during emergencies. However, the recent
organizational changes focused on merging some operational activities of F1 and F2
units to the so called F12 structure, can be challenging in this respect. The plant is
encouraged to consider the application of techniques to prevent human errors deriving
from a merged organization.
Two procedures define internal coordination and interfaces with other groups (F1-I-350
“Operational meetings” and F-I-1115 “Operational review meeting”). There are
operational review meetings and daily review meetings in the morning during which the
conditions of the unit are stated from the nuclear safety and production points of view.
There are also weekly coordination meetings and a monthly company safety committee.
The plant is encouraged to conduct more effective daily meetings in order to increase the
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OPERATIONS

availability of the Shift Supervisor for operational activities.
The Shift Supervisor does not supervise the coordination of other departments’ activities
and can not control the operating objectives for the shift. Such activities are the
responsibility of the Unit Operation Manager.
Before resuming shift work after three weeks off shift and starting a new seven week
shift cycle, the shift team spends a half day (known as “Little d day”) for getting back to
duty. It covers technical experience feedback from the past three weeks and from all
three units, safety concerns, the coming two weeks programme and also management and
human resource issues. This is also a dedicated time for the shift to be with their
managers and discuss various topics. The team considers this as a good performance.
The plant already has a programme to increase the number of shift crew members from
6-7 to 7-8 individuals, which is a positive plant management activity in this matter.
Operation Managers take care of the appropriate balance between experienced and new
incoming staff members for each shift crew. The plant faces some difficulties in
attracting and hiring new young personnel in field operator positions, which is
considered as the starting position in the shift crew. For emergency situations, if referring
to the existing technical specifications, shift staffing level is sufficient to respond to and
face emergency situations. However, in some situations the team considers this situation
is not adequate and provides a recommendation to the plant in this area.
A rigorous “fitness for duty” program, covering initial entrance tests and random tests for
alcohol and drugs consumption is implemented. Moreover, every three years “on shift”
personnel must undergo a medical examination to confirm their capacity for such shift
work. Regular personnel performance reviews are conducted by shift supervisors and
operational managers at the end of each seven week shift cycle, on a yearly basis and
then every three years in order to renew the operational licence.
The shift supervisor and radiation protection groups of all three units report the key
aspects of operational activities and events of various logbooks into the DIGILOG which
is an information system available to everyone at the site. Entries consist of important
information that has occurred during the past 24 hours, actions taken to support
maintenance or radiation protection activities and information from the daily morning
meeting. A search of the database can be initiated by system number, keywords or date.
The team recognizes this as a good performance.
3.2 OPERATIONS FACILITIES AND OPERATOR AIDS
The lighting is generally of very good quality in all areas of the plant and more
specifically in the main control room. The plant is equipped with adequate
communication means, which are properly used. The use of mobile phones is restricted
in some areas.
There is a clear panel policy applied in the MCR. There is an aid to localization of
alarms on the panels. However, there is no prioritization of alarm, which could make
operators confused in case of perturbation or incident. The team encourages the plant to
prioritize the alarms.
There are several computers which provide all necessary information concerning plant
performance. A video system allows operators to visualize the various plant areas which
are not accessible during power operations.
Monitoring functions for safety functions (BSF) and computerised operating status
checking (DDK) are software-based and present operating status, component status and
process parameter information. The functions present deviations from expected status or
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OPERATIONS

value. The team considers this as a good practice.
Main control room and shutdown panel facilities assure habitability of the work spaces in
compliance with appropriate documents.
The emergency shut down panel is available for Units 1&2. Unit 3 is equipped with two
emergency shutdown panels, well separated from the main control room, with adequate
communication means fed by batteries. Necessary procedures and communication tools
are available in the shut down panel room.
Generally good cleanliness, housekeeping and adequate labelling of equipment were
observed at the plant areas. There are first aid kits distributed in many places at the plant
with adequate numbers of breathing apparatus provided to the shift personnel. Personnel
pass medical examinations and receive training on use of the apparatus.
In general, isolated equipment is clearly identified in the field. Equipment isolations for
the administrative locking (system which have to be in a defined configuration for safety
reasons) are not tagged though they are locked effectively and checked periodically.
3.3 OPERATING RULES AND PROCEDURES
Operational Limits and Conditions (OLC) are clearly defined in chapter 3 of Technical
Specifications (STF). They are applicable at various modes during the start-up activities
after a refuelling outage and/or shutdown for maintenance. There are very effective
controls and procedures to ensure compliance to OLC before a change of reactor mode.
Operators and Shift Supervisors are well trained and knowledgeable about OLCs. Any
deviation has to be reported to the regulator and properly documented through an
appropriate report. However, during the review, the entries into OLC were logged as any
other record in the SS logbook and were not highlighted for easy identification. In Daily
Review Sheets, only the identification of the associated system relevant to the OLC was
recorded and no additional information relative to the time limits was included. Exact
entry and exit times for safety system unavailability can help prevent an unsafe condition
caused by inadequate plant staff awareness and is an important parameter for
probabilistic risk assessment. The team encourages the plant to improve in this area.
Procedures are clearly written, understood and supported with appropriate references.
They are available in the main control room, work authorization room and other plant
areas. There is an adequate method to report and document procedure deficiencies; a fast
administrative process is applied with hand written authorized changes in the procedures
in urgent situations. The plant operational procedures are regularly reviewed on a two
yearly basis to ensure they are up-to-date. However, the team observed the potential for
improvement and provided a recommendation in this area.
Emergency Operating Procedures are clearly written and easily accessible by any of the
operators. There are event-based procedures for the operators and symptom-based
procedures for the Shift Supervisor. Such a combination does not have any adverse
impact on the management of such operating conditions. However, there are no
symptom-based emergency procedures for shutdown conditions. The plant is encouraged
to develop and implement these procedures.
3.4 CONDUCT OF OPERATIONS
Operators are attentive and responsive to plant conditions. The system and component
status changes are appropriately authorized. The plant system operating procedures
contain the alarm response information. There is a policy on the use of alarm response
procedures established by the plant. However, the policy is not fully implemented and
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OPERATIONS

the plant is encouraged to improve in this area.
Shift turnover is well organized and conducted: there is a quiet atmosphere; tours of the
panels are made by the operators of both in-coming and out-going shifts at each level.
The shift crew briefing is conducted immediately after the turnover. He briefing is led by
the Shift Supervisor, each shift crew member reports to SS and receives instruction from
the SS concerning the shift program. The access to the control room is limited and
controlled by the SS.
The surveillance programme is well defined by chapter 4 of the STF and well managed
through the FENIX database in term of schedule and results follow-up. The shift
supervisor verifies all surveillance testing results before input into the FENIX database.
Results of tests performed by other departments are also handed to the Shift Supervisor
in a timely manner. The maximum tolerance of 30% in terms of surveillance test
scheduling is strictly followed. Any deviation requires reporting to the regulator.
However, the team suggested some further improvements in the surveillance test
procedures, in addition to already planned modifications.
The policy in the plant is that periodic tests should be performed during the afternoon
shift, when possible. No tests are scheduled in the night shift which is appropriate as the
attention of operators is lower during these periods.
The field operator rounds are divided into different areas: Reactor, Turbine and Other
facilities and cover the operational rooms in the plant. Rounds are scheduled accordingly.
The team observed field operators with high professionalism, having a prudent and
interrogative attitude as regard to hazards as well as consideration for the importance of
the equipment as regard to nuclear safety.
Industrial safety deficiencies are systematically reported by the field operators as it is part
of the normal patrol. Specific patrols are dedicated to plant cleanliness and
housekeeping.
Provisions are made for the performance of verifications in the procedure F12-I-0001:
Shift engineer and operators shall be in the field three times/shift period. However, the
team has not observed this practice while being on site and encourages the plant to
strengthen this activity.
The shift has several appropriate and efficient tools to work with during disturbed
operations. Problems are communicated between shifts during the shift turnover and shift
briefing and to other departments through the FENIX database as well as during the daily
meeting. The requirements are stated in the procedure F-I-1034 “Operation proficiency”.
An overall operational readiness scheme is used to verify that all necessary checks and
tests are performed before the plant is taken into operation after refuelling outage or a
maintenance shutdown. All these requirements are followed with the support of the
Start-up Activity Diagram (green pen diagram). The diagram is a primary tool used by
the operations personnel and gives a quick and easy means for transmitting information
to all concerned parties. The team considers this procedure as a good performance.
There are adequate procedures and requirements to restart the unit after a reactor scram.
The decision to start-up the plant is made by the President who gives delegation to the
production unit manager to start the unit when certain conditions are met. Immediately
before start-up, there is an operational meeting, where the fulfilment of these conditions
is checked.
3.5 WORK AUTHORIZATIONS
The work authorization process is properly described in the plant procedures. Roles,
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OPERATIONS

esponsibilities and authorities are well defined and understood by plant personnel. The
plant developed its own software application FENIX to effectively run and control the
work authorization process. By this application, all work permits and access permits to
any unit work is authorized and managed.
There are well equipped, spacious and well organized work areas prepared to handle the
work authorization process. The shift operation personnel are adequately supported by
daily supporting staff in the work authorization process administration, especially during
the outages. A special list of all ongoing work permits and access permits is prepared
daily before the morning operational review meeting.
There is an appropriate key control system, strictly managed by the SS and off shift
operations personnel. Isolation tags are properly used to mark all equipment isolation
points during maintenance in the field. The shift crew personnel are aware of plant
systems and equipment out of service.
There is a shutdown risk programme fully integrated into the preventive maintenance
programme. Mainly, the deterministic approach is used to define the minimum required
configuration of available safety systems during power operation and during outages.
The probabilistic approach is not applied for this purpose.
Modifications and temporary modifications (TM) are adequately controlled by operations
personnel. Temporary modifications are properly implemented in the field. The MCR
staff is aware of all temporary modifications currently implemented in the unit. However,
the team encourages the plant to improve the management and administrative tasks
related to temporary modifications such as timely closure of TM, no hand written notes
and drawings in TM approval sheets and the strict application of the approval process of
TM.
Preliminary hardware modifications are marked well in advance, before implementation,
in red colour into operational drawings. This gives the operational shift crew and other
operational staff enough time to review, comment and become familiar with future
modifications. The team considers this to be a good performance.
3.6 FIRE PREVENTION AND PROTECTION PROGRAMME
The overall management of the fire prevention and fire protection programme is good
and well organized at the plant. Adequate fixed fire protection systems are installed;
portable fire fighting equipment is available at the plant and well maintained. The
maintenance of fire barriers to isolate the fire cells is very efficient. A state-of-the-art fire
detection system is implemented at the plant facilities. There was ninety one fire alarms
recorded in 2006 from which only sixteen were false alarms. All required fire protection
components are included in the plant surveillance programme and are regularly tested.
The team recognized the management of fire cells in the plant as a good practice.
The plant fire protection programme is effectively supported by a professional, on-site,
adequately equipped fire brigade, run by a contracting company. The same company is in
charge of fire extinguishers and breathing apparatus maintenance and inspections. Five
fully qualified and well trained professional fire fighters are present at all times at the
site.
Adequate theoretical and practical initial training is provided to shift crew members, who
assist the fire brigade in case of fire. In addition, further assistance to the plant is
provided, if necessary, by the off-site professional fire brigade located nearby in
Östhammar.
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OPERATIONS

There are regular walk downs carried out by on-site fire brigade personnel in order to
check the fire load in the plant areas. However, the team recommended further
improvements in the control of combustible materials in the plant areas.
There are fire drills conducted by the on-site fire brigade, jointly with designated
operational staff, on a yearly basis. However, during the team review, the drill scheduling
did not ensure equal opportunities for all shift crews to take part within a specific period
of time. The team encourages the plant to consider better scheduling of joint fire drills.
3.7 MANAGEMENT OF ACCIDENT CONDITIONS
There are clearly described roles and responsibilities during emergency situations at the
plant. The shift personnel are regularly trained to cope with plant accident conditions on
realistic scenarios during full-scope simulator training. The event-based abnormal
operating procedures, symptom-based emergency procedures and severe accident
management guidelines (SAMG) are developed and implemented with plant staff being
adequately trained on their use.
There is clear link between symptom-based emergency procedures and severe accident
management guidelines. SAMG are supported by the necessary hardware installations, so
the plant can efficiently cope with beyond design basis accidents. In addition, a technical
handbook (THAL) has been developed for the senior management level, to manage
severe plant conditions.
The shift crew is supported by an on-call engineer on duty and supporting emergency
groups. The use of emergency procedures is practiced by the shift crew during the first
day of each seven week shift cycle. There are regular monthly drills provided to
engineers on duty and annual site emergency drills with activation of the whole plant
emergency organization. However, the shift crew composition can be, in some
emergency cases, inadequate – see chapter 3.1 Organization and Functions.
There is a comprehensive database with technical information on unit conditions
available to supporting groups throughout the plant computer network application.
Several independent communication means are available to shift personnel and
supporting plant personnel.
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OPERATIONS

DETAILED OPERATIONS FINDINGS
3.1 ORGANIZATION AND FUNCTION
3.1(1) Issue: The plant has not been in a position to demonstrate on which basis the
minimum team has been sized.
The team observed the following facts during the review:
• During a 2006 incident, the shift supervisor requested the support of three
operators from Unit 2 according to the procedure (First Check) if the
supervisor identifies the need of extra personnel due to insufficient staff in a
field (Electrical Field Operator)
• In some situations where actions have to be performed in the switchyard
and/or in the controlled area simultaneously with a fire, the existing staff can
not perform all necessary actions.
• There is no permanent independent evaluation of unit safety parameters during
abnormal conditions,
• No actual basis for the sizing of the existing shift team could be located.
In such situations where multiple units could be affected (e.g. general black out) or with
the complication of one incident combined with a fire, the plant would face difficulties in
safely managing each unit.
Recommendation: The plant should perform an analysis and based on the result of the
analysis define the size of the minimum shift staff complement taking into account
abnormal operation scenarios involving fire and accident conditions.
Basis: NS-G-2.2 ; par I.38. Plant staffing
The plant personnel required to be on duty for the various operational states should be
specified and shall be sufficient to implement the necessary emergency procedures. The
minimum staffing required for the control room should be stated, including the necessary
qualifications for their duties.
NS-G-2.4; par 6.14, Staffing arrangements should take into account:
• the minimum number of persons necessary for performing all functions with
respect to plant operation and emergency situations, with a view to avoiding
excessive loads being placed on individuals;
• the need, particularly in the case of remotely located plants, for adequate
expertise, special equipment and spare parts to be available locally for dealing
with emergency situations until such time as they are augmented from off-site
sources;
NS-G-2.14, Conduct of Operations, Personnel Resources and Qualification
par. 2.10. The operations manager should ensure that an adequate number of competent
staff is available at all times to operate the plant safely in both normal and abnormal
plant conditions. There should be sufficient numbers of operational staff, so that they
may be periodically released to meet training and development requirements. A long
term staff succession plan should be in place, supported by career development reviews,
associated action plans and recruitment plans. These reviews should aim to foster
continuous improvement and learning.
par 2.11. The shift crews should be staffed in a way that there is a sufficient number of
authorized operators and other staff for the reliable accomplishment of assigned tasks
based on normal and abnormal operation scenarios which consider also fire and accident
33
OPERATIONS

conditions. Special attention should be paid to ensure that staffing levels provide
adequate redundancy and diversity of the competence needed both in normal and
abnormal situations.
3.3 OPERATING RULES AND PROCEDURES
3.3(a) Good Practice – Computerized Monitoring of Safety Functions (BSF) and
Operating Status Checks (DDK)
How does it work?
BSF - The computer compiles the status of safety systems using pre-defined parameters
and limits. When a deviation in the BSF exists, an audible alarm is actuated and an alarm
annunciator identifies the issue to the operating staff. The BSF-panel is divided into five
function-areas and is presented by each train:
• Reactivity A B C D
• Core cooling A B C D
• Barriers A B C D
• Heat sink A B C D
• Electrical systems A B C D
DDK - The computer also has a function to check parameters against plant status. There
are more than 700 parameters checked within this program. Deviations are identified on a
computer screen. Six plant modes are available:
• Check before start-up
• Check before 100 °C
• Check before 286 °C
• Check before 8%
• Check before 54%
• Check at 108%
Who can use it?
When an alarm is indicated by the BSF the operator is made aware of a deviation from
normal status. The operator can then quickly check where the specific deviation exists.
The DDK is used at least once every day and is presented to operations management
during the daily review meeting. When complemented with results of surveillance
tests recorded in FENIX, it is also used prior to changing the reactor operational mode
to ensure compliance with Operational Limits and Conditions and that all operational
parameters are within normal limits.
What improvements are achieved?
The BSF indication provides an easy way to check deviations that might exist with
safety systems and to determine which functions may be threatened. The DDK make it
easy to have an overall check that all parameters are within expected values and
limits. Safety parameters can be checked in a few seconds.
3.3(1) Issue: The control and review process of operational documentation,
emergency preparedness procedures and operators aids at the plant is not rigorously
applied.
The team observed the following facts during the review:
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OPERATIONS

• The periodical reviews of plant drawings posted in field locations are not evident.
o There is a periodic check-up of drawings every 6 month, but the field
observations identified drawings more than 20 years old in F3 MCR without
any record of periodical review appearing on the drawing.
o There was the procedure No. 1.962 A which includes the copy of two extra
drawings at F1, DG A control room. The drawings were obviously very old,
they were authorized many years ago and never reviewed since; in some parts
they were not clear enough to read.
• There were several sets of unit operational drawings distributed in the plant. These
locations include areas like the MCR, MCR meeting room, work authorization
area, etc. In the F1 operational department administration area there was one set of
drawings in the rack, the rack was labelled as uncontrolled documentation.
However, the drawings were not marked as uncontrolled copies and could be
mixed with controlled copies in other unit work places.
• There is a list of drawings required at some workplaces (F3, DG B control room),
however, there is no list of operational procedures required in these workplaces.
• Some of the controlled documents are out of date. For example:
o Allman del, Ansvar, Organisation och Verksamhet, Kärnkraftverkens
Gemensamma Beredskapsstyrka (“Support from other plants”), last updated
2004-06-24, contains phone numbers (home, mobile, work) of persons who
retired. This is apparently an obsolete version that has not been replaced by the
current version from 2006.
o Operativa Stöddokument F1/2, contains mention “shall be updated by 2007-
12-31”
o Beredskap planerade övningar och utbildningar 2007 “calendar of training and
exercises for 2007”.
• Phone list is more than seven months old, yet the phone numbers should be
checked twice a year.
o Document Operative pärm, updated in 2007-06-08
o Note that the numbers in this document may be correct, the date on the
document has not been changed each time the phone numbers were checked.
• Some of the controlled documents contain handwritten corrections without initials
and they are not captured in the electronic version. For example Document F-I-315
Rev 2, 2006-12-28, page 8. “Procedure for operation of equipment”.
• There were unauthorized operators aids (diagrams) observed attached to the panels
at plant MCRs. Although some of them were the copies of the part of the latest
version of SAR (Safety Analysis Report) or other procedures, they were obviously
uncontrolled documentation.
• Numerous operators’ aids (pink sheets on cardboard) with no obvious authorization
were observed in room 1D02.41 (11-414-P1 and 12-414-P3).
The use of uncontrolled or unauthorized operational documentation can lead to
operational events due to referencing of incorrect or out-of-date information.
Recommendation: The plant should rigorously apply the control and review process of
operational documentation, emergency preparedness procedures and operators aids.
Basis: NS-G-2.4, The Operating Organisation for NPPs, par. 6.75. Documentation
should be controlled in a consistent, compatible manner throughout the plant and the
operating organization. This includes the preparation, change, review, approval, release
and distribution of documentation. Lists and procedures for these functions should be
prepared and controlled.
DS347 Draft 3 – Conduct of Operations, par. 6.17. The operator aids control system
should prevent the use of unauthorized operator aids and other supportive materials such
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OPERATIONS

as unauthorized instructions or labels of any kind on the equipment, local panels, boards
and measurement devices within the work areas. The aids should be placed in close
proximity to where they are expected to be used and posted aids should not obscure
instruments or controls.
par. 6.18. The control system for operator aids should ensure that operator aids contain
correct information, which has been reviewed and approved by a competent authority. In
addition all operator aids should be reviewed periodically to determine if they are still
needed, if the information in them has changed or been updated, or if they should be
permanently incorporated in some manner.
3.4 CONDUCT OF OPERATION
3.4(1) Issue: Although the plant has a plan to improve the conduct of surveillance test
procedures, some additional changes can be applied.
The team observed the following facts during the review:
• The final acceptance or non-acceptance of surveillance test results should be
noted by a responsible operation’s staff member onto the test cover sheet.
However, currently no clear acceptance criteria are provided on the test cover
sheet or surveillance test procedure.
• Surveillance test procedures are step by step procedures with an expectation
each step be signed by the responsible individual immediately following
completion of the step. However:
o no responsible individual is designated to conduct each step in the
surveillance test procedure.
o a summary of which staff members are necessary to conduct the
o
surveillance test is not provided.
most of the procedures do not use the table format, so in some cases the
signature does not clearly indicate which step was actually conducted.
• The test No. 14.10.1.040A to check the automatic back-up for system No. 576
consists of two independent procedures, one for maintenance and one for
operations personnel. There are no links included in these procedures to ensure
good work coordination between involved personnel.
• During the test of system No. 1 320-1 the operator checked, verified and
cleared the summary alarm indications of unit critical safety functions placed
in the 1KA8 panel. However, these steps were not mentioned in the
surveillance test procedure.
Precise, detailed and unique surveillance test procedures with clearly identified
acceptance criteria can ensure that potential human failures are avoided during the test
conduct and acceptability of the test results is uniquely verified by responsible personnel.
Suggestion: The plant should consider further detailed improvements to the surveillance
test procedures in addition to the planned improvements.
Basis: NS-G-2.4 – Conduct of Operations, par. 5.19. Departments other than the
operations department may be assigned responsibilities by the plant to develop the
individual surveillance test procedures, specify the appropriate frequency of testing,
complete some of the testing and identify acceptance criteria. The operations department
should be responsible for the scheduling and accomplishment of tests that involve
equipment operation, of the review of completed test reports to ensure completeness and
of verification that the test results meet the approved acceptance criteria.
Surveillance results should be reviewed for long term trends that may indicate a
deteriorating situation.
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NS-G-2.6 – Maintenance, Surveillance and In-service Inspection in Nuclear Power
Plants, par. 5.3. Acceptance criteria and actions to be taken if acceptance criteria cannot
be met should be clearly specified in the procedures.
3.6 FIRE PREVENTION AND PROTECTION PROGRAMME
3.6(a) Good Practice – Effective management of fire cells
Fire cells monitoring - Fire cells divide the unit into separate compartments in order to
prevent the spread of fire and fumes. In order to monitor the integrity of the fire cells,
each door in the fire cell is monitored and an alarm is tripped if a door is open too long.
(Fig. 1) This feature ensures a high standard for fire cells integrity, even during outage.
Anyone who is in the plant and discovers an open fire cell door must close it. If this is
not possible, the Shift Supervisor must be informed immediately.
Fire cells service openings - During work, service openings are used whenever possible.
When in use these are sealed by seal bags specially designed for this purpose. (Fig. 2)
This feature ensures that the fire cells are closed even during work in plant
(Fig. 1) (Fig. 2)
Adaptive Fire Alarm Detectors - The fire alarm detectors system can be adapted (with
increased or reduced sensitivity) to the actual work situation in specific plant rooms.
Changes can be accomplished via a PC software application, e.g.: when hot work is
performed or a transportation vehicle enters into the plant. The fire alarm detectors are
always ready to monitor fire status; there is no need to switch them off completely. The
sensitivity of the fire alarm monitoring system is specified by the fire protection foreman
when issuing the directive for fire protection measures as part of work authorisation
process.
3.6(1) Issue: The plant did not establish and implement the appropriate controls to
manage the amount of combustible materials (fire loads) in the plant areas.
The team observed the following facts during the review:
• There are regular walk-downs by on-site fire brigade personnel in order to
check the fire load in the plant areas. In general, acceptable fire loading was
observed in the plant areas; however, the current general fire load rule (max 25
l of combustible liquid in the room) is not strictly applied:
o there is no limitation for non-liquid flammable materials
o 200 l oil drum and 200 l drum with glycol were stored in the unit 1, DG A
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and C rooms
o significant amounts of paper documents and other combustible materials
were placed at work places at the back side of unit 1 MCR
• In several plant areas the team observed no compliance with the plant policy
which gives limitation to the storage of combustible liquids in the fire cells,
recommends to unpack equipments or consumables before taking them into the
controlled area (wood, plastic and paper packaging, …)
Without clear fire load limits for plant areas the control of combustible materials will not
be effective.
Recommendation: The plant should establish and implement the appropriate control of
fire loads, especially in the areas containing the safety systems.
Basis: NS-G-2.1 Fire Safety in the Operation of NPPs, par. 2.12. “Procedures should be
established for the purpose of ensuring that amounts of combustible materials (the fire
load) and the numbers of ignition sources be minimized in areas containing items
important to safety and in adjacent areas that may present a risk of exposure to fire for
items important to safety.”
par. 6.5. “Administrative controls should be established and implemented to ensure that
areas important to safety are inspected periodically in order to evaluate the general fire
loading and plant housekeeping conditions, and to ensure that means of exit and access
routes for manual fire fighting are not blocked. Administrative controls should also be
effected to ensure that the actual fire load is kept within permissible limits.”
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4. MAINTENANCE
4.1 ORGANISATION AND FUNCTIONS
The maintenance policies of Forsmark are clearly stated in an instruction and are suitably
distributed to all maintenance workers.
Appropriate goals, objectives and performance indicators are established for maintenance
and improved performance has resulted. The indicators include safety, production
results, productive upgrades and organizational effects.
Evaluating and revising the policy can be undertaken in accordance with a specific
instruction.
Maintenance programmes are adequate and maintained current with industry practices
and are based on suppliers/manufacturers recommendations, experience from operation,
maintenance and experience from other Swedish nuclear power plants.
The Maintenance Department is staffed by highly motivated, qualified and experienced
personnel. The department is led by the Maintenance Manager and there are over 200
full time employees which is considered sufficient for the role of the department. This
number increases to approximately 800 personnel during an outage. The department has
seven sections for the following functions: Electrical, Installation Workshop & Technical
Service, I&C, Mechanical, Planning, Radiation Protection & Industrial Safety and
Maintenance engineering. The responsibilities and authorities within the maintenance
sections are clearly defined in an instruction. There is a commitment to sustain and
develop safety culture within the department.
There is an interface between all the Swedish nuclear power plants on various
maintenance activities. This is well defined and is working well on a number of fronts
including the exchange of information regarding component faults.
The interface between operations and maintenance is well established and meetings are
held regularly such as the daily planning meeting and various outage meetings. A formal
maintenance-operations agreement meeting is scheduled annually.
The interface with contractors is effective and is structured in an effective manner. The
plant has many years of experience with the contractors such as ISS (technical support),
Westinghouse (reactor service, I&C), and Alstom (turbine services).
The qualification and experience level requirements for the maintenance staff are
adequately described in the document which contains the training programme for
maintenance contractors and plant personnel. Contractors comply with these plant
instructions concerning the qualification of their staff and consultants. Contractors
undergo the same basic training as plant personnel. The proficiency of all staff is
determined by the supervisor and managers on a regular basis.
The maintenance staff clearly demonstrated that they possessed a very good working
knowledge of current practices and procedures.
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MAINTENANCE

4.2 MAINTENANCE FACILITIES AND EQUIPMENT
The current maintenance facilities have been recognized by the plant to have limitations
with respect to space. A new 2000 m2 workshop and storage facility is under
construction where diesels and large pumps can be maintained. It will be ready for use in
the autumn of 2008.
The LWR-Centre in Västerås has training facilities (with mock-ups) for maintenance
personnel, particularly with respect to the main circulation pumps and reactor inner parts.
There is also a maintenance training centre in Barsebäck where training for employees
and contractors will commence in March 2008.
Tools and equipment are maintained when they are returned after use if required. Plant
components removed are only maintained if it is economically viable to perform the
maintenance. Plant equipment is controlled and segregated to prevent its use if it is
unserviceable.
Measuring and test equipment are adequately calibrated and controlled to ensure
accuracy and traceability.
Decontamination of components is performed in the decontamination centre e.g.
gasblasting for main circulation pumps cleaning, ultrasonics for smaller non-greasy parts,
chemical and brush cleaning of reactor main flange bolts.
Remote controlled equipment is used for the welding machine for operation inside pipes,
a remote controlled TV robot for inspection on the inside of pipes and clamshell
equipment for cutting pipes. This is considered satisfactory.
Chemicals used by maintenance are approved and classified according to a specific
instruction and are classified and labelled into five groups. Chemicals are stored in
appropriate lockers.
The register for tools is connected to the maintenance system. This allows the
opportunity to check which tool has been used in every specific occasion and if the
reference tool is calibrated at the correct interval. The team considers this as a good
performance.
4.3 MAINTENANCE PROGRAMMES
The correct balance of resources is assigned to each facet of the maintenance programme
and management allocates resources according to the needs of this programme. The
scope and frequencies associated with the preventative maintenance programme are
based on the appropriate regulatory guidance, supplier recommendations, operation and
maintenance experience and industry experience. Regulatory requirements are contained
in the associated SKI regulations.
Activities, in the main, are completed in a timely manner and extensions are only granted
when authorized by management. They are tracked using the FENIX maintenance
management database. All information on completed activities is transferred to the plant
archives.
If there is lack of resources, the list of priorities of the president is used by the managers
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MAINTENANCE

to allocate further resources.
The effectiveness of the programme is periodically evaluated by management and
upgraded based on experience.
Maintenance history records are accurate and kept up to date. Managers approve
completed work before the measure is archived.
The effectiveness of the predictive maintenance programme in improving equipment
reliability and availability is periodically reviewed. The maintenance system is kept
current with respect to internal experience and external contractors' experience.
Identified equipment degradation is reported promptly for correction. When equipment
degradation is detected, a corrective maintenance work order is initiated according to the
appropriate procedure.
Good predictive maintenance techniques are used and these are comparable with industry
practice. These include fixed vibration monitoring which is used for the main circulation
pumps, turbines and generators, portable vibration monitoring which is used for rotating
equipment such as pumps and motors, thermographic monitoring which is used for the
identification of hot surfaces, thermal and water leakages and oil samples taken for
example from the turbine lubrication system, transformers and the feed water pumps
systems.
The plant uses REM (reliability experience maintenance) which is a systematic analysis
which takes experience into account regarding the maintenance of equipment.
The principles, methods and assessment procedures is reviewed by SKI and is in
accordance with its directives as contained in the Regulation Code of the Swedish
Nuclear Power Inspectorate regarding mechanical devices in Nuclear Facilities. The
Swedish utilities have, in a cooperation programme, interpreted the code into a series of
documents called PAKT, where the requirements are described in more detail. Forsmark
has produced its own instructions from these documents. The production units are
responsible for the application of the requirements.
A number of procedures exist which adequately describe the necessary actions to be
taken.
Mechanical devices are qualitatively classified at Forsmark into three inspection groups
(A, B & C) for directing the extent and aim of the in-service inspection, as required by
the Code. There is also a Group F for prescribed inspection areas.
The Code states that the non-destructive testing of the reactor vessel and mechanical
devices which are in inspection group F, A and B shall be carried out with inspection
systems which are qualified to detect, characterize and also size the defect. The licensee
shall attend so that such qualification is supervised by a body which has an independent
and neutral position and the necessary competence. The Swedish utilities founded SQC
(Swedish Qualification Centre) for this purpose and are therefore self-accredited. This is
approved by SKI.
The results of ISI (In Service Inspections) can either be in the form of a protocol or a
report. The document describes all the existing basis and conditions for the inspection
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MAINTENANCE

and the results of the inspection. All NDE (Non-Destructive Examination) reports at the
plant are reviewed by a Level III competent person.
If the laboratory reports an indication over the acceptance limit, then sizing and
characterization of the defect is commenced. Decisions are then taken on whether to
repair or not, time schedules etc. If a failure is discovered during operation, then actions
to be taken are immediately discussed between all concerned parties.
The frequencies of inspections are based on structural integrity analyses. A
computerized aid is now used to determine these frequencies.
The plant has its own limit on the number of corrective maintenance work backlogs
which is less than 1000 work orders per unit. Currently, Unit one is above this figure and
corrective actions around this issue are ongoing.
As Guides for identification of ageing degradations, Forsmark uses NRC Gall reports,
EPRI documents, Westinghouse documents and information from OEM (Original
Equipment Manufacturing), mainly ABB. All individually applied mechanism are
thereafter reviewed by a team of specialist for each main group, building (concrete,
concrete reinforcement etc.) mechanical (rubber, plastic, copper, aluminium etc) and
electrical/I&C (copper aluminium, PVC, rubber, plastic etc).
Information on components which are susceptible to ageing is compiled. Only class 1-3
components and electrical function class 1E or 2E are included. No differentiation is
made between active or passive components and all safety components are analyzed.
The plant has electrical power monitoring for performance-based maintenance on
isolation valves and control rod drives and team considered that this is good practice.
The Maintenance Department has developed an Action Plan to enhance their activities.
The Plan is based on analysis of the “60 point bullet list” developed after the 25/7/2006
event, Root Cause Analysis conducted on underlying maintenance issues identified from
the event and the results of three maintenance management seminars. The Action Plan is
being progressed and includes activities to reduce the Technical documentation backlog,
manage ageing of equipment and reduce the backlog of registering new equipment and
including it in the preventive maintenance programme. It was noted that actions
identified for maintenance from the “60 point bullet list” have been completed.
4.4. PROCEDURES, RECORDS AND HISTORY
A policy on the use of procedures exists and is implemented accordingly. Procedures,
work instructions, and their revisions are properly controlled. The revision of instructions
is undertaken every two years.
A backlog of 380 maintenance document of grade 1 currently exists. A recovery
programme is ongoing and the backlog is planned to diminish by June 2008. A project
manager is in charge of this recovery project and he has a staff of up to fifteen
experienced persons who work on this project part-time.
The content of all other procedures reviewed was found to be technically correct with
clear acceptance criteria.
Procedures for the preparation of work orders are clear, concise and contain adequate
information. Procedures and work instructions are periodically updated according to the
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MAINTENANCE

appropriate procedure and reflect in-house and industry operating experience.
Temporary changes are adequately controlled and minimized. All changes are marked in
the procedure/drawing and a satisfactory process is then implemented to make the
required permanent change to the procedure/drawing.
A sample of some maintenance history files were reviewed and found to be accurate,
current and include sufficient detail for important plant systems and equipment. These
historical records were easily retrievable and properly secured.
4.5 CONDUCT OF MAINTENANCE WORK
All the maintenance work which was reviewed by the team was performed according to
the approved work orders and instructions by competent and professional personnel.
Adequate resources were available at all the worksites.
Where work in the controlled area was undertaken, the plant programme for ALARA
principles was used and put into effect according to the relevant instruction.
With regard to the number of fuel damage events at the plant, a FME (foreign material
exclusion) programme was launched in 2001. The main goal of the FME programme was
to reduce/eliminate the risk of getting foreign material into the primary and turbine
systems. Preventive actions include the installation of cyclone filters in the feed water
system of unit 2. Other initiatives include an Instruction on Cleanness Requirements for
Work and Work Preparations and On-site Check list for FME preventive actions. Basic
training on FME is given for all, available online and also used for training contractor
maintenance personnel.
The tagging system is used correctly and good safety practices are evident. Managers and
supervisors effectively monitor and guide work. Contractors follow the plants’ controlled
procedures and standards.
Post maintenance/modification testing is carried out in a satisfactory manner.
4.6 MATERIAL CONDITIONS
The plant policy is that the material condition of the plant should be maintained in such a
way that its safe, reliable and efficient operation can be ensured. Standards are identified
satisfactorily at the plant but the actual implementation of the required standards and
instructions is not in accordance with management expectations.
The team was made aware that two instances of through-wall leaks occurred on a system
418 pipeline on Unit One, as a result of flow assisted corrosion, in December 2007 and
January 2008. The pipeline had been inspected eight years ago and was programmed to
be inspected again in June 2008. The inspection of similar pipes was taken, repairs
undertaken and permission to restart the turbine was received from the third party control
body. All pipework in this system for each unit will be inspected in the next scheduled
outages.
Regular system walkdowns by management are done to the power plant and work places.
Walkdowns are scheduled and have a given frequency, depending on the position of the
manager.
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A number of leaks were identified and some have been in existence and tolerated for a
long period of time and the team made a suggestion in this area.
4.7 WORK CONTROL
Corrective and preventive work is efficiently planned and scheduled in the maintenance
planning system FENIX. Three weeks before preventive maintenance work is to be
carried out, the system automatically generates a work order, including all related
information that is required (calibration cards, material requisition for replacement parts
etc).
Authorizations required for implementation of the work are clearly described and printed
in a separate form e.g. work permit/work authorization, radiation protection and
industrial safety instruction and fire protection instruction.
Work prioritizing is efficiently performed in the morning maintenance and operations
meeting. Scheduling for daily preventive and corrective work is also done at this
meeting.
Temporary repairs are minimized with less than 5 temporary repairs being done annually.
Outage planning is integrated into the FENIX work control process.
Contractors are effectively managed by agreements.
Suggestions for modifications are made by the production and maintenance unit.
Modifications are reviewed weekly at the maintenance meeting.
ALARA is part of the planning and conduct of work. The Industrial safety and Radiation
Protection Department is part of the maintenance unit.
Post maintenance reviews improve maintenance effectiveness. Audits are performed
every year in different maintenance areas.
4.8 SPARE PARTS AND MATERIALS
The responsibility for procurement rests with the Service and Facilities Department on
the request of the Maintenance Department. Receipt inspection is conducted initially by
the contractor ISS to ensure that the correct quantity and that the correct product is
received – the information is input into the SAP R/3 program. Acceptance inspection is
undertaken by the Spare Parts Officer and Quality Control to ensure that the correct
functional and quality item is received and this information is also input into SAP. No
procedure currently exists for the job function of Spare Parts Officer and also no
procedure for the repair of spare parts, other than I&C.
The necessary technical and quality assurance standards are confirmed by this acceptance
inspection process.
It is considered that the control of receipt of spare parts is effectively and efficiently
organized.
Commercial grade parts go through a satisfactory process for certifying new spare parts.
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Quality assessment is adequately applied in this process.
Adequate material management facilities exist for the storage of spare parts. Further
storage facilities will be constructed during 2008 and 2009 in anticipation of stock level
increases owing to the planned power upgrade modifications.
A new storage strategy has been adopted for new spares from January 2008. Four levels
(A, B, C&D) of storage environmental conditions have been formulated ranging from the
requirements for materials which are extremely sensitive to environmental influences (A)
to Level D which is for materials which can be stored outdoors.
Upon receipt of a spare part, the item, with its receipt date, are logged into SAP. A shelf
life is then allocated to the item depending on manufacturers recommendations etc. A
regular interrogation of the database is conducted to determine which items are about to
exceed their shelf life. When the team performed an interrogation of the 217 items due
for disposal in 2008, as they had exceeded their predetermined shelf life, the first two
items were found to have exceeded their shelf life by one and three years.
Hazardous materials are identified at the receipt inspection stage, having been
appropriately labelled by the supplier. Such materials are stored in designated areas
Small items which do not pass the acceptance inspection are placed on a very narrow
shelf in close proximity to the inspection area. This is not considered to be sufficient
separation from those items which are considered as acceptable. Larger items which
cannot be placed on the shelf are stored on the floor and a note attached to the item.
There are no demarcated areas for such non-conforming or damaged items.
It was stated that, during the 27 years of operation of the plant, there has only been one
time when operation was affected due to the lack of spare parts and this had been due to
an LP rotor having been dropped from a crane and the resulting damaged turbine blades
were not in stock.
It is recognized by the plant that full traceability of safety related spare parts is not
evident where the item does not have a specific identifier – if a batch were found to be
faulty, then all the components which had the spare utilized would have to have the
faulty spare replaced.
All spare parts are labelled prior to being placed in storage and the information includes
date, order number, part number, description and storage location.
Stock levels are kept at a level that considers past requirements, delivery times and
safety. The current stock levels indicate that there are 220000 spare parts in stock.
Items made of rubber are not accepted as return parts. The team found some areas in the
plant where apparently surplus spare parts were observed to be stored/placed.
Access to the storage location is controlled.
QA audits are performed on a regular basis but it is considered that these audits are
limited to the documentation relating to spare parts – more emphasis should be placed on
the physical storage and storage environment. The staff has initiated an informal selfassessment
of their work and workplace and consideration should be given to
formalizing this self-assessment process.
The control and surveillance of spare parts for maintenance is not sufficiently robust and
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MAINTENANCE

the team made a suggestion in this area.
4.9 OUTAGE MANAGEMENT
An outage organizational chart is available and clearly delineates the individual
responsibilities.
Planning meetings are held on a regular basis prior to the start of the outage. These
meetings cover organization, scope of activities, current status of schedules, progress of
preparations and experiences from previous outages.
During the outage, up to twelve individual meetings are held daily ranging from
‘Operational Managers Planning Meeting’ to ‘Shift Supervisors Planning Meeting’.
Contractors are supervised by plant personnel.
A waste reduction programme is adequately applied at the plant.
The requirements of Operating Technical Specifications are adequately addressed but
there is no methodical, structured approach to determining the risk associated with
outage activities. Currently a meeting is convened of experienced engineers and all
activities are discussed and the items of high risk are subjectively identified.
Restart of the unit following an outage is comprehensively addressed and is subject to
authorization from the President.
An Outage Review Report is produced which adequately addresses all outage aspects
and any follow-up items.
Experiences during the outage are collected on forms and the involved staff is
encouraged to complete these forms with any findings they may make. These forms are
collected and relevant information is feedback into the outage process.
Long term planning has been a part of the scheduling of the plant since 2004 and
nowadays adequately caters for outages up to four years ahead. A simple matrix system
is utilized to predict the critical path of the outage.
The production unit manager has overall responsibility for the outage and is also
responsible for the safety status of the unit and the operations related activities in the
plant. The outage project manager is responsible for ensuring that maintenance outage
activities are performed with the specified quality and within the planned time.
The production unit manager is also responsible for appointing personnel responsible for
granting work permits, personnel for the operation of plant modifications and appointing
officials for isolation valve testing.
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DETAILED MAINTENANCE FINDINGS
4.3 MAINTENANCE PROGRAMMES
4.3(a) Good Practice: The plant has electrical power monitoring for performance-based
maintenance on isolation valves and control rod drives online, (SODEM).
An online computerized electrical power measuring system is optimal for monitoring
performance of isolation valves and control rod drives. The electrical power measuring
system can be used for tracking changes from a fingerprint curve or as an indicator of
increased friction that may affect the operability of the valves.
The Plant uses such a system for measuring electrical power demand by motor-operated
isolation valves. The computerized system is triggered at each individual operation of the
valves or control rods.
In the valve monitoring system, the alarm levels are calculated for each individual valve.
The alarm levels are based on the valve calculations in the SAR. The curves are analyzed
on a regular basis and the maintenance engineers make recommendations for
maintenance action during outage. Written procedures provide assistance with analysis
and adjustment of alarm levels. The performance analyses also enable operability
assessments for the motor operated isolation valves.
The valve monitoring system is used for troubleshooting on both valves and actuators. It
also enables identification of mechanical errors, e.g. increased friction, bent stem and if
the actuator is fitted off centre of the valve.
Alarms from the control rod monitoring system are used in combination with other
monitoring systems to evaluate the status of the control rod drives and collect data for
maintenance actions during outage.
4.6 MATERIAL CONDITIONS
4.6(1) Issue: A number of leaks were identified and some have been in existence and
tolerated for a long period of time.
There were a number of components which are indicating leakage and these
include:
• Level 3 12-415 E309 Oil leaks have been occurring for over a year – no
remedial action taken.
• Room 1.S1.13 Valve 767 W401 leaking and encrusted with solids.
• Diesel generators A and B. Two plastic containers collecting oil leakage –
plastic containers have been in place for over a year - oil also in surrounding
area.
• Oil leaks in 12-415 P301, P302 – feedwater pumps.
• Several oil leaks in 11-414 P1-P3.
• Valve 711V164 was leaking fluid onto the floor.
Visible leakage is a sign of poor material condition which can lead to
unavailability of safety related equipment and also increase the fire risk in the case
of oil leakages.
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Suggestion: Consideration should be given to enhancing the current material condition
initiative to ensure that all leakages from components are timely and effectively repaired.
IAEA Basis:
DS347 Conduct of Operations at Nuclear Power Plants
4.35 Personnel assigned the task of carrying out rounds should be made responsible for
verifying that operating equipment and standby equipment operate within normal
parameters. They should take note of equipment that is deteriorating and of factors
affecting environmental conditions, such as water and oil leaks, burned out light bulbs
and changes in building temperature or the cleanliness of the air. Any problems noted
with equipment should be promptly communicated to the control room personnel and
corrective actions should be initiated.
4.8 SPARE PARTS AND MATERIALS
4.8(1) Issue: The control and surveillance of spare parts for maintenance is not
sufficiently robust.
There are deficiencies within the spare parts section which should be improved
such as:
• The control system for spares contains items which should have been discarded
• There is inadequate segregation of non-conforming items
• QA audits on the section are documentation focused
• There is not full traceability of some safety related equipment
• Instructions do not exist for the position and responsibilities of Spare Parts
Officer and no instruction for ‘The repair of spare parts’.
Inadequate control of spare parts could result in inoperability of safety systems should
deficient or inappropriate spare parts be utilized.
Suggestion: The plant should consider enhancing the current control and surveillance of
spare parts.
IAEA Basis:
NS-G-2.6
8.32 The operating organization should ensure that storage facilities offer adequate space
and provide for the secure retention of stocks in suitable environmental conditions, in
order to prevent deterioration.
8.37 Items that have a limited shelf life should, if not used, be replaced at the appropriate
time in order to ensure suitability for the expected function when they are needed.
8.51 Defective items,…., should be repaired in accordance with established
procedures….
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5. TECHNICAL SUPPORT
5.1 ORGANIZATION AND FUNCTIONS
Technical support (TS) tasks are assigned to the TS unit and other related units, e.g.
maintenance unit, production unit and the common facilities unit. The responsibilities
and assignments of each department of the TS unit and relevant units are clearly
documented in LOK and FT-I-001 (Instruction for TS unit work).
All the departments of the TS unit, except the project management department, have a
role as specialists within their own area of expertise. They adequately provide the
technical investigations, analysis and assessments for a broad range of different
assignments from the production units (clients).
Considering the features of the assignments, the TS unit incorporates a matrix
organization in performing project tasks, with the aim of improving efficiency and
effectiveness.
The TS unit has set up the interdisciplinary engineering department (FTT) to facilitate
technical issues in interdisciplinary analysis of plant functions and nuclear safety. One
important task is to create conditions for future plant renewals through the analysis of
design requirements and nuclear safety.
In addition to the fundamental organization, the TS unit has set up a management team
which functions as a decision-making forum and ensures that engineering issues are
addressed and the decision-making is taken collectively in an effective and efficient
manner. The team is comprised of the TS unit manager, unit department managers and
employees for coordination of the TS unit.
The TS unit makes special efforts to limit the number of direct subordinates of subunits,
in order that each manager can maintain sufficient oversight in the manager role, because
the assignments cover a broad range of competence areas. The TS unit conducts an
annual review of competence and resource status of each department and the entire TS
unit. Based on the review result, the staffing can be changed appropriately to ensure the
necessary staffing for each department of the TS unit.
The system to improve each individual’s competence and skill is properly established in
the plant. The competence and skill requirements for each position of the TS unit are
clearly documented and registered in the strategic competence system (STRAKO). The
gap between actual skills and requirements for each individual is identified at an annual
performance review and a development plan is formulated based on any identified gaps.
The plan is signed by the employee and the responsible manager and administered by the
human resources unit.
A three year activity plan of how each department of the TS unit will achieve the goals is
issued annually.
The average overtime of the TS unit is maintained at a low level (3% of annual working
hours).
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5.2 SURVEILLANCE PROGRAMME
The surveillance programme verifies functional safety requirements and it is clearly
compiled into three programmes, e.g. the technical specifications (STF) (priority 1), the
ISI programme (priority 2) and the maintenance programme (priority 3).
Operations department has clear responsibilities for ensuring that 1) tests, inspections
and checks are performed, 2) the results are evaluated, and 3) any unacceptable results
are remedied. The maintenance unit and TS unit take part in the assigned execution, such
as the ISI activities.
Tests, inspections and checks are clearly specified in the technical specifications (STF,
Chapter 4) as measures to ensure that the production unit is operational. The information
necessary for planning surveillance tests, including acceptance criteria and scheduling
(time interval limit), are contained in the maintenance database (FENIX).
Surveillance tests required in the technical specifications are properly conducted in
accordance with F1-I-312 (Administrative procedures for technical specifications -
related testing) and relevant procedures. Operational management approves the tests to
be performed during the daily operation review meeting held in the morning.
Tests are documented in FENIX as well as in binders after review by the Shift
Supervisor and are noted in the minutes of the daily operation review meeting. Trend
analysis of test results is performed by shift members and the technical department of
maintenance unit. However, the comprehensive review of surveillance test results
including trend analysis over a long term, is not conducted systematically. A suggestion
by the team is made in this area.
In cases where the test is not performed or is not successful, the operations management
is informed by the Shift Supervisor. It is clearly stated in the technical specifications
(Chapter 3) what correctives actions should be taken when a surveillance test result is
found to be unacceptable.
Changes to the technical specifications are reviewed by the safety committee as an
independent safety review. The President approves the change proposal based on the
committee’s recommendation. All changes of operating and maintenance procedures
used for surveillance tests required in the technical specifications, should be reviewed by
the safety and environment unit as an independent safety review after the primary safety
review by the operational manager. The process is implemented in accordance with F1-I-
302 (for unit 1).
5.3 PLANT MODIFICATION SYSTEM
Plant modifications are defined as all changes and new facilities that affect the technical
documentation, including changes of operation, maintenance and safety analysis.
Plant modifications are properly implemented such that:
• Plant modifications are selected and prioritized in the best possible manner that
supports the company’s business concept.
• Each plant modification is performed with the least possible disruption to
production and while retaining nuclear safety.
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The TS unit has an overall responsibility for the plant modification process. The roles
and responsibilities for relevant departments are clearly documented. The process owner
is the TS unit manager and the process manager is the project department manager of the
TS unit. The production unit is responsible for planning, prioritization and specification
of plant modification, while the project management is responsible for ensuring that
design, procurement, implementation and commissioning are planned and executed as
requested by the production unit.
Plant modification programmes are performed according to systematically established
instructions and procedures. F- I- 259 (Plant modification process) is the primary
instruction for processing plant modifications. F-I- 274 (Inventory and Specification) and
F-I-261 (Implementation) are sub process instructions and several instructions are
provided for performing each specific modification activity. Procedures for each plant
modification are prepared under the requirements specified in the above instructions. A
good practice was identified by the team in the application of the Human-Machine-
Interface design.
A safety review for each plant modification is conducted in compliance with F-I- 824
(Safety review). The instruction clearly describes how the plant modifications are
classified according to the safety significance and how the safety review is performed
depending on the safety significance. Plant modifications belonging to safety review
group 1 should be reviewed in full and finally approved by the operational management
level 1 following the safety committee.
Installations, inspections and tests are properly implemented in accordance with F-I-299
(Installation) and F-I-271 (Commissioning) and the testing records are properly
documented.
Controlled documents which are required for operation and maintenance are clearly
defined. They include an operational systematic diagram, an operations manual and a
maintenance manual. The revised controlled documents, relating to a plant modification,
are drafted by the TS unit and are well controlled and are submitted to the operations unit
and maintenance unit (clients) in advance, i.e. several months before the hand-over stage.
However, the finalization of controlled documents is not always completed at the handover
stage of the modified system and equipment, from FT to the clients. A suggestion
by the team is made in this area.
5.4 REACTOR CORE MANAGEMENT (REACTOR ENGINEERING)
The core and fuel department of the TS unit (FTB) has clear responsibilities for reactor
physics and fuel engineering. Reactor physics group handles 1) In Core Fuel
Management (ICFM) for operational safety monitoring and 2) core design within the
project of “Ready Core”. The fuel engineering group (FTBR) mainly addresses the
project of “Ready Core”, relating to the reload of fuel and control rods, in addition to
other activities of fuel transport.
FTB has one physicist and at least one “backup” physicist allocated for each unit to
ensure smooth and high quality work. Thorough recruiting, training and experience
feedback are appropriately performed to maintain the expertise of reactor physics and
fuel engineering.
The procedures of core management and fuel engineering are properly documented in F-
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I-338 (comprehensive instruction on description of process of ready-core) and other
instructions.
Reactor core and associated safety parameters are properly monitored and trended in
accordance with FT-I-206 (Instruction for TIP-analysis). In core calculation results serve
as the basis for evaluation of core operation and they are reported monthly to the relevant
units including senior management. A good practice by the team is identified in the
application of the core stability prediction calculation code.
The reactor thermal power change rate is clearly prescribed in D-I-1003 and D-I-1000
(operation manuals) to mitigate PCI (pellet clad interaction).
The plant has experienced ten fuel failures since 2004. The plant issued the Safety
Directive (FKA-2004-193) including policy regarding fuel failure. Root cause
investigations of failed fuel have been conducted intensively by FTBR in accordance
with FT-I-224 (Instruction for project management of repair of failed fuel). Most of the
fuel failures were identified to have occurred due to debris fretting.
After a fuel failure is detected, the actions to be taken are discussed at a special meeting
consisting of operations unit, chemistry department and FTB and the actions are clearly
noted in the meeting minutes. Based on the decision taken, the operations unit and
chemistry department appropriately take necessary actions regarding implementation of
neutron flux-tilting operation, increased frequency of monitoring of radionuclides in the
coolant water and other necessary activities in accordance with the prepared instructions.
Various considerations are taken into account in the application of computer
programmes. A computerized offline system can only receive data from the online
system through a firewall, while the data from the offline system only can be transferred
to the online system through external media, e.g. CDs. The routines for transferring
updated data such as burn-up to the online system are supervised by the operational
management. In addition, the change of the programme CASMO, with corresponding
cross-section directory, and POLCA used for online and offline core calculation
applications are always performed in accordance with the plant modifications procedure.
Only the FTB manager can change the authorization level of the Core Master, part of the
offline core calculation system.
The inventory of fissile material for each production unit is regularly verified and
checked with a computerized system.
5.5 HANDLING OF FUEL AND CORE COMPONENTS
The roles and responsibilities of relevant departments in handling fuel and core
components are clearly documented in LOK.
The inspection and transportation of new fuel assemblies is properly conducted in
accordance with standards, e.g. UIM-3246-001 (unit 3). When new fuel assemblies
arrive at the plant, they are transported to the dry storage area for inspection. If no
problems are detected on the fuel, they are stored in the designated dry area with
adequate control. Dry, fresh fuel assemblies are handled with an overhead traversing
crane in the reactor hall. Likewise spent fuels, stored in the fuel pool, are handled by the
fuel handling machine.
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All administrative fuel handling steps are sufficiently performed by means of the plant’s
computer-based system LADDA. The position of each fuel assembly is registered on
paper and independently checked against data in the LADDA system. The approved
storage of irradiated fuel and core components are ensured and the minimum cooling
period of spent fuel, before transportation, is established as nine months.
Transportation of spent fuel stored in casks is managed in accordance with procedures
for handling and loading of transport casks.
The “STAR” system used during accounting and safeguards reporting of fissile materials
fulfils every requirement in the EU regulation 302/2005.
5.6 COMPUTER BASED SYSTEMS IMPORTANT TO SAFETY
It is clearly documented in LOK that the TS unit is responsible for designing all systems
and equipment relating to computer applications, while the maintenance unit is
responsible for all maintenance activities for these systems.
The instruction (F-I-181) states that computer based application for software in safety
and safety-related systems should be met with the TBE (nationwide technical
requirements) and the KBE (nationwide quality assurance requirements) in accordance
with the requirements of the SAR.
Computer based applications, important to safety, are limited to two main groups, i.e. 1)
programmable electronics with a simple fixed application used in some dedicated
components and equipment such as UPS and switchgear equipment, and 2)
programmable electronics with a more complex fixed application used for the neutron
flux measurement systems.
In addition, consideration is also given to ensure that digital controls in safety
applications is based on implementation of programmable electronics with a fixed
application and the software applications cannot be overwritten or changed without
special equipment.
The plant process computer (PPC) has no direct safety function and is categorized to
safety class 4 and is a non-class 1E function, however, PPC has an important role of
monitoring and logging of plant operation. Handling and maintenance on non-safety
process computer applications are properly regulated in relevant procedures.
The plant has established that PPC and other process computers send all events and
almost all analogue signals once a minute to the long-term storage in the process data
base (PDB) containing process information dating back to the beginning of 1980s, which
is very useful for personnel outside the main control room.
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DETAILED TECHNICAL SUPPORT FINDINGS
5.2. SURVEILLANCE PROGRAMME
5.2(1) Issue: The comprehensive trend analysis of results of surveillance tests required
in the technical specifications is not conducted systematically.
The team observed the following facts:
• Test results are stored in FENIX as well as in binders after the review by
the shift supervisor.
• Trend analysis of test results is performed by shift members and technical
department of maintenance unit. However, this analysis is not always
conducted in a systematic manner. Exceptions include the frequency of
analysis and evaluation method of analysis.
• In addition, the trend analysis over a long term (several months to one
year) is not performed in a systematic way.
Without comprehensive and systematic trend analysis of surveillance test results,
the plant could increase the potential of missing the opportunity for early detection
of equipment vulnerability and unavailability.
Suggestion: Consideration should be given to conducting a comprehensive and
systematic analysis of surveillance test results.
Basis: IAEA Safety Guide NS-G-2.6;
Para 6.10
“Additionally, the results should be examined, where appropriate, for trends that may
indicate the deterioration of equipment.”
5.3. PLANT MODIFICATION
5.3(1) Issue: Some of the controlled documents are not finalized at the hand-over stage
of a modified system and equipment to operation and maintenance unit.
The team observed the following facts:
• At plant modification, the engineering department (FT) submits the draft
controlled documents to be revised to the operation unit and maintenance unit
(clients) in advance, i.e. several months before hand-over stage.
• The finalization of controlled documents is not always completed prior to
hand-over stage from engineering department to the clients.
• Operational documents for the replaced air compressor system were
handed over on 14 October 2007 but was only finalised on 12 February
2008.
• Operational documents for the replaced power range neutron monitor
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system were handed over on 21 June 2007, but are only going to be
finalised in March 2008.
• Operational documents for the process signal system were handed over on
26 June 2006, but was only finalised on 10 December 2007
Without finalized controlled documents being provided at hand-over stage to operation
and maintenance units, the plant could fail to prevent errors caused by use of preliminary
approved controlled documents.
Suggestion: Consideration should be given to finalizing all required controlled
documents prior to commissioning new modifications.
Basis: IAEA Safety Guide NS-G-2-3
Para 11.1
“The following should be ensured by means of the document management system:
- That all relevant documents affected by the modification are identified and updated,
and remain consistent with the plant specific design requirements, and that they
accurately reflect the modified plant configuration;
- That all changes to the design over the lifetime of the plant are based on the actual
status of the plant, as reflected in the current plant documentation;
- That the modified plant configuration conforms fully with the documentation and
conditions of the operating license.”
5.3(a) Good practice: The TIGER procedure ensures that HMI (Human-Machine-
Interface) design can be incorporated in modernization projects in an appropriate
manner. The TIGER procedure was developed in 1998. It has subsequently been well
applied to about 30 modernization projects in this plant since the start of application.
• The TIGER procedure is based upon a number of norms and guides from the
nuclear industry, e.g. NUREG, IEC and ISO.
• The TIGER procedure consists of a five step procedure, e.g. TIGER extent
description, present description, HMI design review, HMI verification and HMI
validation.
• At the stage of present description, all the operator work tasks that are affected by
the modernization are identified and analyzed by the TIGER group. Each TIGER
group consists of operators and different type experts.
• At the stage of HMI design review, a new HMI design developed by technical
design department is reviewed and approved by the TIGER group.
• At the stage of HMI verification, the TIGER group can be complemented by an
independent person that has not been involved in earlier steps in the TIGER
process, in order to achieve a more independent verification.
• At the stage of HMI validation, it is always performed by operators that have not
been earlier involved in the earlier steps of the TIGER process in order to show
that the modernization is in accordance with the other systems and functions
within the plant.
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5.4 REACTOR CORE MANAGEMENT
5.4(a) Good practice: MATSTAB (a full 3-dimensional neutron model in combination
with thermal hydraulic model) can provide information on core design for stability
prediction and stability optimization. This model features fast calculation speed and high
prediction accuracy. MATSTAB was developed by the plant in 2001 and subsequently
applied to all BWR Swedish plants.
• MATSTAB is developed in the context to prevent core instability incidents
mainly due to thermal hydraulic oscillation occurred in reactor vessel.
• MATSTAB takes full advantage of sparse matrix technology and frequency
domain methods to meet with the CPU requirements for a full 3-dimensional
reactor representation.
• MATSTAB can predict the behaviour of a global oscillation within 3 minutes,
using the interface with the online steady state core simulator (POLCA).
• MATSTAB can display the influence to stability of an individual fuel assembly.
This allows new insights into the mechanisms behind instabilities and also to
optimize the core design or a control rod pattern with respect to stability.
• The predictions of the code are validated against stability measurements obtained
at the plant.
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6. OPERATING EXPERIENCE
6.1 MANAGEMENT, ORGANIZATION AND FUNCTIONS OF THE OE
PROGRAMME
The operating experience feedback (OEF) programme is in place and includes the basic
functions of the OEF process. However, the criteria for reporting low level events and
near misses are not clearly defined in the existing documents. The team has made a
recommendation in this area.
The plant management has declared and demonstrated its commitment to follow safety
culture principles including a blame free policy and a commitment to support and
improve OEF as an effective tool to enhance operational safety. The OEF process is
considered as a production activity. All employees have a responsibility to contribute to
the OEF process. The plant policy, main goals, objectives and management expectations
are defined and described in a set of documents (LOK 3 “Quality Management System”,
F-I-845 “Operating Experience” (revised in October 2007), FT-I-1379 “FTQ
Organization and Responsibilities”).
A set of procedures dedicated to handling reportable events have been developed,
implemented and are used at the plant. However, under the process of the OEF
programme improvement, the existing procedures should be thoroughly reviewed and
updated to ensure that all duties, responsibilities and lines of communication within the
plant are clearly defined and understood.
In October 2007 a new department for OEF and analysis support (FTQ) was established
in the Technical Support Unit (FT) to manage all OE in a systematic and structured way.
The new department for OEF is composed of six persons qualified in plant operation,
personnel training and human performance. The allocated resources for the new
department for OEF are currently considered as adequate.
The plant has a plan to benchmark with British Energy on the organizational issues of the
OEF programme. A technical visit for OEF members of the new department is planned
to Heysham NPP (UK).
A group of coordinators for OEF was established at the plant in January 2008. The main
plant units (including: F1 – Forsmark 1, F2 – Forsmark 2, F3 – Forsmark 3, FM –
Maintenance Unit, FT – Technical Support Unit, FP – Human Resources, FQ – Safety
and Environment Unit, FG – Services and Facilities Unit, FU – Business Development)
have a nominated person responsible for ensuring that matters are handled as specified
by the OEF process and for ensuring that actions are taken within their unit. The OEF
coordinator is a liaison officer between their unit and the new department for OEF which
coordinates the group activity of OEF. A few of them have been trained on analysis
techniques for events that affect the interplay between Man, Technology and
Organisation (MTO). However, most of the relevant department staff for OEF have not
been specially trained in a root cause analysis methodology or the methodologies in the
OEF process. The team has made a recommendation in this area.
The organization of the OEF process is assigned between two departments: FQ (Safety
and Environmental Unit) and FT (Technical Support Unit). The first has a functional
responsibility for the OEF process, the second is responsible for some activities
(collecting, analysis, processing external and internal events, implementation of
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corrective actions programme (CAP), development of a new data base related to the
plant events, trend analyses). However, since the organizational changes started at the
end of 2007, it is too early to evaluate the effectiveness of this responsibility subdivision.
The plant uses the plant safety index (FSI) as a tool for monitoring the OEF process
effectiveness. Annual reports submitted to the safety committee, evaluating causes of
events and some trends, are also used for this assessment. However, the existing
monitoring system only covers high level indicators of the OEF process at the moment.
Reasonably low level indicators would make it possible to assess that the tasks carried
out in the OEF process are effective. It is very important to provide measurable goals and
objectives regarding the effectiveness of the OEF process. The team has made a
suggestion in this area.
6.2 REPORTING OF OPERATING EXPERIENCE
Operating experience at the plant is identified and reported according to established
criteria and procedures. The main types of events reported outside and inside the plant
are:
• events to be reported to the Swedish Nuclear Power Inspectorate (SKI) in the
form of Licensee Event Reports (LERs);
• events to be reported to the Swedish Radiation Protection Institute (SSI);
• component failures;
• low level events;
• near misses;
• observations of operating staff.
Reporting of different types of events at the plant is regulated by numerous procedures
(more than 12). Such fragmentation of reporting requirements in the plant documentation
may lead to a situation when the relevant plant personnel are not fully aware of the
reporting process. As a result, the fragmentation in the reporting process may lead to
performance issues. The plant is encouraged to integrate reporting requirements for
different types of events into a single document.
The reporting criteria for events to be reported to SKI and SSI and the timeliness of their
reporting are well defined and strictly met.
A formal procedure for organization of the investigation process exists at the plant (F-I-
158 “Description of LER Documentation”). In addition, the procedures which have stepby-step
instructions for managing the event inquiry are also provided for each unit (for
example, for unit 3 it is the “Operational Disturbance Management and In-depth
Technical Disturbance Analysis” (F3-I-1158).
The following levels of in-house reporting are established at the plant:
• Shift supervisor;
• Operational management level 3 (operations manager);
• Operational management level 2 (unit manager);
• Operational management level 1 (President);
• Safety and Environment Unit;
• Engineering and Maintenance Units.
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The reporting process at the plant also includes reports to the following authorities:
• County Administrative Board;
• Swedish Work Environment Authority;
• Swedish National Electrical Safety Board;
• Municipality Rescue Service Board;
• National Board of Fisheries;
• Swedish Environmental Protection Agency.
Activities of the OEF programme, such as the handling and analysis of low level events
and near misses are covered, but the criteria for reporting is not clearly defined in the
existing documents. Such uncertainties may lead to missed opportunities to evaluate
events or potential problems such as precursors of significant events as well as additional
data to draw realistic conclusions and take actions to improve the operational safety of
the plant. One of the reporting procedures, namely F-I-324 “Reporting of work injuries
and near misses and reporting to the authorities”, gives more clear definitions for near
misses in the area of industrial safety and radiation protection. However, this approach
has not been applied by the plant to other areas of activities (operation, maintenance,
etc.). The team has made a recommendation in this area.
6.3 SOURCES OF OPERATING EXPERIENCE
The possible sources of in-house operating experience are identified at the plant. These
include areas such as: significant events, low level events and near misses, quality
reports, reports and data from operation activities, maintenance testing and in-service
inspection, surveillance reports, results from plant specific safety assessments, training
feedback, non-blame reporting programme, performance indicators. Licensee Event
Reports (LERs) are the main source of OE at the plant. According to the procedure, all
events reported to SKI are used in the OEF process. Access of the plant personnel to
these sources is formally established and reports are distributed in a printed version and
electronic formats.
The plant uses several different external sources of OE, including good practices, as a
source of improvement. For the BWR operating experience feedback, Sweden is part of a
Nordic system where a common organization ERFATOM reviews experience feedback
for reactor safety and operation of nuclear facilities. Other experience feedback, initiated
by ERFATOM or internal organizations, is also reviewed and placed in a common
database. ERFATOM is formed by the Swedish and Finnish BWR-operators and
Westinghouse Electric Sweden AB. The analysis work is performed by representatives of
these organizations and the result of the work is reported to the plants in weekly and
monthly reports complemented with topical and annual reports. The event reports are
classified. Severe events also include recommendations directed towards the Swedish
and Finnish operators.
Other external sources of OE include reports from IAEA/NEA IRS and reports from
WANO (including SER, SOER). These sources of information are screened by KSU in
cooperation with ERFATOM. KSU maintains the interface between the plant and
WANO. In addition, external sources of OE include information on OE of similar
systems and components (electrical, mechanical, etc.) from other power industry
activities in the country and from other countries operating BWRs. There is intensive
participation of plant personnel in exchange of OE related to maintenance matters in
different programmes and forums such as Nordic Owners Group, BWR Owners Group,
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INPO/EPRI, Vattenfall, Westinghouse, Alstom (not only nuclear enterprises), IAEA
programs for training maintenance personnel and contractors, I&C technical and
managerial meeting, Outage maintenance experience and SKI meetings.
6.4 SCREENING OF OPERATING EXPERIENCE INFORMATION
Internal events are primarily screened at the plant during daily planning meetings, the
weekly operational review meetings and the safety committee meetings.
The department for OEF initiated, in January 2008, a new screening process for internal
events of any categories with a group of OEF coordinators. One of the items of this
“weekly screening meeting” is the presentation of the main stages of RCA
methodologies (as self-training) as well as the demonstration of access to the external
sources of OE information (for example WANO Operating Experience Programme).
However, the screening process for internal OE is not established in the plant procedures.
Accordingly, there are no criteria for systematic screening of in-house events. Screening
of OE information should be undertaken to ensure that all significant matters relevant to
safety are considered and that all applicable lessons learned are taken into account. The
screening process should also be used to select events for detailed analysis and to
prioritize OE information use according to safety significance and the identification of
adverse trends. The team has made a recommendation in this area.
External events are primarily screened and evaluated at ERFATOM teleconference
meetings held every second week. The participants of the teleconference meeting are
senior engineers from Westinghouse, Nordic utilities, FKA and KSU. The events are
classified by participants on four categories: Class A (High impact on safety. Evaluated
in details and followed by actions to be taken at the plant. In some cases the actions to be
taken are upgraded to ERFATOM Recommendation), Class B (Medium impact on
safety. Root cause analysis and relevance for other Nordic BWR is reported), Class C
(Minor impact on safety. May be of interest for other plants and is reported), Class N
(Not applicable or of no interest to Nordic BWRs). After consensus has been reached on
the evaluated event, the project manager issues the ERFATOM evaluation report which
is distributed electronically to the utilities. ERFATOM handles approximately 300
reports per year.
At the plant, ERFATOM evaluation reports are handling by the group of OEF
coordinators and administered by the department for OEF.
Significant reports, such as WANO SOERs are screened and reviewed by the plant safety
committee. As a result of the review, analysis of the applicability for the plant is
performed and reported back to the safety committee, where decisions on further actions
are taken.
6.5 ANALYSIS
Special analyses techniques are established for events that affect the interplay between
Man, Technology and Organisation (MTO). Nuclear safety events and industrial safety
incidents and accidents are analysed. The events are categorised and trended by an MTO
group comprising representatives of the Production Units, Maintenance Unit, Technical
Support Unit and the Safety and Environment Unit. Behavioural scientific experts also
participate in the analyses.
Both the Maintenance and Technical Support Units have resources for technical analysis.
The process of event analysis in the Maintenance Unit is controlled by FM-I-017
“Maintenance Unit’s and Production Unit’s Operating Experience Feedback Activities”.
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Full root cause analysis is required if an event has involved safety or safety related
systems, i.e. for events to be reported to SKI. However, the existing RCA methodology
(FT-I-1397) as well as the MTO-analysis (F-I-126) is used for a limited number of events
(only significant events from the plant’s point of view or upon request of the regulator).
The team took into account that the improvement of the OEF process at the plant started
in autumn of 2007. Review showed that this is being progressed.
As stated, root cause analysis process is described in two separate documents for
different levels of investigation: FT-I-1397 “General Instructions for Analysis” and F-I-
126 “MTO process”. Taking into account similar elements of applied methodologies
(ASSET, HPES and MTO) it would be more logic and practical to provide the root cause
analysis process for different types of events in a single document. It is very important to
provide a document with clear definitions of abnormal events, recurrent events, apparent
causes, direct causes, root causes, contributing factors, etc. as well as a classification of
causes applicable to any event at the plant. Therefore, the plant is encouraged to enhance
the procedure for the event root cause analysis process.
In 2007, an independent review of all LERs and assessment of significant external events
by the safety committee was initiated. The review involved an assessment of root causes,
of the adequacy and the applicability of corrective actions and a safety assessment of the
event. The LERs are submitted to SKI after this review.
A structured approach in presenting evaluations of high level OE reports to the top
management ensures that dissemination of OE is efficient and correctly addressed. Each
WANO Significant Event Report (SER) and Significant Operating Experience Report
(SOER) at the plant is assessed in the highest and most important forum for safety issues:
the plant Safety Committee. Upper management is involved in the processing and
evaluation of these documents. An assessment is first performed for applicability,
relevance and importance to safety and then the reports are forwarded to the responsible
department for more thorough analysis. Time for presentation of the results in the FKA
Safety Committee is scheduled in the meeting agenda. The WANO SER and SOER
documents have been processed in this manner since March 2007. The team considers
this as a good performance.
6.6 CORRECTIVE ACTIONS
The development of corrective actions is described in FT-I-1397 “General Instructions
for Analysis”. The corrective actions are expected to be SMART (specific, measurable,
achievable, realistic, within appropriate time). However, criteria for prioritization of
corrective actions and for conservative decision making are not clearly defined in
procedures because the existing programme was developed a long time ago and has not
been adapted to cater for the follow up of corrective actions.
The work order system is used to track corrective actions. For LERs and component
failures registered in the FENIX tracking system, the progress of corrective action
implementation is provided. For minor events and near misses, tracking is provided in
limited areas of activities at the plant.
A review of corrective actions status and effectiveness is periodically performed by the
plant units responsible for implementation of corrective actions and by the plant safety
committee.
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During the mission, the plant demonstrated to the team that positive steps were being
taken to improve the OEF process including the development of a Corrective Actions
Programme (CAP) which was started in autumn of 2007. The new CAP includes the
detection of deviations, documentation, decision on analyses, prioritizing, identification
of corrective actions, control and approval of actions, tracking of actions, monitoring and
trending.
6.7 USE OF OPERATING EXPERIENCE
Information on event reports and analysis results is accessible to plant personnel through
the intranet. However, the department for OEF (FTQ) has no access to the unit’s data
bases on LERs. The plant is encouraged to enhance the existing process for access to inhouse
sources of OE information.
Operating experience data is extensively used in the main control room and for other
plant personnel training at the training centre. Information on most significant events is
analyzed and then implemented in KSU simulator training. The data that are considered
to be applicable to the plant are analyzed and incorporated into the training programmes
of the relevant personnel. In the Maintenance Unit, the information on the applicable
internal and external OE is introduced to the supervisors and workers (including
contractor personnel) to focus them on the important aspects: specifics, cautions, etc. of
the forthcoming activity. The plant practices the utilization of the relevant OE
information before important operating activities via pre-job briefings.
The plant also maintains the following systems for OE dissemination: the outage
experience system on the results of the units’ maintenance, Digitala Logböcker
(observations of operating staff), the system for all employees to report to the
management “Öppen Kanal”.
Despite the fact that the plant has disseminated a large amount of valuable information
regarding internal and external OE to the staff, feedback is not mandatory. This is
because of the feedback process regarding the OE information is not clearly formalized
and documented at the plant. A considerable amount of external and internal OE
information is placed on the plant intranet system. However, the existing system of
organization and logging the feedback from recipients of OE information does not allow
tracking to assess adequately who was specifically informed and what further actions
follow, i.e. findings and remedial actions. The plant is encouraged to enhance the
established procedures for the control of in-house activities of the feedback of OE to
ensure that they are consistent with the objectives of the management system.
6.8 DATA BASE AND TRENDING OF OPERATING EXPERIENCE
The plant maintains several data bases to facilitate the handling of OE throughout the
respective units.
The data base on events reported to SKI (LERs) complies with the investigation reports
with their safety assessment, identified causes and proposed corrective actions. This data
base is generated and maintained by each responsible production unit. Results of
supporting in-depth event analysis are stored separately in the form of analysis reports.
Specific corrective actions developed after the event investigation are stored and tracked
in the work order system. The existing subsystem for tracking LERs, in particular, has a
limited structure and coding of causes. The software of the data base allows for the
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etrieval of events by a limited number of attributes (report number, category, causes,
etc.).
The plant maintains the FENIX system which provides the integrated information
analysis support of plant operation problems related to component operation history, to
maintenance, to spare parts, radiation safety and fire protection, etc. LER information
related to component operation is also put into the data base. The FENIX system has a
procedure called “Data export into “TUD system” for the automatic preparation of
structured information package to be transmitted from the unit into the TUD system (for
Swedish and Finnish BWR plants). The TUD system collects data of component and
equipment faults. The data is the basis for component and equipment failure rate
calculations that, in turn, are used for probabilistic safety analysis (PSA).
For minor events, including low level events and near misses, a data base has not been
developed. Fragmented parts of minor events are stored in different systems.
The classification/coding of events of different types is not defined in the plant
procedures. The existing trending system covers only events reported to SKI and
component failures. Trending is performed by different plant units on the basis of
experts’ experience because of the absence of established criteria. Using data base
information, the plant issues monthly, quarterly and annual unit operation reports. These
reports contain information on component reliability, plant operation schedules,
economic indicators, WANO performance indicators, etc. Reports are also forwarded to
interested organizations (Vattenfall, SKI). Results of trend analyses are compiled in
annual reports presented to the safety committee.
A new data base is under development to provide access to OE information to the plant
employees. The team recommends enhancing the structure of the existing data base on
events reported to SKI (LERs) by developing an integral data base with minor events,
with application of a common coding system for all types of events. Coding systems
developed by the IAEA/NEA (IRS) and WANO could be a basis for the plant system.
6.9 ASSESSMENTS AND INDICATORS OF OPERATING EXPERIENCE
A review of the OEF process has been performed by the plant Safety and Environmental
Unit and Technical Support Unit. However, no performance indicators directly related to
the plant OEF process have been established, other that a monthly review (report) on
reportable events and an annual report on plant operation, neither of which can be
considered as a comprehensive self-assessment. The plant also has had no opportunity to
benchmark with other plants and utilities to identify further improvements because it has
no data on the particular trends of low level events and near misses.
The plant uses the Forsmark Safety Index (FSI) as a tool for monitoring the OEF process
effectiveness. Annual reports submitted to the safety committee evaluating causes of
events and some trends are also used for this assessment.
In addition to the FSI, there are twenty one Quality Indicators that were developed in
2007 and are in trial operation. These indicators are there to measure the effect of the
corrective action programme. However, some of the indicators are duplicated with the
indicators from FSI.
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These indicators do not reflect the timeliness of OEF process, recurrent events and root
causes, average time for initial screening of OE, number and age of reports awaiting
evaluation, number and age of corrective actions awaiting implementation, etc. The team
has made a suggestion in this area.
A special review of the event of 25 July 2006 was conducted and is included as an
attachment to this section.
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DETAILED OPERATION EXPERIENCE FINDINGS
6.1 MANAGEMENT OF OPERATING EXPERIENCE FEEDBACK
6.1(1) Issue: The plant procedures do not clearly define the criteria for reporting of
events less significant than events to be reported to the regulatory authority.
• The procedure FT-I-1397 “General Instructions for Analysis” sets only
generic definitions of minor events, low level events, near misses, namely:
“Minor events (of lesser importance to reactor safety)”.
• The procedure F-I-324 “Reporting of work injuries and near misses and
reporting to the authorities” gives relatively clear definitions for near misses
but in the area of industrial safety and radiation protection only.
• The procedure FM-I-037 “Disturbance analysis instruction – Maintenance”
has only a generic definition of minor events. For example:
“Level 1
Disturbance for which the cause is unknown and analysis is required. This indepth
analysis is initiated for major disturbances where internal operational
disturbance analyses are deemed insufficient.
Level 2
Minor disturbance for which the underlying cause is unknown and a simple
disturbance analysis is deemed sufficient. It is normally initiated by FMY
when assessing a work order. A simple reporting template is used.”
It may lead to missed opportunities to evaluate events or potential problems such as
precursors of significant events as well as additional data to draw realistic conclusions
and take actions to improve operational safety of the plant. By taking action in
response to minor events and potential problems as part of the plant OE data can
prevent more significant events from occurring.
Recommendation: The plant should provide clearly defined criteria for reporting
of events which are less significant than events to be reported to the regulatory
authority to enhance the plant operating experience feedback system. The criteria
should be clearly communicated to all staff and contractors to ensure adequate
reporting levels.
Note: IAEA-TECDOC-1477: Trending of low level events and near misses to enhance
safety performance in nuclear power plants.
“The objective of this publication is to provide guidance for the enhancement of
operational safety performance through the use of the low level events and near
misses as an important input to the operational experience feedback (OEF) process”.
Basis: NS-R-2; 2.24 All plant personnel shall be required to report all events and
shall be encouraged to report on any ‘near misses’ relevant to the safety of the plant.
INSAG-15; 3.4 (a) Failures and ‘near misses’ are considered by organizations with
good safety cultures as lessons which can be used to avoid more serious events. There
is thus a strong drive to ensure that all events which have the potential to be
instructive are reported and investigated to discover the root causes, and that timely
feedback is given on the findings and remedial actions, both to the work groups
involved and to others in the organization or industry who might experience the same
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problem. This ‘horizontal’ communication is particularly important. Near misses are
also very important because they usually present a greater variety and volume of
information for learning. To achieve this, all employees need to be encouraged to
report even minor concerns.
The following are pointers to consider in moving towards a strengthened safety
culture:
(a) Are employees encouraged to report all events and near misses? Given that
research has shown that the number of near misses usually exceeds the number of
actual events by at least an order of magnitude, is the ratio of reports of near misses to
events with real consequences sufficiently high?
6.1(2) Issue: The plant has no initial training (for full scope of methodologies applied)
or periodic requalification of personnel involved in the event root cause analysis
process and use of operating experience.
• A new department (FTQ) established at the plant for OEF and analysis
support is composed of people qualified in plant operation, personnel training
and human performance but not specially trained in a root cause analysis
methodology as well as a methodology on OEF process.
• Within the plant departments, there are insufficient staff fully trained to
conduct full root cause analysis.
Without having properly trained experts the analysis of events with respect to causes and
contributing factors as well as the operating experience process can be treated in an
improper manner possibly resulting in recurrent safety significant events.
Recommendation: The plant should organize and implement the system for regular
training and retraining of personnel involved into an event RCA process and OEF
process.
Basis: NS-G-2.4; 6.67 The responsibilities, qualification criteria and training
requirements of personnel performing activities to review operating experience should be
clearly defined. Personnel who conduct investigations of abnormal events should be
provided with training in investigative root cause analysis techniques such as accident
investigation, human factor analysis (including organizational factors), management
oversight and risk tree analysis, change analysis and barrier analysis. Event investigators
should be knowledgeable of plant design, procedures and operations.
6.1(3) Issue: The plant does not provide a comprehensive and regular monitoring of the
effectiveness of the OEF process.
• The existing monitoring system only covers high level of the OEF process and
does not provide clear information on the effectiveness of the OE process at
different levels of the organizational structure.
• The organizational enhancements started in the end of 2007 as responsible
subdivision for the OEF process.
Ineffective assessment of the OEF process’ effectiveness may lead to the situation where
a portion of employees are not involved into the overall process for preventing the
reoccurrence of similar events and improving operational safety of the plant.
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Suggestion: The plant should consider the enhancement of methods for review and
monitoring of the OEF process effectiveness.
Basis: NS-G-2.4; 6.62 An effective programme for the review of operating experience
should be established to provide methods to analyse both in-house events and events in
the nuclear industry generally so as to identify plant specific actions needed to prevent
the occurrence of similar events. In-house events of interest to other plants should be
shared with the industry to prevent the occurrence of similar events. The effectiveness of
the operating experience review programme should be assessed periodically to identify
areas of weakness that require improvement.
6.4 SCREENING OF OPERATING EXPERIENCE INFORMATION
6.4(1) Issue: The screening process for in-house operating experience information is not
defined in the plant procedures.
• Screening criteria for in-depth root cause analysis are not established.
Responsibilities for this decision are unclear.
• The thresholds for exclusion or inclusion of events as well as the prioritization
of actions to be taken are not specified.
• The amount of information introduced into the plant OEF process is not
evaluated.
Recommendation: The plant should develop and implement a procedure for screening
in-house OE information.
Basis: NS-G-2.11; 3.1 Screening of event information is undertaken to ensure that all
significant matters relevant to safety are considered and that all applicable lessons
learned are taken into account. The screening process should be used to select events for
detailed investigation and analysis. This should include prioritization according to safety
significance and the identification of adverse trends.
NS-G-2.11; 3.6 The screening of internal events should be carried out promptly to
assign priorities in the process for the feedback of experience from events and in the
follow-up actions. The screening of internal events should be performed first by
appropriate personnel to determine whether there is any immediate implication for the
plant. Events should then be screened by a suitable multidisciplinary group of plant
personnel on the basis of specified criteria to determine whether the regulatory body or
representatives of the utility need to be notified. This group should meet regularly to
review every event that occurs at the plant and to discuss whether the causes have been
clearly identified, whether corrective actions have been taken or planned, and whether the
corrective actions are commensurate with the causes of the event. The events that were
screened and initially found to be of less safety significance should be considered for
trend analysis. The results of screening may be reviewed in subsequent periodic plant
self-assessments or in peer reviews. The history of the screening process should be made
available to the regulatory body.
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6.7. USE OF OPERATING EXPERIENCE
6.7(a) Good Practice: Structured cooperation with the original equipment manufacturer
(OEM) for OE dissemination for improvement of safety.
It is advisable to integrate the knowledge from the OEM in the OE process for two
reasons. Firstly, the expertise of personnel at the OEM can be used for the evaluation of
the reports. Then the reports can be used as a basis for initiating bilateral technical
projects.
In cooperation with the original equipment manufacturer (OEM) Westinghouse Electric
Sweden (former ASEA-ATOM) the plant has together with the other operators
established a programme for screening external events. This programme is called
ERFATOM and has been operational since 1994.
The input comes from sources commonly used in the industry, e.g. WANO, IRS, and
NRC. In addition Finnish and Swedish reports (Licensee Event Reports) to the regulatory
bodies are used as input.
Each utility has the opportunity to report events of interest even if the event is not
reportable to the regulatory body.
Each event is screened for applicability for the BWR-plants in Sweden and Finland. The
programme has a designated engineer at each site for the evaluation of the reported
events. A common database is used for the processing of the reported events. At the
OEM the knowledge from safety experts and component/system engineers are used for
the evaluation. The events that pass the first screening are classified according their
relevance to safety.
A telephone conference is held every fortnight with representatives from FKA, OKG,
RAB, TVO and OEM Westinghouse in cooperation with ERFATOM. At the conference,
the events are to be evaluated (international events and international and Swedish LERs)
are selected. These events are then evaluated and prioritized before they are presented to
the operators. This approach ensures that disciplined contact with the manufacturer
(OEM) concerning events that have occurred in the nuclear-branch is maintained.
The output is a report issued every second week where additional relevant comments are
noted. The plants have this report and may use it for additional work in a separate
database.
In this way the utilities use the OEM expertise evaluations of events for improving
safety.
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ATTACHMENT
EVENT OF 25 JULY 2006
Summary of Event
On 25 July 2006 Forsmark Unit 1 was in full power operation when a disturbance
occurred in the off-site 400kV sub-station that caused the reactor to automatically trip.
The event generated two transients on the power supply to the unit. The first was an over
voltage transient that caused the failure of two Un-interruptible Power Supply systems
serving the 220 V AC grid in trains A and B. (C and D were unaffected by the transient)
These 220V AC systems were necessary for the operation of the emergency diesel
generators (EDG) associated with trains A and B. The second transient was a low
frequency transient that caused disconnection of the off-site power to the safety related
bus bars.
The transients resulted in an automatic reactor power reduction and reduction of the
speed of the main recirculation pumps. The unit went onto house load operation for a
short period before signals were received for reactor automatic trip, isolation of the
primary containment and the start of the reactor safety systems.
All four EDGs started automatically, but A and B EDGs did not connect to their
respective bus bars due to loss of their speed signal power supply.
In this situation two out of four trains in each safety system were operationally available
(auxiliary feed water system, core spray system and containment spray system). Two out
of four trains will provide 100% capability. The loss of two 220V AC bus bars however
caused several isolation signals and also loss of several information systems in the Main
Control Room (MCR). All of the above failures, automatic changeovers, and transients
occurred within the first minute of the event. The 70kV electrical system remained
available throughout the event.
The control room staff initiated the “first checks of disturbances” immediately. On
completion of the initial checks, the “General Disturbance Instruction” was implemented
and following a review of all available information, after approximately 22 minutes, the
6.6kV power supply to sub-divisions A and B was reconnected and thus all power was
available to the unit. After 45 minutes the operators confirmed that the unit was in a shutdown
mode (Hot Standby). Following initial fault finding investigations and review of
the status of the reactor the unit was placed in Cold Shutdown the following morning (26
July 2006)
Summary of Event Review Process
Following stabilisation of the unit in Hot Standby the event review was commenced with
a meeting chaired by the Unit 1 Manager and attended by representatives of the
departments of Operations, Maintenance, Electrical, Control and Instrumentation, Safety
and Environment, Engineering and Technical Maintenance Analysis (the event occurred
during the vacation period and many staff were on vacation and not all departments were
represented by their Heads).
The plant procedure F1-I-609 “Operational disturbance management and in-depth
technical analysis of disturbances” was used as the basis for the subsequent event
investigation. This procedure specifies the Objective, Scope, Initiation and Execution of
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an investigation and has appendices for convening personnel, trouble shooting, collection
of suggested measures, underlying information for action plan, data collection after the
disturbance, and template for disturbance analysis and event description.
An analysis leader with supporting deputy was appointed. At the initial Unit 1 meeting it
was decided that each focus area of the event inquiry would be analysed by sub-teams
and that the appointed analysis leader would bring these separate inquiries together into
an overall report. Their focus was to identify the cause of losing the safety trains,
analysing how the plant had responded to the event in general and identifying the
consequences of the event on pressure vessels, fuel etc. It is apparent that at the time
many people still thought they would be returning the plant to power in the near future.
At the first Unit 1 meeting it was decided that the initial areas requiring review were:
Event Sequence, 400kV activities, UPS failure, EDG failure, and Control Room
activities.
As the event review progressed the importance of topics for in-depth investigation were
reviewed and more focus areas were added including; reactor and turbine functions, low
frequency protection of the Generator circuit breakers, vessel integrity, reactor coolant
pump rundown, relay testing procedures, possible voltage transients, 70kV automatic
functions, and “What If” analysis. In total 22 focus areas were identified as requiring indepth
analysis.
The initial event report was developed within three days and reviews conducted through
the regular Unit 1 Primary Safety Review Meeting, the plant independent review process
and the plant Safety Committee. The agreed initial report (version 3) was then submitted
to the Swedish regulatory authority (SKI) on 3 August 2006.
As the event inquiry progressed further revisions were made and passed through the
review process culminating in the issue of the final event report on 27 September 2006
(version 8).
During the progress of the event investigation the frequent ad-hoc Unit 1 meetings were
formalised into a daily meeting held at 1300hrs with a formal agenda considering
progress on on-going analysis, progress of corrective actions and completed analysis
reports, etc.
Following completion of the event review, and non-requirement for the continuation of
the special Unit 1 daily progress review meetings, an action plan was developed to
control and track corrective action progress. A list of actions (the 60 Point list) was
prepared. The list contained actions already completed plus those in progress and their
proposed completion date. The list is now overseen by the Business Development Group
and regular progress reports given to plant Management Meetings and plant Safety
Committee meetings.
Off-site Reporting and Communication of Event Information
Swedish Regulatory Authority (SKI)
SKI was immediately informed that the event had occurred and they conducted their own
investigation following the event to satisfy them that the plant was in a safe condition.
SKI representatives also attended the plant Safety Committee as observers. Throughout
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the event investigation SKI was also provided with specific information to answer
various international inquiries.
KSU/ERFATOM
KSU/ERFATOM was informed shortly after the event. ERFATOM received the LER of
the event on the 11 August 2006 and handled it according to normal procedures for
evaluation and reporting to the other Swedish and Finnish BWRs.
IAEA Nuclear Event Web-Based System –International Nuclear Event Scale
notification
The event was reported to IAEA NEWS - INES system on 27 July 2006 as an INES
Level 2 event.
IAEA/NEA Incident Reporting System (IRS)
A preliminary report was received by the IAEA on 16 August 2006 and the final report
was received on 4 September 2006. These were discussed at the IAEA General
Conference in September 2006 and the IRS country co-ordinators meeting in October
2006.
World Association of Nuclear Operators (WANO)
Reporting was via KSU/ERFATOM. An Early Notification Report (EAR) was prepared
by the plant and posted by WANO on their proprietary web site (not available to nonmembers
of WANO) on 10 August 2006.
Following a plant visit by WANO a Significant Event Report (not available to nonmembers
of WANO) was issued in June 2007.
Nuclear Energy Agency (NEA)/Organisation for Economic Co-operation and
Development (OECD)
The event information was presented in detail to a NEA/OECD meeting in December
2006 (note: this was not an IRS co-ordinators meeting).
Local Community
Key persons within the Local Safety Council and Local Community Government were
informed (this was not actually required by the procedures but is usually done when
events occur as a matter of courtesy and helps to build confidence between the plant and
the local organisations) A special meeting was held with the Local Safety Council on 17
August 2006 to detail the event. (The Local Safety Council is formed from locally
nominated council representatives (however, it does not include the local emergency
services)).
Press Reports
The plant made their first press release one hour after the event occurred on 25 July 2006
and SKI issued a press release two days later.
The national and local newspapers first published articles about the event on 28 July
2006
The plant ran through the event on the simulator for media (approximately three weeks
after the event). This exercise was considered a successful method to demonstrate and
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explain the event in a concise and visual manner and was also performed for other groups
including the SKI senior management, local government and council representatives, etc.
COMMENTS ON SPECIFIC TECHNICAL AREAS AND OPERATIONAL
ACTIVITIES
The 400kv Electrical Sub-station
Identified Causes
The cause of the initiating event was determined to be an inadequate review of switching
work orders by grid owner due to deficient administrative routines.
Status of Corrective Actions
The damaged isolator was repaired and restored to an operational state.
The plant and the Grid Authority have established a working party to look at interfaces
and a common control document was developed and agreed to specify communication,
outage planning, handling of operating instructions/work orders, Interface Meeting
schedule, education and competence.
One point of contact for the plant has been identified (Control Room is still main point of
contact for routine operations) and Grid Authority contacts have been defined in the
control document.
Operations involving Bus-bar protection (Collector Rail) can no longer be carried out if
the reactor is on load.
The entire 400kV sub-station will be replaced in 2009 ( this decision was made prior the
event).
OSART Comment
The new instruction on Operations involving Bus-bar protection appears to be too
equipment specific; it maybe appropriate to include that a higher level of scrutiny should
be applied to reviewing tasks that are infrequently performed or are innovative. (The
plant did receive the draft switching work order two weeks before the fault occurred and
it was sent to all the relevant departments; however the omission of the requirement to
block the protection was not recognised. The switching work order was complex and
covered many operations and activities to be fulfilled). Breaking complex switching
work orders into more discrete orders may have assisted in identifying anomalies.
Un-interruptible Power Supplies (UPS)
Identified Causes
The installed UPS had not been designed to handle a voltage transient as large and rapid
as it was subjected to in this event. There was a lack of selectivity between the rectifier
over voltage protection and the inverter over voltage protection.
The root cause was identified as a lack of a requirement to cater for voltage transients
outside the 85-110% range when the UPS was originally designed in the early 1990’s
Status of Corrective Actions
Voltage protection limits were changed based on extensive testing and verification
performed by the equipment supplier in order to safeguard the function of the inverter in
case of a voltage transient. Settings were changed to cope with transients within the 80 –
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130% range and testing has been performed on the plant. The Safety Analysis Report has
been updated with regard to the design requirements.
OSART Comments
There has been no explanation of why the other trains (C and D) remained available,
(although a probable cause has been identified).They had been set up exactly the same as
those that tripped and the likelihood of them also tripping was not prevented by design
requirements. The most likely reason was the different load and impedances between the
trains A, B, C and D.
Low Frequency Protection trip of Generator Breakers
Identified Causes
The plant identified that root cause of the failure of the low frequency protection system
was deficiencies in the modification design process.
The plant also identified that inadequate testing procedures contributed to the failure to
recognise the deficiency.
The plant modification process has been reviewed and amended.
Status of Corrective Actions
The phase sequence has been connected in the correct way and inter-boundary testing
conducted.
A new modification testing administration procedure has been developed for Electrical
and Instrumentation and Control. Extensive testing of other equipment has been
performed
OSART Comments
The plant should also ensure that they have reviewed past modifications, especially to
ensure that boundaries of responsibility between contractor and plant are adequately
considered. Lack of adequate testing (or inadvertent omission of testing of some parts of
an installation) has resulted in significant international events in the recent past and the
plant should ensure that they have adequately reviewed recent generic industry advice in
this area.
Emergency Diesel Generators
Identified Causes
The direct cause for the failure of the EDGs to connect to their associated 500V busbars
has been identified in the report. There is no reference to it having been a known
weakness in the design that was considered acceptable; the root cause of the weakness
continuing to exist at the time of the event.
Status of Corrective Actions
The direct cause has been rectified by modifying the signal to DC supplied, and
diversifying the supply (two EDGs on one DC voltage, two on another).
No root cause was identified and therefore no corrective action was proposed.
OSART Comments
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Because the direct cause of the EDG failures was obvious it seems that the plant did not
consider the root cause to be significant enough to warrant further analysis. The main
event report does not discuss the root causes of the weaknesses in the design of the
supply for the start speed signal of the EDGs. If the EDGs had connected to their
associated 500V bus-bars correctly the effects of the significance of the event would have
been reduced. A possible root cause could have been a failure to adequately assess
identified weaknesses in design. The corrective action would be a review of all known
rejected modifications to ensure that there are no other known weaknesses that have not
been fully assessed. (To review records for known weaknesses in design is perceived to
be extremely difficult – maybe too difficult when considering the possible returns in
enhancing safety)
70kV System
Identified Causes
The 70kV system remained available throughout the event, however, the back-up Gas
Turbine did not start when requested as stand-by. The cause for this was lack of adequate
maintenance.
Status of Corrective Actions
The maintenance processes and testing programme have been enhanced and put in place.
OSART Comments
It is important that each unit considers the impact of loss of 70kV on its operation when a
loss event occurs even if the loss is not as a direct cause of that unit. In most
circumstances it was noted that possibly affected units reported and considered the
implications (multiple LERs) however, there was one event noted (25 January 2002)
where this does not appear to have happened.
Control Room Activities and Indications
Identified Causes
The Main Control Room (MCR) activities were assessed by the plant to have been
conducted effectively in the circumstance of reduced available information and
indication. The review of MCR activities, however, identified twenty six improvement
measures (or areas for further investigation). The MCR activities report identified these
issues as Procedures/Documentation, Training Issues, Control Room Design and
Equipment. One of the concerns expressed by Operation Control Room staff was the
adequacy of shift staffing.
Status of Corrective Actions
An improvement in presentation of status of the 6kV bus-bar has been implemented. The
electrical redundancy for the process computer network will be doubled during 2008.
Replacement of bottleneck of information flow to the event recorder and increasing the
number of signals connected to it are some of the outstanding corrective actions awaiting
resolution.
A review of MCR staffing has been conducted and the long term goal for staffing is to
have an additional reactor competent operator on each shift. The purpose is to relieve
some of the workload on the shift supervisor and the other reactor operator.
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The electrical system control/indication computer supplies have been enhanced to
minimise possibility for loss during an event.
OSART Comments
The subsequent review of MCR was conducted by operations staff after the event. The
review was conducted through a meeting of all participants present during the event. The
assessment of improvement measures and deficiencies is basically done by “brainstorming”.
The leader of investigation had some knowledge of Root Cause Analysis and
Man-Technology-Organisation techniques but was not formally trained and had never
conducted a formal Root Cause Analysis before. The simulator was not used to
reconstruct the event, however, it was used later to demonstrate the event. The scope of
investigation was not adequately specified and was at the discretion of Operations
Management.
Many deficiencies were identified in the MCR, however, a full systematic root cause
analysis was not conducted to determine why they existed. The MTO process could have
been used (or adapted) to identify all the challenges to the operators during the event,
together with the root causes of these challenges and any contributing factors. The actual
review appears to have identified all the problems (direct causes) and corrective actions
have been taken or are planned to correct them.
Safety Assessment
Probabilistic Safety Assessment (PSA) on the Event of 25 July 2006
The event was analyzed by the plant in order to calculate the risk as a year based risk if
the error was present continuously. The probability for an un-acceptable release to the
environment during the event was 2.69·10 -5 . The probability for large release was
2.21·10 -6 .
The plant determined that four parallel actions were possible that would stop the scenario
developing further. The failed components were not broken and manual action could
have restored supplies to the 500V bus-bars from the 6.6kV system, the Gas Turbine
could have been started manually, the failed UPS could have been returned to service
manually, and the EDGs could have been started by-passing the start delay blocking.
Therefore, it was determined that, in the worst case scenario with no trains available and
no manual actions taken, the risk of loss of core cooling was not guaranteed after one
hour. However, it was observed that the decay heat, one hour after shutdown, would
have been substantially lower than that postulated in the assessment. This would have
resulted in a much greater time period to take mitigatory actions.
Conclusions
The plant has determined that failed components were not damaged and could have been
reinstated by manual intervention. They also considered that there were several
possibilities to recover the situation and low decay heat would have allowed more time
for manual intervention, a core damage scenario would have been extremely unlikely
even if all four trains had been lost during the event.
Evaluation of Root Cause Analysis
Prior to the event, training in performing event investigations and the use of event
analysis techniques appears to have been minimal. Approximately 15 people had been
trained in the Man-Technology-Organisation (MTO) analysis methodology, however,
only about three events a year are analysed using MTO so they are not all very
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experienced in its use. The establishment of the event inquiry and the conduct of the
analysis were not conducted to a comprehensive and systematic procedure. Terms of
Reference were not produced and the scope of the inquiry was not defined before the
various areas of concern were analysed. The methods used to conduct the investigation
and analysis varied between the responsible sub-teams and there is no evidence to
suggest that analysis tools such as Causal Factor Charting, Task Analysis, Change
Analysis, Barrier Analysis, and Equipment Failure Analysis were used systematically.
The event review was therefore heavily focussed on technical issues that had to be
corrected to return the unit to service. The original objectives (of the procedure used)
were focused on “identifying underlying technical causes of the disturbance to prevent
similar events, describing the measures to achieve operability and other technical
recommendations” Little focus was applied to Organisational Issues that could have been
at the root cause of the numerous failures. From the event report it is difficult to
determine whether all the identified causes resulted in corrective actions and vice versa.
The lack of focus on Organisational issues was eventually highlighted to the plant by SKI
in a decision (September 28, 2006) requiring the plant to implement measures to enhance
problem identification, analysis, and resolution including conservative decision making,
the Maintenance Process (including periodic testing), the routines and processes for
altering the plant (design and modification), and Safety Culture at all levels in the
organisation. Subsequent to this the plant developed an overall Action Plan.
Summary of Corrective Action Progress
Sixty six corrective actions (activities) were identified following the issue of the final
report by reviewing the notes of all the meetings (some had already been completed)
Of these, twenty three were classified as Priority 1 (actions that will have the most
(positive) impact of safety) addressing Forsmark Unit 1 or both Unit 1 and 2. All these
actions have been completed and assessed as effective. The last action to be completed
was on 31 December 2007.
Ten were classified as Priority 1 addressing Forsmark Unit 2 issues specifically. All these
actions have been completed and assessed as effective. The last action to be completed in
this group was on 31 May 2007.
Twenty one actions were classified as Priority 2 (Actions that give some (positive)
impact on safety) addressing issues on Forsmark 1 and 2. Eleven of these actions are
outstanding (at the time of this review) and many include lengthy in-depth reviews of
plant programmes. The most significant action remaining is deciding what information
should be available (presented) to Operations and Analysts during and after an event
(The need for segregated/prioritised alarm indications and a high speed event recorder,
completion date for this activity is 31 December 2008, however, that is not the specified
date for implementation).
Twelve actions were classified as Priority 3 (Actions that can wait for action and receive
priority later (reviewed again in September 2007)) addressing issues on Forsmark 1 and
2. Of these, six are outstanding.
Priority 4 were classified as actions that could be deleted (required a panel of Technical,
Maintenance, Unit 1 Manager Engineering and Operations to approve them).
In addition, the plant has developed an action plan for safety and culture improvements
resulting from regulatory concerns raised following the event review.
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Tracking of corrective actions from the “60 point programme” (as well as the programme
to enhance programmes and processes identified as necessary by SKI and outstanding
actions from international reviews) is conducted by the Business Development Unit and
reported to the regular Management Meeting. The Business Development Unit also
conducts an effectiveness review. In addition, quality audits and the weekly F12 plant
status review are performed. (However, to conduct this effectively will require a fully
established Corrective Action Programme (CAP) that is in the early stages of
implementation). The current “effectiveness review” only ensures that the corrective
action has actually been fully completed.
Main conclusions
At the time of the event the plant did not have adequate detailed procedural guidance to
conduct an in-depth event inquiry. The inquiry was almost exclusively conducted as a
technical inquiry and there is no reason to believe that any of the initiating faults or
activities were not identified, analysed and corrective actions proposed. However, the
plant did not comprehensively and systematically identify the root causes of the event.
This failure in the analysis process led to the imposition of corrective actions in this area
by SKI. Overall sixty six actions were identified. Forty nine were completed by the end
of 2007 and seventeen are outstanding. Some of lesser priority are scheduled to take until
2010 to implement.
Known problems from previous events and previously identified areas of concern (both
by management and staff) had not been adequately eliminated or compensated for and
contributed to the event. One factor not considered by the event inquiry was “why was
this event not prevented (or its consequences minimised)” The lack of an effective
operating experience programme at the time of the event was a contributing factor to this
failure.
Summary
At the time of the event there was a lack of an integrated operational experience (OE)
feedback programme (Corrective Action Programme (CAP)) at Forsmark. This was
coupled with the weak use of the systematic analysis methodology. While technical
issues were investigated in depth utilising the expertise of experienced and
knowledgeable staff, underlying organisational issues took longer to recognise. The
deficiencies in the OE programme had been highlighted to the plant by an international
review prior to the event. The subsequent international follow-up review conducted after
the event highlighted that insufficient progress had been made to date in this area. The
follow-up review resulted in the plant requesting an international technical assistance
mission. One of the suggestions arising from the technical assistance mission was that a
strategic plan should be developed that should include: Targets and timescales for project
deployment, A staged approach to improvement of the various programme elements,
Management sponsorship, Milestones to tune and refine, Performance Indicators to
monitor effectiveness, Accountability measures. The technical assistance mission also
highlighted that the MTO methodology is equally applicable to technical investigations
and as a minimum should be used on all LER investigations.
These recommendations, together with the relevant recommendations and suggestions in
the main body of the OSART are supported by this review.
However, with special regard to Significant Event Investigation it is recommended that
the plant should ensure that the current initiatives to enhance their Operating Experience
programme includes detailed procedures for managing and conducting complex
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significant event inquiries. Adequate numbers of staff should be trained and practiced in
the techniques of Root Cause Analysis. Technical staff should also be knowledgeable
about the techniques so that they can assist in investigations and analysis.
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7. RADIATION PROTECTION
7.1 ORGANIZATION AND FUNCTIONS
The radiation protection policy is defined in the top document, LOK Management and
quality control, part 1.4: “RP issues should always be taken into account”. On the basis
of LOK, plant and unit instructions as well as the radiological year plans are developed.
Radiation protection staff and radiation protection matters are divided between several
departments within different units. The Safety and Environment unit is responsible for
the plant programme for radiation protection as well the plant-wide procedures on
radiation protection. The Radiation Protection Manager (RPM) within the Safety and
Environment unit is a “Radiation protection official” as required by national legislation
and is responsible for liaising with the regulatory authority, the ALARA programme and
reporting to the plant management. The RPM is independent of operational and
maintenance units. The chemistry department within the Technical Support unit is
responsible for personal dosimetry, whole body counting, effluents and environment
monitoring. The industrial safety and radiation protection department (FMS) within the
maintenance unit is responsible for radiation protection of personnel, operational
dosimetry, maintenance of RP instruments, training in radiation protection and survey
measurement. Moreover, there are three external companies performing survey
measurements and supervising radiation works. The system of responsibilities and
authorities is clearly defined and working.
The integration of the RP and industrial safety matters in one department has had a
positive effect on improving personal safety and work preparation. The team recognised
this as a good performance in the field of operational radiation protection.
The ALARA programme is very good and functioning well, the ALARA principles are
well understood. Moreover, the best available technique principle is applied. The
ALARA programme is evaluated and revised every year – results are compared with
goals and new targets are determined. The results are reported to the plant management.
The ALARA group is appointed by the President and has ten members from all units; its
meetings are held four times per year. The ALARA group makes recommendations,
which are developed into modification plans and implemented.
To measure the effectiveness of the RP programme, several indicators are used. The
collective and individual doses from operational dosimetry and the number of
contaminated people are checked daily. These data is reported every second week to the
RP manager in an RP meeting. Doses, contamination, and effluent indicators are reported
to the production unit managers every month.
There is no instruction on radiological events with respect to root cause analysis and
reporting. The team encourages the plant to include this into a general root cause analysis
procedure. On the other hand, anybody may write a report on “near-miss” situations in
industrial safety and RP; the reports are regularly processed. The team recognised this as
a good performance. The relevant instructions define near-miss situations and describe
routines for its reporting and evaluation. The radiological near-miss situations are
defined as “any situations which could lead to an external or internal dose greater than 20
mSv”.
Radiation protection staff has adequate authority and independence. Budgets and
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esources correspond to requirements. The radiation protection managers perform
periodic observations of radiation work performance or supervision, take notes from
their observations and evaluate them. Results are regularly reported to the RPM. A
radiation protection meeting is held every second week – this includes the exchange of
operational experience, feedback and coordination.
Radiation protection staff also reviews operational procedures addressing radiological
issues. Radiation protection staff (including radiation protection contractor staff) write
down measured results or observations in an electronic logbook. Important facts can be
easily checked, sorted and evaluated in this way. The team recognised this as a good
performance.
The FMS department cooperates with other maintenance departments, the production
units, the radiation protection official and the safety and environment unit in order to
create long-term, constructive work on radiation protection, industrial safety and
environmental issues.
RP staff qualifications and experience are adequate. Plant instructions include basic
qualification requirements for personnel with RP tasks and prescribe their follow-up.
Once a year, each employee is interviewed by a manager concerning qualification.
Prescribed training and retraining is checked and new training requirements are set. On
the basis of the interview record, an education plan is developed which is sent to the
Human Resources unit to ensure its implementation. Inside the industrial safety and
radiation protection section, an internal training programme is followed up.
The medical surveillance of radiation workers is satisfactory. A medical report is
necessary once a year with a medical examination at least once every 3 years (by national
legislation). Data are stored in a database; the system notifies workers automatically 60,
30 and 10 days before expiration of the term.
Medical support is available if necessary for decontamination; instructions for
summoning help are prepared. RP staff is supposed to perform personal decontamination
with chemicals; a written instruction is in place but the staff is not regularly trained. The
team encourages the plant to apply prepared training schedules as soon as possible.
The documentation system for RP seems to be well developed, however not always
accessible to the personnel involved. The team encourages the plant to ensure that the
personnel have all the necessary instructions at their disposal.
7.2 RADIATION WORK CONTROL
All work in the plant is planned in advance. Routinely performed work follows prepared
instructions. During the work planning, any activity is analyzed with respect to possible
associated health hazards – both industrial and radiation. The integration of the RP
department into the Maintenance unit makes it easier to assess. The FMS personnel
support answering questions on radiation. In case of any hazards including radiological,
the request for a Safety Work Directive (SWD – radiation work permit) is made. The
FMS personnel prepare the SWD in co-operation with the Operational and Performance
units. The work permit (WP) is then approved only with a valid SWD. All the WP and
SWD are prepared via the FENIX database, which enables effective work planning. The
SWD procedures are suitable for the working conditions and are strictly complied with.
When work with an enhanced radiological hazard is planned, special provisions are
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made, including pre-job briefings or suitable mock-up training, if necessary. The
individual, as well as collective doses, are minimised in this way.
The work order instructions are summarized in relevant documentation. Moreover, the
plant must send a report on planned activities with assumed collective doses to the SSI.
Automatic personnel contamination monitors are located at the entrance to the reactor
hall, at the exit from the controlled area (pre-measurement) and in the locker rooms (final
measurement), which is adequate for the plant design. A sufficient amount of manual
contamination monitors are prepared in the RP office, near to the controlled area
entrance. If any contamination is detected during pre-monitoring, the RP staff performs a
follow-up of the performed work, contamination occurrence etc. The events are recorded
in the logbook and further analyzed. The number of contaminations is reported to
management. This way, the number of contaminated persons has been decreased by a
factor of three in the last two years. The team recognised this follow-up as a good
performance.
All controlled area rooms are clearly marked with information tables in a simple threecoloured
(blue, yellow, red) system. Surveillance measurements are performed regularly
by a prescribed monitoring plan. All measurement results are inserted into a database,
which simplifies the SWD preparation and helps to keep the dose ALARA.
Contaminated tools are adequately handled. Every contaminated tool is put into a bag
and carried to the decontamination workshop. No contaminated tool is stored elsewhere.
A comprehensive survey programme in the controlled area is established. During
operation, rooms and areas are monitored at regular intervals once, twice or four times a
year, or weekly, as prescribed in a monitoring plan. During outages, the monitoring is
adapted to the work performed. However, a satisfactory RP survey programme for the
chemistry labs is not established. The team has made a recommendation in this area.
As the operational RP staffing is limited, contractors are recruited for certain specific
activities. Contractors perform periodical survey measurements during regular unit
operation as well as during outages. Contractors also supervise activities performed by
the radiation work permit during outages. Such contractor workers are trained in
accordance with plant requirements.
All controlled area access points have proper and logical layouts. However, some
imperfections were found and the team has made a recommendation about the
organization and work practices.
7.3 CONTROL OF OCCUPATIONAL EXPOSURE
Optimization of radiation protection is performed by implementation of the ALARA
programme. Occupational exposure is carefully planned; target values are estimated and
then evaluated. The ALARA principles are applied already at the planning stage. For
each activity, the individual as well as collective doses are estimated; any other hazard is
taken into account. Special measures are taken when there is a risk of airborne activity
which could lead to internal contamination, including providing adequate respiratory
equipment.
Supervisors are appointed in order to ensure radiation protection for activities on a
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adiation work permit. The supervision is done by the FMS staff or by contractors.
Appropriate dose rate monitoring and survey measurement is provided that way.
An internal contamination assessment programme is well installed. The internal
contamination monitoring programme is widely developed and based on the periodical
monitoring of a reference group of workers who work in particularly hazardous
situations (e.g. control rod servicemen) or are suspected of internal contamination. The
programme also includes workers performing special activities (measured before and
after their work) and everyone who requests to be measured.
Whole body counting procedures are well implemented. The measuring time is adequate
to measured nuclide activities. Last year, there was no internal contamination cases
reported indicating that there were no cases of a committed effective dose above the
investigation value of 0.25 mSv.
The plant has implemented air sampling monitoring whenever a risk of airborne activity
is recognized. Mobile measurement devices are used and appropriate alarm levels are set.
Effective protective equipment is prescribed and used by all workers.
The routine exposure monitoring programme is well established, “legal” (TL) and
operational (electronic) dosimetry are used. The TL dosimeter badge also includes a
neutron dosimeter. Every radiation worker is equipped with TL and electronic dosimeter
as well as with supplementary dosimeters if necessary (e.g. extremity dosimeters).
Visitors are adequately monitored by means of electronic dosimeters.
The number of both electronic and TL dosimeters available is fully sufficient, as is the
number of readers. The electronic dosimeter readers are located at the controlled area
entry points and the evaluating routine is fully automatic so the reader does not permit
the use of a dosimeter with an expired calibration.
Individual doses are stored in a database and periodically evaluated. Each month, the
doses are reported to the Central Dose Register in Sweden (CDIS) shared by the Swedish
plants and some other companies in the nuclear industry. The CDIS is open to the
regulatory authority and forms part of a national dose register. Contractor exposures are
tracked in the same way; contractors receive their workers’ doses via the national dose
register.
7.4 RADIATION PROTECTION INSTRUMENTATION, PROTECTIVE
CLOTHING, AND FACILITIES
The inventory of fixed and portable dose rate and contamination measuring devices is
adequate. Fixed personnel contamination measuring devices are properly located at the
controlled area entry points, in the locker rooms and in appropriate locations inside the
controlled area. The portable instrumentation is located in dosimetry rooms near the
controlled area entry points for easy access. The portable device inventory includes
instruments for measuring alpha, beta, gamma, and neutron radiation.
RP instruments, procedures and routines are documented in the relevant guidelines.
Instrument handling, operative maintenance and calibration are described in individual
documents. All the documents are easy available for both the RP section and the
contractors’ personnel in the FMS homepage which was recognised by the team as a
good performance.
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Calibration of dose rate and contamination measurement instrumentation is performed in
the site calibration laboratory. Although not up-to-date, the calibration facility is
adequate and ensures safe operation with the large radiation sources used. Calibration
procedures are comprehensively described in documents for individual devices. Co-60
and Tc-99 sources are regularly used for calibration. Personnel responsible for
calibration keep calibration records in a written form as well as in the FENIX database.
The database is also used for maintenance and calibration planning in accordance with
the prescribed terms. The calibration facility is periodically traced (every 2 years) to
national standard sources and confirmed by the SSI laboratory, the protocols are
archived.
The schedule for routine device checks is well established and carefully respected. The
portable devices are checked before each use applying the Cs-137 and/or Tc-99 sources;
written records are kept. The check response information is available at the place of
issue.
The plant adequately controls all effluent release paths. All components of gaseous
effluents are measured at appropriate intervals. To ensure requested redundancy in
nuclide-specific gaseous effluents monitoring in the main stack, the plant is going to
replace the low-volume chambers with larger ones.
In addition, the liquid effluents monitoring is suitably organized. Samples are analyzed
before each waste water tank release for the release permit. A proportional sample is
taken during release and the collected sample is analyzed monthly for the balance. Sr-90
and alpha-radionuclides are analyzed and balanced twice a year.
The environmental monitoring instrumentation and equipment is adequate. It enables
sampling of all components of the environment prescribed in the relevant instructions.
Sample analyses are performed via HPGe spectrometry in the chemistry department. The
spectrometers are regularly calibrated, QA routines are implemented.
Protective clothing and respiratory equipment inventory is adequate, covering all types of
hazards anticipated at the plant. There are several types of respiratory equipment
ensuring protection in various situations. All the protective equipment is carefully
maintained, checked and/or periodically tested; written records are kept. The
maintenance schedule is well established. Protective clothing routines and procedures are
well documented in the relevant instructions. Another instruction regulates
decontamination activity limits. All necessary routines and information are accessible at
the FMS homepage. Miscellaneous supplies such as shielding, signs, ropes, stands, etc.
are adequate and periodically restocked.
Laundry, storage and shower facilities are well maintained and housekeeping is well
performed. The laundry and housekeeping are performed by contractors; sorting of
laundry by contamination is under the responsibility of RP staff.
No radioactive waste is temporarily stored in the workplace or at the sorting station. All
waste with a dose rate of above 0.3 mSv/h is transported directly to the radioactive waste
treatment facility. The decontamination workshop is adequately equipped to perform the
activities and appropriately monitors the area with respect to possible contamination and
airborne activity.
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7.5 RADIOACTIVE WASTE MANAGEMENT AND DISCHARGES
The plant has declared a policy that all waste streams shall be minimized and what can
be shall be recycled. The policy was implemented in a radioactive waste management
programme – the instruction on waste sorting according to source. In the instructions, the
goals and objectives of minimizing solid waste are clearly expressed. The instruction
classifies the radioactive waste according to its nature and activity, its chemical and
physical form, and the intended methods of processing. The instructions prescribe waste
sorting; the waste sorting scheme at the sorting stations is displayed there and in several
places inside the controlled area, e.g. in lifts. The collecting, storing and packaging of
radioactive waste during normal unit operation as well as during an outage are developed
in order to minimize exposures. However, the team found some deficiencies and made a
suggestion on waste sorting at the source. The plant recently recognized that there is no
solid-waste related performance indicator and has already started a discussion on its
implementation.
The gaseous and liquid releases are kept far below the authorized limits. Every year the
goals are set in the ALARA programme; it is reported to the management and the
regulatory authority how the goals were met. The plant set an ambitious long-term goal
to decrease water effluents to the value of 1E-7mSv per year per unit before 2013.
The plant has developed effective procedures for controlling effluent releases. The best
available technology approach is applied to reduce effluents. Nearly all liquid radioactive
waste is reprocessed, so its impact on the environment has been minimized in recent
years. The team consider this as a good performance.
Both the liquid and gaseous releases are adequately monitored and balanced. The results
are evaluated monthly and reported to management and to the regulatory authority.
Effluent release monitoring records are carefully maintained and archived. Alarm levels
are specified and the alarm signals are transmitted to the MCR.
The environmental monitoring programme is established in accordance with the
authority’s requirements. Calculation of doses for critical groups of the population is
performed using approved methods. The programme is well structured and covers all
important parts of the environment. Moreover, the plant has “Biotest zones” at several
small islands in the plant’s neighbourhood for investigation of the influence of the
plant’s releases on the sea life.
7.6 RADIATION PROTECTION SUPPORT DURING EMERGENCIES
Plant emergency documentation defines detailed responsibilities of radiation protection
staff in emergencies. RP staff understands their duties and responsibilities with respect to
emergency situations which might arise. Procedures regarding maximum doses in
emergencies are appropriate.
The standard set of dose-rate and survey measurement instruments is also used for
emergencies. RP personnel will use their standard survey and dose-rate measuring
devices to monitor the assembly points for radiation. For this purpose, the range of
survey meters seems to be insufficient and the team encourages the plant to take
corresponding corrective measures.
Two special sets of ten individual electronic dosimeters for monitoring of rescue
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personnel are available at the main entrance and at the fire brigade, which is adequate.
The dosimeters are periodically checked and maintained at full charge.
RP personnel regularly train on emergency procedures with other emergency staff.
Training is recorded and evaluated.
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DETAILED RADIATION PROTECTION FINDINGS
7.2 RADIATION WORK CONTROL
7.2(1) Issue: The organization and work practices do not cover all aspects of minimizing
exposure of workers and the risk of spreading contamination.
• Radiation survey programme for the laboratories is not satisfactory.
• Chemistry laboratories are not equipped with measuring devices for routine daily
workplace monitoring (after finishing the work).
• In the chemistry laboratories, active samples were standing on a desk without
shielding. Dose rate measured – 0.4 mSv/h. Laboratories are not satisfactorily
equipped with shielding.
• In the chemistry laboratory 1.P2.19 inside the controlled area, there is an
emergency exit (a window). There was no seal on the window handle to prevent
non-controlled openings of the window. A person could leave and return to the
controlled area without being noticed.
• A similar handle on a window (not an emergency exit) was found in maintenance
room 1.P2.02 within the chemistry laboratories.
• In the chemistry laboratory 1.P2.21 the wheels of a carriage were covered with
yellow tape. The purpose is not clear, but it can cause more problems – e.g.
spreading the contamination rather than keeping the wheels uncontaminated.
• A stainless steel floor of a draught cupboard in a chemistry laboratory was covered
with a plastic film which was probably not removed when the floor was installed.
The film was torn in several places. This could cause problem during
decontamination. The same thing was seen in another room on a laboratory sink.
• “Clean” and possibly contaminated paths cross in the area next the RP office,
which could cause unwanted spread of contamination e.g. to the RP office.
Without organization and work practices covering all aspects, the exposure of workers
and the risk of spreading contamination cannot be minimized.
Without a satisfactory RP survey programme for the chemistry laboratories, surfaces may
accidentally become contaminated or personnel could be irradiated.
Recommendation: The plant should improve the organization and work practices to
cover all aspects in order to limit the exposure of workers and the spread of any
contamination.
IAEA Basis: NS-R-2, para 8.5.
“The operating organization shall verify, by means of surveillance, inspections and
audits, that the radiation protection programme is being correctly implemented and that
its objectives are being met, and shall undertake corrective actions if necessary. The
programme shall be reviewed and updated in the light of experience.”
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IAEA Basis: NS-G-2.7, para 3.24.
“The main objectives of radiological monitoring and surveying are: to provide
information about the radiological conditions at the plant and in specific areas before and
during a task; to ensure that the zone designation remains valid; and to determine
whether the levels of radiation and contamination are suitable for continued work in the
zone.”
IAEA Basis: NS-G-2.7, para 3.26.
“The frequency of monitoring and surveys as well as the types and locations of the
measurements to be performed should be designated on radiological surveillance forms
as part of the RPP and updated as necessary in accordance with the prevailing
conditions.”
IAEA Basis: NS-G-2.7, para 3.28.
“The operating organization should ensure that equipment necessary for the RPP is
provided, including various instruments for measuring radiation and for sampling and
analysis. The quantities and types of equipment provided should be adequate for
anticipated needs in normal operations and emergencies, and account should be taken of
radiological conditions prevailing and suspected or expected to prevail in the local area.”
IAEA Basis: NS-G-2.7, para 3.57.
“The plant should be equipped with radiation shielding materials of different types for
temporary use in special jobs. Examples of such shielding materials are lead blankets
(lead wool in flexible covers), sheets and bricks of lead, sheets of transparent perspex
and blocks of concrete.”
IAEA Basis: NS-G-2.7, para 3.9.
“Access to a controlled area is required to be restricted and should be restricted by way
of a limited number of checkpoints in order to limit the spread of any contamination and
to facilitate control at any time of exposure and occupancy. Procedures should be
established for control of access to a controlled area or to a particular zone. These should
include an authorization to enter, together with instructions on the use of monitoring
devices, the wearing of specified protective clothing and equipment, and time limits for
remaining on the premises.”
7.5 RADIOACTIVE WASTE MANAGEMENT AND DISCHARGES
7.5(1) Issue: Instructions on waste sorting at the source are not satisfactorily developed
and implemented.
• Instruction F-I-353 on “Waste sorting according to source” (radioactive waste
management programme) defines in parts 3.2.1 – 3.2.3 “soft (compressible)” and
“hard (incompressible)” waste and requires waste sorting.
o
o
In accordance with the instruction (part 3.2.2 or 3.3.2), the soft waste is
collected in 125 litre bags in a bag frame located at the unit and at the sorting
stations.
In accordance with instruction (part 3.2.3), the hard waste is collected in
Berglöfs boxes at the point of generation or delivered to the sorting stations of
each respective unit.
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• In accordance with instruction, boxes for hard waste (e.g. metal) are located at two
“sorting stations” located on the ground floor.
• Most rooms contain labelled bags for waste (soft waste according to the
instructions) but there are no corresponding boxes for hard waste. Personnel must
take the hard waste to one of the two sorting stations on the ground floor.
• The lack of hard waste bins in rooms forces personnel to mix wastes:
o
o
o
Metal strips were found in a plastic bag in a container for (soft) waste in the
room 1.J01.03. They could tear the bag when it is taken from the container.
A piece of a metal grid was found in a plastic bag in a container for (soft) waste
in the room 1.D4.50.
A metal coil spring was put in plastic bag for (soft) waste in the room 1.F1.21.
Additional sorting is necessary before moulding.
Without satisfactorily developed and implemented instruction on waste sorting at the
source, opportunities to reduce the amount of radioactive waste (e.g. decontamination of
hard waste) may be lost.
Suggestion: The plant should consider that instructions on waste sorting at the source
are satisfactorily developed and implemented in order to ensure an efficient waste
management programme.
IAEA Basis: NS-G-2.7, para 4.16.
“The segregation of radioactive waste into appropriate categories should be carried out as
near to the point of generation as practicable. The waste should be segregated in
accordance with written procedures.”
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8. CHEMISTRY
8.1 ORGANIZATION AND FUNCTIONS
The responsibilities and functions of the Chemistry Department at the plant are described
in the Management and Quality Handbook (LOK). Plant management is committed to
this document. The Chemistry Department at the plant is responsible for preserving the
integrity of systems and components, controlling and monitoring activity build-up,
controlling the release of activity and monitoring activity in the environment.
The Chemistry Department at the plant is part of the Technical Support unit. The
Department is clearly structured as it is subdivided into four groups, the process
chemistry group for unit 1&2, the process chemistry group for unit 3, a chemistry
specialist group and the radio physics group. The members of the specialist group reports
directly to the department manager while the other groups are headed by group
managers. The chemistry specialist group forms a strong and important office for the
whole department.
With the support of upper management, the department recently increased the number of
employees and is now sufficiently staffed.
Additional goals to those already mentioned in the LOK are established.
In 2004, a WANO peer review with subsequent follow-up in 2007 was conducted. Self
assessment was identified as not being undertaken. However, in preparation for the
OSART mission the department performed a non formalized internal audit that proved to
be beneficial. Indicators for human performance are available. The team recommends
formalizing further internal audits and self assessments.
Interfaces with other plant groups are well described. Cooperation with other groups,
especially the material group, is intensive and will be promoted by the modern analytical
instruments, like the scanning electron microscope (SEM) that will be installed. Health
physics and chemistry work closely together, e.g. when new chemical substances are
approved.
Operations are informed about the measures that need to be taken if chemical parameters
exceed certain limits. The operations instructions give clear guidance. If operations are
not able to fix the problems, the chemistry department is asked for help. The overall
cooperation is good as operations appreciate the professional work of the chemistry staff.
However, operations staff wants to have even more information on chemistry
specifications, procedures and organization.
During normal working hours, chemistry responds in a timely manner to requests from
operations and other departments. Corrective actions to chemical parameter variations
are properly taken, as other departments, especially operations, are sensitive to the
chemistry department’s concern. However, there is no chemist on call during nights or at
weekends. The team recommended implementing such a service and in the course of the
mission the plant decided to reinstall the service of chemists on duty.
The chemistry department gives strong support in all plant-related chemical issues, e.g.
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fuel cladding related questions or material optimization. Chemistry competence is also
effectively brought in e.g. to minimize risk of flow assisted corrosion of feed water in the
preheater drain system when power is upgraded, or reducing waste by oxidization of
evaporator concentrate in a plasma flame. For bigger projects, like the renewal of the
water treatment plant, appropriate project groups with specialists from different
departments are assembled.
Chemistry department management is responsible for monitoring national and
international developments inside and outside the nuclear community by attending
scientific conferences and workshops. Chemistry management promotes nuclear
competence with research and development projects on site. Communication with
external organizations is adequate.
Regular reports are distributed to the other units, the upper management and the
regulatory authority, containing relevant operational and chemical parameters.
Department management is responsible for providing qualified staff. The basic education
of the chemistry staff is very good and most have a university background. Department
management has realized that only motivated staff can be retained and only well trained
staff is able to perform the high level tasks at the plant.
Responsibilities and functions for all levels of management and staff are clearly
described and more personally specified in job descriptions that have been recently
updated.
The department has very experienced senior staff and young employees that are eager to
learn from the older colleagues. For a new employee, a designated senior staff member
acts as their mentor and introduces the trainee to laboratory work and culture. Line
management records and follows the progress of the training by a checklist, the so called
“driver’s licence”, that contains all relevant techniques required for professional work in
the laboratory. The initial training is facilitated as the work in each laboratory is well
organized. Any additional need for individual development, e.g. external training, is
agreed on during the annual goal talks between line management and staff.
Each laboratory group is organized in such a manner that the work can be done by
several group members, so the groups are independent. Nevertheless, each laboratory can
backup the other.
The information flow within the department is well organized. In a series of formal and
informal meetings, information is transferred from the top management and operations to
the staff and vice versa. The daily meetings of chemistry staff are also used for teambuilding.
By a combination of manager meetings and specialist meetings, different
subjects can be discussed and decisions taken in a timely manner.
Staff has an open attitude to discussions with experts and seek advice on improving their
performance. Staff appreciate the open atmosphere within the department.
8.2 CHEMISTRY CONTROL IN PLANT SYSTEMS
The Management and Quality Handbook (LOK), the Operational Technical
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Specifications (STF) and the Safety Directive are the basic instructions that contain the
expectations of the plant designer, the regulatory authority and the management and set
limits to operations. The Process Chemical Specification procedure and the Samplingand
Analysis Frequency procedure are the basis for the daily work of the chemistry
department. They have been recently changed due to the organizational merging of units
1 and 2.
However, the above-mentioned procedures are not comprehensive as regards the
surveillance of reactor coolant and other systems as specified in international guidelines.
Parameters with action levels, e.g. conductivity of reactor water, time limits are not all
defined. Therefore, not all necessary actions might be taken in a timely manner. The
plant has already recognized this issue but has not yet made the necessary changes. The
team made a recommendation in this regard.
Responsibilities for quality control of diesel fuel and lubricant oils rest not only with
chemistry but also with other departments like the maintenance department and
procurement. However the process is not clearly organized. The team provided a
suggestion in this area.
The water steam circuits of the three reactors are operated under normal water chemistry
conditions (NWC) without any additives. The concentration of impurities like chloride,
sulphate, fluoride and corrosion products in the feed water is very low. The corrosion
product transport into the reactor pressure vessel is properly monitored; the values are
also low.
A combination of online monitoring and sampling of the reactor water, in the off gas
system and in the condenser evacuation system, are used to detect fuel failures early.
During power operation, the defective fuel is roughly localized by flux tilting. After the
results are evaluated together with other departments, mast sipping is performed
according to procedure. The plant is developing a technique to measure helium in the off
gas to get additional information on defects. Records of the results are available.
According to the material composition, the closed cooling water systems should be
oxygen free with hydrazine used as the reducing agent. Due to a management decision,
hydrazine is banned from the site and oxygen is removed with a de-gasifier. However,
this system does not always work adequately. Since the outage in 2005, the systems are
operated without hydrazine. Also, an increased tritium level in the closed cooling water
system indicates an in-leakage from the reactor coolant system and the reason for that
leakage is not clear. Therefore, changes in the chemistry of this system should be done
only after thorough evaluation.
De-mineralized water is prepared from water from a nearby lake. A new water treatment
plant is being installed with several technical benefits, e.g. reduced chemical
consumption. Optimization processes in the water management has significantly reduced
the water requirements of the plant. The new and the old plant were properly monitored,
including online silica meters. The online monitors are properly checked by the operation
units with support from chemistry.
The plant has scrubber tanks for washing gases from the containment during pressure
release. The released gases can be analyzed online and by grab samples. The contents of
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the tank are regularly analyzed.
The post accident sampling system (PASS) has been recently modified. The system can
sample the reactor water, the condensation pool and the atmosphere of the containment.
It is set up to test the system regularly.
The mechanism of erosion/corrosion in the condensate and feed water system is well
understood and the plant is operated accordingly. By adjusting the oxygen level in the
pre-heater drain, the formation of protective layers is favoured. The team identified this
to be a good practice.
8.3 CHEMICAL SURVEILLANCE PROGRAMME
Chemistry staff is technically qualified to do their work and their performance is
annually assessed. Procedures for analysis are available and are clearly understood and
followed by the staff. The sample preparation and the calibration of most instruments are
done very thoroughly. The sampling plans are properly followed; exceptions are only
possible under certain conditions.
The theory of proper instrument calibration and the quality control of analytical
measurements are well understood. Online instruments are regularly controlled by
comparison with grab samples or with the results of laboratory instruments that are
transported in the field. However, the team observed some online conductivity meters
that showed values that were below the theoretically possible value. It turned out that
online conductivity meters have been controlled with laboratory instruments that were
not included in the quality control programme. The team provided a suggestion in this
area. Appropriate chemical standards that are traceable to certified reference standards
are used for calibration and quality control.
The plant understands the influence of the different analytical steps like sample
preparation and instrument calibration on the overall accuracy of chemical
measurements. Measurement uncertainties are taken into account when results are
evaluated, especially when only a few values are available. However, the experimental
measurement results that are used for the validation of analytical methods and the
determination of the analytical characteristics like detection limits, should be archived
together with the results of theoretical approaches to the subject.
Comparisons between different laboratories, so called ‘round robin tests’, are regularly
carried out for the chemical and radiochemical examination techniques. Some samples,
especially from liquids released to the environment, are independently analyzed by the
Swedish regulatory authorities.
8.4 CHEMISTRY OPERATIONAL HISTORY
The water chemistry in the three reactors is normal water chemistry (NWC). Forsmark 1
& 2 were the first BWR units in the world with internal recirculation pumps to inject
hydrogen (HWC, Hydrogen Water Chemistry). However, thermo hydraulic calculations
indicated that mixing in the down comer was not sufficient, so the units were the first
and only to return to NWC in 1991.
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In 1997, all three plants replaced several pipes and nozzles in the residual heat removal
system and the feed water system due to cracks. However, the material handbook has not
been changed since 1990.
It happens frequently that residual boron solution from the annual testing of the boron
injection system is injected into the reactor. Therefore the reactor coolant is
contaminated by boron, with a maximum concentration, in unit 2 in 2001, of 250 ppb
boron. In unit 1 since 2004 the boron concentration has increased slowly and is now
some 70 ppb. Experience from other plants show that concentrations over some 100 ppb
increase the conductivity and therefore other impurities, e.g. corrosion inducing can be
hidden. Although the plant started to improve the technical situation it should go on to
further improve it. It is foreseen, that with the change to 10-boron-enriched boron the
problem will be finally fixed.
Increases in conductivity in the reactor water could be attributed to nitrate in
concentrations of up to 25 ppb that develops from organic amines when new resins are
leached. Again, other impurities could be hidden under these conditions. To know that
the conductivity increase is always “under control” the plant should consider improving
the surveillance of plant systems e.g. with online ion chromatography.
The review of the activity concentrations in the reactor water and the off gas system
since 2000, revealed several fuel defects in unit 1 and 2, presumably due to debris. The
defects have been indicated early by the ratio of Xe-133 to Xe-138 in the off gas system.
The nuclide specific online monitors in the off gas helped the plant to identify fuel
defects early. The plant has installed cyclone filters to remove debris from feed water.
The oxygen level in the closed cooling water system came up to 25 ppb, since hydrazine
is abandoned by the plant, which is not in compliance with the specifications. However
as the material concept is still the same, i.e. there are forty three identified stainless steel
components in conjunction with carbon steel components according to the plant,
electrochemical reactions that cause corrosion will start. The applied chemistry is not in
accordance with the original designed materials concept. A surveillance programme has
been updated during the period of the review.
Responsibilities for trend analysis are clearly assigned to a chemistry staff, who report to
line- and upper management. However, in February 2008 tritium values in the closed
cooling water system were published and turned out to be false.
The laboratory information and management system (LIMS), the data base for all
chemical results, does not meet the expectations. It is very difficult to display several
parameters, like concentrations, conductivities and thermal power in one diagram.
However, this type of diagram is important for discovering interactions between these
parameters. Nevertheless, analytical data are stored properly and are easy retrievable.
The chemistry department has access to operational process data via the Plant Vision
data application. The plant digital logbook is used for recording chemistry-relevant
issues in operations and in the lab as well for retrieving documents. The project
management register (KUR) is used to track open tasks.
The chemistry department has put much effort into improving its performance and the
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control of plant systems. During the last years radioactive liquid discharges have been
significantly reduced by optimizing the treatment process and by minimizing the volume
of unwanted water in-leakage. Thus the impact on the environment is being reduced to as
low as reasonably achievable (ALARA).
When the destruction of yarn of the filter candles of the condensate polishing plant was
discovered the chemistry staff was strongly involved in developing and implementing
new stabilized yarn for the candles. At the same time, new sulphur free ion exchange
powder resins have been introduced to reduce the risk of sulphate induced stress
corrosion cracking in the systems, which is a major problem in boiling water reactors. In
addition, the chemistry department is operating a test rig for coating filter candles with
powder resins. Therefore the department is able to continuously seeking improvements
in this area. The team identifies this as a good practice.
8.5 LABORATORIES, EQUIPMENT AND INSTRUMENTS
The hot laboratory of unit 1 and 2 is very spacious with several rooms. The different
analytical chemical and radiochemical techniques can be spatially separated and special
environments created, e.g. with reduced radioactive contamination. The laboratory is
equipped with exhaust hoods and laminar flow devices, both surveyed with electronic
flow meters. This equipment is regularly tested. A circle line with demineralized water
provides high quality water in the whole lab, the quality is continuously surveyed.
The laboratory is equipped with all necessary instruments, like high purity Germanium
detectors, inductively coupled plasma optical emission spectrometer (ICP-OES), ion
chromatograph, gas chromatographs etc. However some of these instruments are old and
the team suggests replacing them.
Analytical equipment is regularly calibrated with appropriate calibration ranges. The
calibration is checked with an independent quality control standard. Although each
standard is labelled with preparation date and name of operator, there is not yet a
procedure that required such a consistent labelling.
Logbooks for the instruments are available and clearly structured. However, there is no
entry on who is responsible for the instrument. The instruments are not labelled to
indicate that they are quality controlled. Handbooks are stored close to the instruments
and frequently used by staff. Control charts are available for some instruments, however
when quality control limits are violated no comments are entered and countermeasures
applied are not always retraceable.
The laboratory of unit 3 is equipped with the same instruments, so analytical redundancy
is available.
The laboratories are regularly assessed by health physics under the aspects of industrial
safety, however, the team made a suggestion in the RP area. A comprehensive list of
chemicals used in the plant laboratories is available; however, this list should be
extended to indicate in which laboratory (F12 or F3) these chemicals are stored. Material
safety data sheets are stored in the labs.
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8.6 QUALITY CONTROL OF OPERATIONAL CHEMICALS AND OTHER
SUBSTANCES
Operational chemicals and auxiliary substances like gases, detergents, tapes etc. are well
controlled in the plant. A sticker on each part indicates the application area for the
substance. If new substances are needed, a formalized and clearly structured process is
initiated including an assessment from health physics and the environmental department
and a chemical analysis by a contractor. Approved substances are registered in a data
base that is common for all Swedish nuclear power plants. However the team found
several deviations from these rules and provided a suggestion in this area.
Most substances are only analyzed once, there is no periodical sampling. The team
suggests improving the process. Diesel fuel is sampled periodically; however, the
procedures are not clear, several departments are involved in organizing chemical
analysis.
The handling of material safety data sheets (MSDS) is not yet clearly defined.
International practice is to store MSDS centrally on a single place or in a data base.
Also, a plant procedure describes the labelling of filled bottles but the team found several
poorly labelled bottles and containers in the field resulting in inadequate age
management of these substances.
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DETAILED CHEMISTRY FINDINGS
8.1 ORGANIZATION AND FUNCTIONS
8.1(1) Issue: The chemistry department has not yet implemented clear chemistry
management expectations for a high level of professional work in the department.
The team observed the following facts:
• The department has started to conduct internal audits, however that process is
not formalized.
• The safety expectations in the laboratory are not issued in a procedure.
• In the sampling rooms 1.C.4.16 and 2.C.4.16 hand written procedures
(“Utbildningsmeddelande” 060209 Nr. 06/003) were found, that were not
approved.
• In one sampling lab the team found a non labelled spray bottle.
• Some radioactive samples, which had been prepared for measurement, were
stored without proper shielding.
Without clear rules and chemistry management expectations implemented, staff may take
incorrect decisions which can result in damage to health or endanger the integrity of
systems and components.
Recommendation: The plant should implement clear chemistry management
expectations for the chemistry department.
Basis:
Draft SG DS388
2.9. By touring the chemistry areas the managers that are responsible for chemistry
should observe that indicators of staff behaviour and attitude that are likely to be
helpful to the development of strong safety culture are evident (proper attention to
alarms, timely reporting of malfunctions, minimization of backlog of overdue
maintenance, adequate labelling, accurate recording system etc.).
2.10. Managers and supervisors should routinely observe chemistry activities to ensure
adherence to plant policies and procedures. …
2.11. QA audits and other self assessment and independent reviews should be regularly
conducted, review of non conformances should be reported and status of
corrective actions should be evaluated.
2.12. The plant self assessment programme should include chemistry area.
2.13. There must be a clear distribution of responsibilities at the plant for particular
chemistry activities like control of resources, chemistry control, conducting of
water chemistry regimes, analysis of the results, staff training etc.
5.29. The laboratories should have a good general housekeeping, orderliness,
cleanliness at working areas and sampling points, including contamination levels
as well, according to the plant procedure.
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5.30. Industrial safety (storage of flammable solvents and hazardous materials, safety
showers, personnel protective equipment, as well as first aid kits etc.) and
radiological safety (proper radiation shielding)should be ensured, applied and
well maintained in laboratories, according to the foreseen risk. The whole
laboratory installation and work practice should be in accordance with good
industrial safety and the ALARA principle.
8.2 CHEMISTRY CONTROL IN PLANT SYSTEMS
8.2(a) Good Practice: The Plant has optimized the oxygen content in the drain of the
pre-heaters by changing the ventilation from the pre-heaters to the condenser together
with installation of a bypass flow through some pre-heaters. Thus the formation of
protective Haematite layers was favoured. The mass of transported iron was significantly
reduced, as was the power loss due to pressure drop. This modification is even more
important as power up rates will change the oxygen content in the systems.
8.2(1) Issue: The chemistry specifications and the chemistry control programme are not
in accordance with international guidelines and chemistry experience.
The team observed the following facts:
• For most action levels no time limits are defined before which action must be taken
or the plant has to be shut down.
• For the closed cooling water system (711) normal values for oxygen and hydrazine
are defined in the procedure that cannot be met at the same time.
• The chemistry specifications (F12-I-0017) do not yet contain references to the
material handbook, EPRI guidelines and other documents.
• For the wet well and some other systems there exist non-defined concentration gaps
between normal values and action levels. Staff might be confused, if parameters are
in this concentration range.
• The valid LOK document does not refer properly to the applicable procedures for
the chemistry program.
• The material manual was not updated since 1990 although in 1997 an extensive
exchange of material has taken place.
• In the closed cooling water system, there are forty three (according to the plant)
identified stainless steel components which are combined with carbon steel
components. The system is designed to be operated with hydrazine as reducing
agent. However, due to a management decision, the use of hydrazine has been
abandoned. Since 2005, the hydrazine concentration in Unit 1 has been close to
zero and in action level 1, although the material composition has not been changed.
A surveillance programme has been updated during the mission.
• The important parameter “lubricity” is not included in the analysis programme for
Diesel fuel.
• Oxygen concentrations in the condensate of unit 1 are below normal values
according document F12-I-0017.
Without chemistry specifications and chemistry control that are in accordance with
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international guidelines and chemistry experience the integrity of systems and components can
be endangered.
Recommendation: The plant should implement chemistry specifications and chemistry control
that are in accordance with international guidelines and chemistry experience.
Basis:
Draft SG DS388
2.5. The operating organization should ensure that the chemistry applied to the SSCs
important to safety are of such a standard as to ensure that the level of reliability
and functionality of the SSCs remains in accordance with the design assumptions
and intent throughout the plant ’s operating lifetime. Chemistry is one of the main
contributors to long term operation of the plant.
3.5 Chemistry programme should ensure the following:
• suitable chemistry regime in accordance with original design and material
concept, following any structural modification or due to operating experience;
• evaluation of adequacy of chemistry regimes and chemistry parameters from the
point of view of short and long term operation;
4.40. Dissolved hydrogen and oxygen levels should be within specifications, and
impurity levels (e.g. corrosion products, chloride and fluoride) should be
maintained well below the limits.
8.3 CHEMICAL SURVEILLANCE PROGRAMME
8.3(1) Issue: The quality control programme for chemical analysis and the analytical
equipment is not adequate.
The team observed the following facts:
• In February 2008 tritium concentrations in the closed cooling water system
were released that turned out to be wrong. A closer inspection during the
mission revealed, that incorrect, extremely high blank values (100 counts per
minutes) instead of some 5 - 10 counts per minute were subtracted from the
measurement, resulting in a too low final result. Although the LIMS data base
for chemical results performs a first plausibility check on entered data,
incorrect data have been found in the data base but staff did not add any
comment or inform the laboratory leader.
• On the 4 th of December 2007 the quality control standard for sulfate was lying
outside the control limits. However, at the same day values for sulfate were
entered in the data base. The wrong values were entered in the control chart.
• The QC-data base did not always contain comments when warning or control
limits had been violated, e.g. the warning limit for calcium was violated
several times in January 2007 without any comments or countermeasures
recorded.
• When discussing some control charts with staff it was not clear, what the
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different markings (different colors of crosses) mean.
• The team observed that online conductivity meters had been controlled with
laboratory instruments that were not included in the quality control
programme. The failure was obvious, as the measured conductivity is
theoretically not achievable!
• Some analytical instruments like the inductively coupled plasma optical
emission spectrometer and the UV-vis spectrometer are old.
Without a comprehensive quality control for chemical analysis and reliable analytical
equipment incorrect analytical results can cause decisions which endanger the integrity of
systems and components and may endanger the health of staff.
Suggestion: The plant should consider improving its quality control programme for
chemical analysis and the analytical equipment.
Basis:
Draft SG DS388
5.18 & 5.21 For online/ laboratory instruments, there should be developed a procedure
with: a summary of analytical methods indicating possible interferences, accuracy,
linearity and range capability…
5.39 If instrument performance shows significant scatter from the expected value, an
investigation should be performed to determine the cause of the deviations…
6.3 Analytical data should be reviewed to verify completeness, accuracy and
inconsistency. Chemistry data assessment for identifying of actual and potential
problems should start as soon as data is generated or first recorded. Without timely and
effective review of the data, a chemistry problem may not be identified until it affects the
system or plant performance.
6.15 Plant should have implemented management system, which ensures that data
collected by online monitors and data acquisition system are trustful and reliable. There
are more methods usable for this, such as: …timely comparison of online monitoring and
laboratory results or other well calibrated portable online monitors…
8.4 CHEMISTRY OPERATIONAL HISTORY
8.4(a) Good Practice: The sulphate content in the coolant increased after the power
upgrade (100% to 108%). The new thermo hydraulic conditions caused a more oxidizing
environment at the condensate clean up filters, and the strong cation exchange resins
containing sulphuric functional groups were decomposed. Weak cation exchanger with
carboxyl groups were tested and fulfilled all requirements for coating, waste handling,
clean up function etc. This Low Sulphur Resin (LSR) was tested in a test rig and later on
a real filter during operational conditions. It was concluded that the differential pressure
increase was slower compared to normal resins and the particle separation was excellent.
A draw-back of this type of resin is leakage of trimethyl amine from the anion resin,
which is not captured in the weak cation resin bed, but leaks to the reactor coolant
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esulting in increased nitrate content.
However, nitrate ions are less harmful with respect to stress corrosion cracking as
compared to sulphate ions.
In addition, the chemistry department has developed a test rig for simulating the coating
of candle filters from the condensate clean up system. The test rig consists of sampling
holder of Plexiglas, mixture vessel for resin, stirrer, coating pump, pump for sufficient
flow for adhesion of the resins, flow meter, differential pressure meter, regulation valves
and tubes for connection of air and water. The sampling holder has sufficient space for
mounting filters of different sizes from the condensate cleanup system (CCS). The
construction is built to simulate the real CCS. Mixture time, coating flow, amount of
resins, flocking size and temperature are parameters that can be varied. The result of the
coating is visually determined as the filter inside is seen through the Plexiglas.
Observation of the size of the flock, sedimentation rate, adhesion of the resin and the
distribution over the surface can be carefully evaluated. The coating of the filter can be
optimized by pressure variations. Even small variations of the parameters strongly affect
the result of the coating.
8.6 QUALITY CONTROL OF OPERATIONAL CHEMICALS AND OTHER
SUBSTANCES
8.6(1) Issue: The quality control programme for operational chemicals and other
auxiliary chemical substances is not adequate.
• All chemical auxiliary substances are at least analyzed once. In some cases,
repetitive analyses are performed but there is no periodical sampling.
Suppliers may change their recipes without notifying the plant or violate their
own specifications. The plant itself experienced this several times, e.g. during
the change of turbine oil in F3 in 2004 (the new oil did not meet the promised
water separation capability), Loctite 415 (first analysis in 1991 okay, category
1, second analysis in 1995 increased chlorine values, category 2).
• Diesel fuel is sampled periodically; however, the procedures are not clear,
several departments are involved in organizing chemical analysis.
• Only turbine oil, transformer oil and the oil from the feed water pump gear
box are periodically analysed.
• Specifications for auxiliary substances and bulk chemicals are not included in
a procedure.
• In an unlocked cabinet in the main cooling water room the team found four,
poorly labelled bottles (Rando HD 68, each 1 l, different colour) of lube oil,
obviously to refill some leaking pumps. However, issues like this are not in
accordance with nuclear practice, as the risk of mixing up and pollution of the
content exist. In addition the age management (control of shelf lives) is no
longer under control.
• In 1.K1.08 a tank with glycol with no category, handwritten label “glycol”
was found.
• In the service water building a jug with handwritten sign “Aminosyra” on top
of sulphuric acid pallet was found. Old drum, not labelled on top of spare
natron pallet (pallet looked very temporary- not clean and not easy accessible.
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• Handling of the material safety data sheets (MSDS) is not clearly described,
they will be available online and they are already available in the warehouse.
Workers receive a copy of the MSDS, some of the working groups have their
own collection sometimes single worker collect them, sometimes they are
fixed to the barrels in the field, however the team found also container
without MSDS being attached.
• The online data base, which should have been already in full operation, is still
under construction and does not contain all substances and necessary
information, e.g. the MSDS for Borax 10 Hydrat, which was found in the
field, was not found in the data base.
Without a comprehensive quality control programme for delivered and stored chemicals
serious damage to systems and components can result that endanger humans and
environment.
Suggestion: The plant should consider implementing a comprehensive quality control
programme for delivered and stored chemical.
Basis:
Draft SG DS388
8.6 Chemicals and substances should be labelled (under the responsibility of the plant)
according to the area where they can be used, so that they can be clearly identified. The
label should indicate the shelf life of the material and he application area of the material
(system contact/no system contact).
8.7 If it is necessary to fill a certain amount from a stock container to a smaller flask, this
flask must be properly labelled with name of the chemicals, date and pictograms to
indicate the risk and the application area. This amount must be small enough to be used
within a certain time under work permit… Rests of non needed chemicals and substances
should be disposed accordingly plant procedures.
8.12. Safety Data Sheets for all approved chemicals and substances must be available and
easily accessible
8.15 Shelf life should be clearly defined by manufacturer or a plant organization.
8.16 The storage of chemicals should take into account the reduced shelf life of opened
containers. Unsealed and partly emptied containers should be controlled in such a
manner, that the quality of the remaining product is in satisfactory condition.
8.18 Use of proper chemicals and right quality is responsibility of the plant. Before being
used the specified quality should be verified by chemical analysis and/or by a certificate
and a chemical identity check. The quality of these materials should be rechecked if
appropriate (e.g. Diesel fuel).
8.20 Plant procedure should define the proper quality of lubricant oil for each component
that is essential for safety and availability.
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8.21 Lubricant oils from systems, that are important for safety and/or availability should
be regularly analysed for control parameters that characterize the condition of the
lubricant (e.g. viscosity, neutralization number etc.).
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9. EMERGENCY PLANNING AND PREPAREDNESS
9.1 EMERGENCY PROGRAMME
Sweden assigned clear responsibilities for nuclear emergency planning and response in
two legislations. The Nuclear Operations Act assigns to the plant the responsibility for
safety, planning and response on site. It also specifies that the plant must notify the
authorities in case of an emergency. The Rescue Service Act assigns responsibility to the
Local County Government (Lsty) for preparedness and protective measures outside the
plant. Responsibility is assigned to the Swedish Radiation Protection Authority (SSI) for
providing recommendations to Lsty on radiation protection issues and to organize
nationwide protective measures. Responsibility is assigned to the Swedish Nuclear
Power Inspectorate (SKI) for providing advice to Lsty on reactor safety issues.
Alerting the public of an emergency during working hours is rapid and effective. The
Unit Operation Manager (Level 2) or Duty Engineer (VHI) takes over immediate actions
for emergency response. This includes declaring emergency level and initial notification
to SOS-Alarm in Uppsala.
As soon as SOS-Alarm receives the fax notification of an emergency at Forsmark, its
duty officer phones back the Duty Engineer and requests confirmation. He then asks if
the release has started or is anticipated. This information is entered on a form and used to
select one of the pre-arranged media messages. This message is immediately sent to
media outlets. As was observed during a drill, this means that notification of the public
through the media could start within thirty minutes of the declaration of an emergency.
This is an exemplary arrangement during working hours but the team identified that,
outside of normal working hours, the process for declaring an emergency and notifying
off-site authorities may result in unnecessary delays in the implementation of protective
actions. The team has made a recommendation in this regard in the MOA area.
It should be noted that the Lsty did not receive the usual “courtesy notification” by the
normal channel during the event of July 2006. The Duty Engineer – VHI could not reach
the duty officer through SOS-Alarm. This breakdown in communication is unusual and
is being investigated by the plant and the Lsty.
While SSI is responsible of advising the Lsty on the radiological aspects of protective
measures for the public, this does not delay the decision process. Lsty demonstrates a
good understanding of its responsibilities, and is pro-active in making decisions for the
protection of the population. It maintains a direct link with the plant and exchanges
gamma survey measurements and information that could be useful in the decision
making process. Lsty uses Operational Intervention Levels to promptly decide if
protective actions are required. The use of Operational Intervention Levels is encouraged
by the team.
The Human Resources unit has created a Crisis Group that handles post-traumatic stress
disorders and problems associated with fitness for duty. This arrangement was
established to conform to Swedish Work Environment Authority regulation AFS 1999:7.
The Crisis Group is integrated into the emergency plan and this demonstrates good
foresight and a pro-active attitude on the part of the plant.
The plant recommends that each employee contacts his or her family when an Alert or
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General Emergency is declared. Most use their mobile, but there is a phone near the
assembly point for that purpose. Provided that the employees are well informed, this
arrangement may prove very effective at informing the local population.
During an Emergency, the Lsty, SSI and SKI arrange press briefings and press
conferences at the Joint Media Information Centre in Uppsala. The plant plans to use a
separate Media Centre, located on site at the Information Centre during the first day of
the emergency. On subsequent days, the plant would relocate its Media Team to the Joint
Media Information Centre in Uppsala. Relocation to Joint Media Centre is important for
joint operations with Lsty, SSI and SKI and this should happen as soon as possible. The
plant is encouraged to document this arrangement clearly in the procedures of the Media
Information Team.
9.2 EMERGENCY PLAN
The on-site and off-site emergency plans for Lsty are well coordinated. For example, the
local police, fire-fighters, reception centres, emergency operation centres in Östhammar
and Uppsala use the same maps as the plant. This is evidence of good coordination at
the local level and it is to be commended. It is noted that the plant and the SSI
emergency centre do not use the same maps, although this has no impact on the local
response.
The plant declares an Alert or General Emergency on the basis of
• plant conditions compared to Emergency Action Levels; or
• gamma dose rate measurements from fixed detectors or mobile surveys compared to
Operational Intervention Levels.
At the Alert level, the plant immediately shelters personnel at the assembly points. At
the General Emergency Level, the plant immediately evacuates non essential personnel
from the site. This is a good arrangement that minimizes delays in the implementation of
the on-site protective actions.
The Site Emergency Director receives a high level view of the management of technical
issues during a nuclear emergency that is unique in the Team’s opinion. This has been
identified as good practice.
The Inner Emergency Zone, 10-15 km in radius, represents the area where evacuation is
pre-planned. Reception centres outside the zone are identified and prepared. Every
permanent resident of the Inner Emergency Zone receives a package containing 10
tablets of potassium iodide, and two pamphlets issued by SSI, Lsty and Rescue Services
describing the off-site emergency plan and the protective actions during a nuclear
emergency. The information package for the public is good and effective.
Lsty has recovery plans for the area. This is impressive, since very few countries go that
far in the planning process.
9.3 EMERGENCY PROCEDURES
Source term assessment is carried out at the Emergency Management Centre (EMC) by
the Radiation Protection Manager and the Specialist Group. The procedures for source
term assessment are very good, and great efforts are expended on this task, even if it
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gives results with great uncertainties 1 . The plant is encouraged to emphasize this when
communicating the results of the assessment to SSI.
The procedures for emergency workers are designed for those wearing respiratory
protection and taking potassium iodide tablets. If the emergency workers are not wearing
respiratory protection and not taking potassium iodide tablets, they can be exposed
through inhalation in addition to external exposure. To account for this, the dose alarms
on their electronic dosimeters should be lowered 2 by a factor 10. The plant is encouraged
to include this instruction in the procedures for setting the alarm thresholds of emergency
workers.
Events below the threshold for Alert or General Emergency are handled like normal
operational issues by the plant, even if they have an impact on the safety of the personnel
or the relations with the community. The team has made a recommendation in this
regard.
9.4 EMERGENCY RESPONSE FACILITIES
The Emergency Operations Management Centre (DLC) and the Technical Support
Centre (TSC) are tidy, well equipped with faxes and telephones. The Emergency
Management Centre is in a well protected bunker, has good communication facilities and
a good layout. An air filtration system and a diesel generator are installed. The protection
of this facility is very good and the alternative arrangements are credible since the Fire
Station in Östhammar is the alternate Emergency Management Centre (EMC) for the
plant.
There are nine assembly points on site, near each group of buildings. Forsmark Units 1-
2-3 have an assembly point in the lunch room of the non-controlled area. The nine
assembly points provide minimum protection from radiation in the event of a release. For
this reason, they should be monitored continuously during an emergency. This function
is carried out by the Duty Engineer or the Radiation Protection Manager at the
Emergency Management Centre (EMC). They access the online system of outdoors fixed
monitors, check those that are closest to each assembly point and ask the Communication
Manager to telephone and send a fax to the assembly point if it is not safe. The
Information Centre is not in the vicinity of any of the outdoors fixed monitors. The plant
agreed that local monitoring using portable ambient gamma survey meters would
improve the ability of each assembly point to monitor its habitability. The portable
ambient gamma survey meters will be distributed to the assembly points upon
declaration of an Alert.
The Reception Centres in Norrskedika and Skärplinge were in part provided and
equipped by the plant. This is evidence of the good collaboration between the plant and
the off-site authorities. These locations are also the assembly point for police,
ambulance, fire fighters who will enter and exit the inner emergency zone. These
arrangements are noteworthy for their thoroughness.
The plant does not have a dedicated medical centre on site. Casualties receive first-aid
1 The great uncertainty is not the result of a poor methodology on the part of the plant. It
is inherent in this type of assessment, as discussed in EPR-Method 2003; A7.
2 The recommended factor is explained in TECDOC 955, procedures C1, F1.
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from Rescue Services and are transported by ambulance or helicopter to the hospital in
Östhammar or Uppsala. The Östhammar hospital in the inner emergency zone accepts
contaminated victims and the hospital in Uppsala is specialized in the treatment of
overexposed patients. These arrangements are good however there are currently no
written agreements between the hospitals and the plant. The plant is encouraged to put
more formal agreements in place.
9.5 EMERGENCY EQUIPMENT AND RESOURCES
Unlike the control room at Forsmark Unit 3, the control rooms at Units 1 and 2 are not
equipped with fixed ambient gamma monitor to check the habitability of the control
room during an accident. Procedures at the Emergency Operations Management Centre
(DLC) require RP to bring a portable ambient gamma survey meter to the control room.
The plant plans to equip the control rooms at F1/F2 with fixed ambient gamma monitors
within the next few months.
The Alert system for the population includes Radio Broadcast Warning devices (RDS) in
homes of about 1000 permanent residents, sirens that alert transient populations, and the
use of local television and radio to broadcast alert messages. These arrangements are
good and are tested quarterly.
The plant and Lsty perform and share the results of gamma surveys in the inner
emergency zone. Every fire station in the inner emergency zone is equipped with
portable gamma survey instruments and teams of fire-fighters have been trained to use
them. These teams are deployed to measure dose rates in the communities surrounding
the plant. The fire-fighter monitoring teams use the RADOS SRV-2000 gamma survey
meters with a high range of 10 Sv/h. The plant monitoring teams use the Automess
survey meters that has an inadequate high range (10 mSv/h) and this is not sufficient for
emergency surveys near the release point. The plant is encouraged to include an
additional probe that has a range of at least 1 Sv/h in their equipment bags.
The rest of the equipment used by the plant has an adequate high range (gamma dose rate
monitor in containment up to 10 kGy/h and radiation detection equipment used by RP
inside the plant up to 1 Sv/h). The ring of fixed detectors around the plant is well
implemented and the detectors have a high range (1 Sv/h), ten year battery life and use a
web-based interface that can be accessed from any location on site (but currently not offsite).
A visual alarm is displayed when the user accesses the webpage of the detectors,
but there are no continuously monitored alarms associated with this system. There should
be one, monitored from a location manned 24/7 (such as the Security Centre or the
Control Room). SSI has 32 fixed detectors across Sweden that are used to monitor
gamma dose rates. SSI does not currently have direct access (internet) to the ring of
detectors on the site. These arrangements are good, although the plant and SSI are
encouraged to investigate the feasibility of automatically exchanging the data from the
on site ring of detectors.
The plant has a one hundred meter meteorological tower and uses a very effective web
interface for presenting the weather data. This web site is accessible to the public or any
organization, inside or outside the plant.
Four functionalities are included in the web interface.
1. A simple page shows the temperature, the wind speed and the wind direction using
pictograms that are easily understandable by the public.
2. A map of the area shows the direction of the wind with a large arrow.
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3. Graphical records of the data collected at the meteorological tower are available for
temperature, windspeed, wind direction and standard deviation at three levels.
4. Capability to export data in text or Excel format.
This has been identified as good performance by the Team.
9.6 TRAINING, DRILL AND EXERCISES
The web-based training is very effective and covers emergency signals and emergency
levels well. The basic training would be more complete if it included a description of
signs on the floor that are routinely used in the plant. One set (the “Ut” sign) directs the
person to the nearest exit and the other (the “Running man”) is showing the safest route
to evacuate, but this is not currently taught.
The preparation and conduct of the drills is generally adequate, although the drill
preparation process could be optimized if the objectives of the drill were always selected
before preparing the scenario. As an example, a drill prepared for the Crisis Group did
not achieve the objective of testing the notification and activation process because the
call from the Site Emergency Director (OL) to the Crisis Group was not simulated.
The process for preparing, co-ordinating and conducting exercises is more formal and
this is appropriate since many groups are involved. The large scale emergency exercises
are well organized, involving a group of emergency preparedness personnel from the
Unit that will exercise. The Crisis Group (handling post-traumatic stress syndrome) is
invited to participate in exercise preparation to give visibility to this service to personnel.
This is an effective method to improve awareness since individuals suffering from posttraumatic
stress syndrome may not be aware that this type of support is available after an
emergency.
The exercise evaluation material for generic issues is very good, covering logistics,
procedures, communications, facilities, training, etc… This material was prepared under
the sponsorship of SKI for use by the power plants. The evaluation criteria for the
specific issues that are being tested have to be adapted to match the objectives of each
exercise, and this done well by the plant. In order to facilitate this process, the plant is
encouraged to use the evaluation criteria contained in Appendix III of EPR-Method
2003.
The plant is also encouraged to adopt a list of response functions (such as those in EPR-
Method 2003 section 4.2 or EPR-Exercise 2005 Appendix II) that would be tested in
drills and exercises over a five year cycle.
9.7 QUALITY PROGRAMME
The plant has set forth the requirements for Emergency Preparedness in the Management
and Quality Handbook (LOK) and supporting documents. The QA process for
Emergency Preparedness demonstrates a good high level review at the policy and
functional level. This is carried out by independent reviewers from another power plant.
To supplement the existing QA process, the plant is encouraged to implement an internal
benchmark review against the detailed IAEA Requirements contained in EPR-Method
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2003. This review would be carried out by the plant every five years. This benchmarking
would insure that there are no gaps in the emergency plan following internal or external
organization changes.
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DETAILED EMERGENCY PLANNING AND PREPAREDNESS FINDINGS
9.2 EMERGENCY PLAN
9.2(a) Good Practice:
The plant has developed a tool that identifies strategies for solving technical problems
during a nuclear emergency. This tool is the Technical Handbook for Plant Operational
Manager – Technisk Handbok for Anlaggningsledare (THAL).
Using this tool, the Plant Operational Manager (AL) presents the Site Emergency
Director (OL) with an assessment of the feasibility, data needs, resources, and expected
results for solving technical problems that are not covered by General Disturbance
Procedures. This high level view of the management of technical issues during an
accident is unique in the Team’s opinion.
Instead of entering directly into Severe Accident Management Guidelines (SAMG), the
tool gives management-level guidance on what is needed to solve the problem, who can
help and what tools can they use. The THAL does not replace the SAMG, which are used
by a separate group of engineering and safety analysis specialists. The THAL explains
when to start the SAMG analysis and what to expect from the group of specialists.
The THAL takes the approach that in order to be able to make decisions during a severe
accident, different alternative strategies need to be considered. The THAL is a
knowledge based handbook where such strategies are described, along with other
essential information. The THAL also identifies the short term actions that are important
for long term accident management. The THAL is organized by issues such as
• Short term actions (minimizing the spread of radioactivity, core damage assessment,
reactor vessel integrity assessment, etc…)
• Long term actions (containment pH adjustment, measuring activity and chemical
parameters in the containment, hydrogen control, etc…)
• Instrumentation available in the containment
• Radiological environment (habitability)
• Personal safety measures
• Alternatives for electrical supply
• Communication means
• List of mobile equipment available in the region (pumps, generators, etc…)
• Operation at non affected reactor units
• Process systems relation
Each issue is covered in a dedicated section that contains
o Info
o Strategy
o References
Using the THAL manual, the Plant Operational Manager (AL) can provide the Site
Emergency Director (EL) with a very good overview of the decisions he may have to
make during the emergency.
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9.3 EMERGENCY PROCEDURES
9.3(1) Issue: Events below the threshold for Alert or General Emergency are handled
like normal operational issues by the plant, even if they have an impact on the
safety of the personnel or the relations with the community.
• The 1993 SKI ruling DNR-855/ad 1238/92 requires two emergency levels
that trigger notification of the authorities (Alert, General Emergency)
instead of the usual four levels contained in IAEA Safety Standard GS-R-2;
para 4.19.
• SKI and SSI have no problem if Forsmark decides to have additional alarm
levels that don’t involve the authorities.
• The plant has alarms for fire, gas leak and radiation (evacuation alarm).
These alarms are not considered “Emergencies” by the plant, yet in
combination with the two reportable emergency levels, they meet the intent
of the Safety Standard GS-R-2.
• The Management and Quality Handbook (LOK) does not detail the range of
events, from plant disturbances that affect safety of personnel to severe
accidents that should be covered by the emergency plan
• Emergency Management Centre has not been used during a bomb threat or
fire. These events could evolve into a nuclear Alert or General Emergency.
It would be prudent to muster key personnel (Duty Engineer – VHI) for
these events.
• Once a room or hall is evacuated for a local Alarm (gas leak, radiation
alarm, steam leak) the personnel is mustered at the Unit assembly point. The
accounting process relies on grouping the evacuated persons in work teams
that can quickly identify missing persons and on lists of personnel in the
controlled area that are produced by the Security Centre after the formal
accounting process using the access cards is triggered.
Dealing with disturbances without the resources and structure of the emergency plan can
impair response and reduce the readiness of the organization if the emergency becomes
more serious.
Recommendation: The plant should create an emergency level “Alarm” that would
apply to Unit disturbances that trigger protective actions for Unit personnel.
For example: The plant could increase readiness of the on-site response organization by
sending a Unit Operation Manager (Level 2) or Duty Engineer (VHI) to the control
room. The plant could assign one person to prepare Emergency Management Centre and
remain on standby until the “Alarm” is over.
Basis: EPR-Method 2003. 2.1.5: “Alerts at facilities in threat category I, II or III
involving an uncertain or significant decrease in the level of protection for the public or
for people on the site. Upon declaration of this class of emergency, action shall be
promptly taken to assess and mitigate the consequences of the event and to increase the
readiness of the on-site and off-site response organizations as appropriate.”
GS-G-2.1, Appendix IV, Table 10: “Facility Emergency: Event resulting in a major
decrease in protection for on-site personnel; however, these events cannot evolve into a
general or a site area emergency warranting the implementation of protective actions off
the site. - A fuel handling emergency; - An in-facility fire or other emergency not
affecting safety systems; - Terrorist or criminal activity resulting in hazardous on-site
conditions but with no potential to result in criticality or release off the site that would
warrant urgent protective actions. ”
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DEFINITIONS
DEFINITIONS - OSART MISSION
Recommendation
A recommendation is advice on how improvements in operational safety can be made in the
activity or programme that has been evaluated. It is based on IAEA Safety Standards or
proven, good international practices and addresses the root causes rather than the symptoms
of the identified concern. It very often illustrates a proven method of striving for excellence,
which reaches beyond minimum requirements. Recommendations are specific, realistic and
designed to result in tangible improvements. Absence of recommendations can be interpreted
as performance corresponding with proven international practices.
Suggestion
A suggestion is either an additional proposal in conjunction with a recommendation or may
stand on its own following a discussion of the pertinent background. It may indirectly
contribute to improvements in operational safety but is primarily intended to make a good
performance more effective, to indicate useful expansions to existing programmes and to
point out possible superior alternatives to ongoing work. In general, it is designed to stimulate
the plant management and supporting staff to continue to consider ways and means for
enhancing performance.
Note: if an item is not well based enough to meet the criteria of a ‘suggestion’, but the expert
or the team feels that mentioning it is still desirable, the given topic may be described in the
text of the report using the phrase ‘encouragement’ (e.g. The team encouraged the plant
to…).
Good practice
A good practice is an outstanding and proven performance, programme, activity or equipment
in use that contributes directly or indirectly to operational safety and sustained good
performance. A good practice is markedly superior to that observed elsewhere, not just the
fulfilment of current requirements or expectations. It should be superior enough and have
broad application to be brought to the attention of other nuclear power plants and be worthy
of their consideration in the general drive for excellence. A good practice has the following
characteristics:
− novel;
− has a proven benefit;
− replicable (it can be used at other plants);
− does not contradict an issue.
The attributes of a given ‘good practice’ (e.g. whether it is well implemented, or cost
effective, or creative, or it has good results) should be explicitly stated in the description of
the ‘good practice’.
Note: An item may not meet all the criteria of a ‘good practice’, but still be worthy to take
note of. In this case it may be referred as a ‘good performance’, and may be documented in
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the text of the report. A good performance is a superior objective that has been achieved or a
good technique or programme that contributes directly or indirectly to operational safety and
sustained good performance, that works well at the plant. However, it might not be necessary
to recommend its adoption by other nuclear power plants, because of financial
considerations, differences in design or other reasons.
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Safety Standards
LIST OF IAEA REFERENCES (BASIS)
SF-1; Fundamental Safety Principles (Safety Fundamentals)
Safety Series No.115; International Basic Safety Standards for Protection Against
Ionizing Radiation and for the Safety of Radiation Sources
Safety Series No.117; Operation of Spent Fuel Storage Facilities
NS-R-1; Safety of Nuclear Power Plants: Design Requirements
NS-R-2; Safety of Nuclear Power Plants: Operation (Safety Requirements)
NS-G-1.1; Software for Computer Based Systems Important to Safety in Nuclear
Power Plants (Safety Guide)
NS-G-2.1; Fire Safety in the Operation of Nuclear Power Plans (Safety Guide)
NS-G-2.2; Operational Limits and Conditions and Operating Procedures for
Nuclear Power Plants (Safety Guide)
NS-G-2.3; Modifications to Nuclear Power Plants (Safety Guide)
NS-G-2.4; The Operating Organization for Nuclear Power Plants (Safety Guide)
NS-G-2.5; Core Management and Fuel Handling for Nuclear Power Plants (Safety
Guide)
NS-G-2.6; Maintenance, Surveillance and In-service Inspection in Nuclear Power
Plants (Safety Guide)
NS-G-2.7; Radiation Protection and Radioactive Waste Management in the
Operation of Nuclear Power Plants (Safety Guide)
NS-G-2.8; Recruitment, Qualification and Training of Personnel for Nuclear
Power Plants (Safety Guide)
NS-G-2.9; Commissioning for Nuclear Power Plants (Safety Guide)
NS-G-2-10; Periodic Safety Review of Nuclear Power Plants (Safety Guide)
NS-G-2.11; A System for the Feedback of Experience from Events in Nuclear
Installations (Safety Guide)
GS-R-1; Legal and Governmental Infrastructure for Nuclear, Radiation,
Radioactive Waste and Transport Safety (Safety Requirements)
GS-R-2; Preparedness and Response for a Nuclear or Radiological Emergency
(Safety Requirements)
GS-R-3; The Management System for Facilities and Activities (Safety
Requirements)
GS-G-2.1; Arrangement for Preparedness for a Nuclear or Radiological
Emergency (Safety Guide)
GS-G-3.1; Application of the Management System for Facilities and Activities
(Safety Guide)
50-C/SG-Q; Quality Assurance for Safety in Nuclear Power Plants and other
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Nuclear Installations (Code and Safety Guides Q1-Q14)
RS-G-1.1; Occupational Radiation Protection (Safety Guide)
RS-G-1.2; Assessment of Occupational Exposure Due to Intakes of Radionuclides
(Safety Guide)
RS-G-1.3; Assessment of Occupational Exposure Due to External Sources of
Radiation (Safety Guide)
RS-G-1.8; Environmental and Source Monitoring for Purpose of Radiation
Protection (Safety Guide)
WS-G-6.1; Storage of Radioactive Waste (Safety Guide)
DS347; Conduct of Operations at Nuclear Power Plants (Draft Safety Guide)
DS388; Chemistry Control in the Operation of Nuclear Power Plants (Draft Safety
Guide)
INSAG, Safety Report Series
INSAG-4; Safety Culture
INSAG-10; Defence in Depth in Nuclear Safety
INSAG-12; Basic Safety Principles for Nuclear Power Plants, 75-INSAG-3 Rev.1
INSAG-13; Management of Operational Safety in Nuclear Power Plants
INSAG-14; Safe Management of the Operating Lifetimes of Nuclear Power Plants
INSAG-15; Key Practical Issues In Strengthening Safety Culture
INSAG-16; Maintaining Knowledge, Training and Infrastructure for Research and
Development in Nuclear Safety
INSAG-17; Independence in Regulatory Decision Making
INSAG-18; Managing Change in the Nuclear Industry: The Effects on Safety
INSAG-19; Maintaining the Design Integrity of Nuclear Installations Throughout
Their Operating Life
Safety Report Series No.11; Developing Safety Culture in Nuclear Activities
Practical Suggestions to Assist Progress
Safety Report Series No.21; Optimization of Radiation Protection in the Control
of Occupational Exposure
Safety Report Series No.48; Development and Review of Plant Specific
Emergency Operating Procedures
114

TECDOCs and IAEA Services Series
IAEA Safety Glossary Terminology used in nuclear safety and radiation
protection 2007 Edition
Services series No.10; PROSPER Guidelines
Services series No.12; OSART Guidelines
TECDOC-489; Safety Aspects of Water Chemistry in Light Water Reactors
TECDOC-744; OSART Guidelines 1994 Edition (Refer only chapter 10-15 for
Pre-OSART, if applicable.)
TECDOC-1141; Operational Safety Performance Indicators for Nuclear Power
Plants
TECDOC-1321; Self-assessment of safety culture in nuclear installations
TECDOC-1329; Safety culture in nuclear installations - Guidance for use in the
enhancement of safety culture
TECDOC 1446 OSART mission highlights 2001-2003
TECDOC-1458; Effective corrective actions to enhance operational safety of
nuclear installations
TECDOC-1477; Trending of low level events and near misses to enhance safety
performance in nuclear power plants
TECDOC-955; Generic Assessment Procedures for Determining Protective
Actions during a Reactor Accident
EPR-EXERCISE-2005; Preparation, Conduct and Evaluation of Exercises to
Test Preparedness for a Nuclear or Radiological Emergency, (Updating IAEA-
TECDOC-953)
EPR-METHOD-2003; Method for developing arrangements for response to a
nuclear or radiological emergency, (Updating IAEA-TECDOC-953)
EPR-ENATOM-2002; Emergency Notification and Assistance Technical
Operations Manual
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ACKNOWLEDGEMENT
The Government of Sweden and the staff of Forsmark Nuclear Power Plant provided valuable
support to the OSART mission to Forsmark NPP. Throughout the whole OSART mission, the
team members felt welcome and enjoyed excellent cooperation and fruitful discussions with
Forsmark Nuclear Power Plant managers and staff, and other local and national authorities.
Information was provided openly and in the spirit of seeking improvements in operational safety.
There was a rich exchange of knowledge and experience which contributed significantly to the
success of the mission. It also established many personal contacts that will not end with the
completion of the mission and submission of this report. The efforts of the plant counterparts,
liaison officers, interpreters and the secretaries were outstanding. This was of significant support
to the OSART team in order to complete its mission in a fruitful manner.
The IAEA, the Division of Nuclear Installation Safety and its Operational Safety Section wish to
thank all those involved for the excellent working conditions during the Forsmark Nuclear Power
Plant review.
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TEAM COMPOSITION OSART MISSION
LIPAR, Miroslav – IAEA
Division of Nuclear Installation Safety
Years of Nuclear Experience: 30
Team Leader
HENDERSON, Neil – IAEA
Division of Nuclear Installation Safety
Years of Nuclear Experience: 32
Deputy Team Leader
MITCHEL, Timothy - USA
Arkansas Nuclear One NPP
Years of Nuclear Experience: 26
Review area: Management, organization and administration
KOHLER, Thomas – Switzerland
Kernkraftwerk Gosgen-Daniken AG
Years of Nuclear Experience: 14
Review area: Training and qualifications
GEST, Pierre - France
E.D.F (Electricité de France)
Years of Nuclear Experience: 26
Review area: Operations I
TOTH, Alexander - Slovakia
Slovenské elektrárne, a.s. - Enel
Years of Nuclear Experience: 21
Review area: Operations II
VONKA, Tore - Finland
Loviisa NPP
Years of Nuclear Experience: 33
Review area: Maintenance
YOKOYAMA, Kenichi - Japan
WANO - Tokyo
Years of Nuclear Experience: 30
Review area: Technical support
NICHOLS, Robert - UK
Years of Nuclear Experience: 43
Review area: Operating experience feedback – Forsmark 25/7/06 event
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ZHUK, Yury – Russian Federation
VNIIAES
Years of Nuclear Experience: 27
Review area: Operating experience feedback
HORT, Milan – Czech Republic
State Office for Nuclear Safety
Years of Nuclear Experience: 24
Review area: Radiation protection
BOLZ, Michael - Germany
EnBW Philipsburg
Years of Nuclear Experience: 14
Review area: Chemistry
LEMAY, Francois - Canada
International Safety Research
Years of Nuclear Experience: 26
Review area: Emergency planning and preparedness
HODUL, Roman – Slovakia
Bohunice NPP
Years of Nuclear Experience: 18
Observer
HOLM, Fredrik - Sweden
Oskarshamn NPP
Years of Nuclear Experience: 10
Observer
CALVIN, Hakan – Sweden
Ringhals NPP
Years of Nuclear Experience: 20
Observer
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