Report of the operational safety review team mission to the Forsmark ...
Report of the operational safety review team mission to the Forsmark ...
Report of the operational safety review team mission to the Forsmark ...
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NSNI/OSART/08/145<br />
ORIGINAL: English<br />
DISTRIBUTION: RESTRICTED<br />
REPORT<br />
<strong>of</strong> <strong>the</strong><br />
OPERATIONAL SAFETY REVIEW TEAM<br />
(OSART)<br />
MISSION<br />
TO THE<br />
FORSMARK<br />
NUCLEAR POWER PLANT<br />
SWEDEN<br />
12 - 28 February 2008<br />
DIVISION OF NUCLEAR INSTALLATION SAFETY<br />
OPERATIONAL SAFETY REVIEW MISSION<br />
IAEA-NSNI/OSART/08/145
PREAMBLE<br />
This report presents <strong>the</strong> results <strong>of</strong> <strong>the</strong> IAEA Operational Safety Review Team (OSART) <strong>review</strong><br />
<strong>of</strong> <strong>the</strong> <strong>Forsmark</strong> Nuclear Power Plant, Sweden. It includes recommendations for improvements<br />
affecting <strong>operational</strong> <strong>safety</strong> for consideration by <strong>the</strong> responsible Swedish authorities and<br />
identifies good practices for consideration by o<strong>the</strong>r nuclear power plants. Each<br />
recommendation, suggestion, and good practice is identified by a unique number <strong>to</strong> facilitate<br />
communication and tracking.<br />
Any use <strong>of</strong> or reference <strong>to</strong> this report that may be made by <strong>the</strong> competent Swedish organizations<br />
is solely <strong>the</strong>ir responsibility.
FOREWORD<br />
by <strong>the</strong><br />
Direc<strong>to</strong>r General<br />
The IAEA Operational Safety Review Team (OSART) programme assists Member States <strong>to</strong><br />
enhance safe operation <strong>of</strong> nuclear power plants. Although good design, manufacture and<br />
construction are prerequisites, <strong>safety</strong> also depends on <strong>the</strong> ability <strong>of</strong> operating personnel and<br />
<strong>the</strong>ir conscientiousness in discharging <strong>the</strong>ir responsibilities. Through <strong>the</strong> OSART programme,<br />
<strong>the</strong> IAEA facilitates <strong>the</strong> exchange <strong>of</strong> knowledge and experience between <strong>team</strong> members who<br />
are drawn from different Member States, and plant personnel. It is intended that such advice<br />
and assistance should be used <strong>to</strong> enhance nuclear <strong>safety</strong> in all countries that operate nuclear<br />
power plants.<br />
An OSART <strong>mission</strong>, carried out only at <strong>the</strong> request <strong>of</strong> <strong>the</strong> relevant Member State, is directed<br />
<strong>to</strong>wards a <strong>review</strong> <strong>of</strong> items essential <strong>to</strong> <strong>operational</strong> <strong>safety</strong>. The <strong>mission</strong> can be tailored <strong>to</strong> <strong>the</strong><br />
particular needs <strong>of</strong> a plant. A full scope <strong>review</strong> would cover eight <strong>operational</strong> areas:<br />
management, organization and administration; training and qualification; operations;<br />
maintenance; technical support; radiation protection; chemistry; and emergency planning and<br />
preparedness. Depending on individual needs, <strong>the</strong> OSART <strong>review</strong> can be directed <strong>to</strong> a few areas<br />
<strong>of</strong> special interest or cover <strong>the</strong> full range <strong>of</strong> <strong>review</strong> <strong>to</strong>pics.<br />
Essential features <strong>of</strong> <strong>the</strong> work <strong>of</strong> <strong>the</strong> OSART <strong>team</strong> members and <strong>the</strong>ir plant counterparts are <strong>the</strong><br />
comparison <strong>of</strong> a plant's <strong>operational</strong> practices with best international practices and <strong>the</strong> joint<br />
search for ways in which <strong>operational</strong> <strong>safety</strong> can be enhanced. The IAEA Safety Series<br />
documents, including <strong>the</strong> Safety Standards and <strong>the</strong> Basic Safety Standards for Radiation<br />
Protection, and <strong>the</strong> expertise <strong>of</strong> <strong>the</strong> OSART <strong>team</strong> members form <strong>the</strong> bases for <strong>the</strong> evaluation.<br />
The OSART methods involve not only <strong>the</strong> examination <strong>of</strong> documents and <strong>the</strong> interviewing <strong>of</strong><br />
staff but also <strong>review</strong>ing <strong>the</strong> quality <strong>of</strong> performance. It is recognized that different approaches are<br />
available <strong>to</strong> an operating organization for achieving its <strong>safety</strong> objectives. Proposals for fur<strong>the</strong>r<br />
enhancement <strong>of</strong> <strong>operational</strong> <strong>safety</strong> may reflect good practices observed at o<strong>the</strong>r nuclear power<br />
plants.<br />
An important aspect <strong>of</strong> <strong>the</strong> OSART <strong>review</strong> is <strong>the</strong> identification <strong>of</strong> areas that should be improved<br />
and <strong>the</strong> formulation <strong>of</strong> corresponding proposals. In developing its view, <strong>the</strong> OSART <strong>team</strong><br />
discusses its findings with <strong>the</strong> operating organization and considers additional comments made<br />
by plant counterparts. Implementation <strong>of</strong> any recommendations or suggestions, after<br />
consideration by <strong>the</strong> operating organization and adaptation <strong>to</strong> particular conditions, is entirely<br />
discretionary.<br />
An OSART <strong>mission</strong> is not a regula<strong>to</strong>ry inspection <strong>to</strong> determine compliance with national <strong>safety</strong><br />
requirements nor is it a substitute for an exhaustive assessment <strong>of</strong> a plant's overall <strong>safety</strong> status,<br />
a requirement normally placed on <strong>the</strong> respective power plant or utility by <strong>the</strong> regula<strong>to</strong>ry body.<br />
Each <strong>review</strong> starts with <strong>the</strong> expectation that <strong>the</strong> plant meets <strong>the</strong> <strong>safety</strong> requirements <strong>of</strong> <strong>the</strong><br />
country concerned. An OSART <strong>mission</strong> attempts nei<strong>the</strong>r <strong>to</strong> evaluate <strong>the</strong> overall <strong>safety</strong> <strong>of</strong> <strong>the</strong><br />
plant nor <strong>to</strong> rank its <strong>safety</strong> performance against that <strong>of</strong> o<strong>the</strong>r plants’ <strong>review</strong>ed. The <strong>review</strong><br />
represents a `snapshot in time'; at any time after <strong>the</strong> completion <strong>of</strong> <strong>the</strong> <strong>mission</strong> care must be<br />
exercised when considering <strong>the</strong> conclusions drawn since programmes at nuclear power plants<br />
are constantly evolving and being enhanced. To infer judgments that were not intended would<br />
be a misinterpretation <strong>of</strong> this report.
The report that follows presents <strong>the</strong> conclusions <strong>of</strong> <strong>the</strong> OSART <strong>review</strong>, including good practices<br />
and proposals for enhanced <strong>operational</strong> <strong>safety</strong>, for consideration by <strong>the</strong> Member State and its<br />
competent authorities.
CONTENT<br />
INTRODUCTION AND MAIN CONCLUSIONS ...................................................................1<br />
1. MANAGEMENT, ORGANIZATION AND ADMINISTRATION..................................4<br />
2. TRAINING AND QUALIFICATIONS...........................................................................17<br />
3. OPERATIONS.................................................................................................................27<br />
4. MAINTENANCE ............................................................................................................39<br />
5. TECHNICAL SUPPORT ................................................................................................49<br />
6. OPERATING EXPERIENCE..........................................................................................57<br />
7. RADIATION PROTECTION..........................................................................................79<br />
8. CHEMISTRY ..................................................................................................................89<br />
9. EMERGENCY PLANNING AND PREPAREDNESS ................................................103<br />
DEFINITIONS.......................................................................................................................111<br />
LIST OF IAEA REFERENCES (BASIS)..............................................................................113<br />
ACKNOWLEDGEMENT .....................................................................................................116<br />
TEAM COMPOSITION OSART MISSION.........................................................................117
INTRODUCTION AND MAIN CONCLUSIONS<br />
INTRODUCTION<br />
At <strong>the</strong> request <strong>of</strong> <strong>the</strong> Government <strong>of</strong> Sweden, an IAEA Operational Safety Review Team<br />
(OSART) <strong>of</strong> international experts visited <strong>the</strong> site <strong>of</strong> <strong>the</strong> <strong>Forsmark</strong> Nuclear Power Plant and<br />
concentrated its <strong>review</strong> on unit one from 12 February <strong>to</strong> 28 February 2008. <strong>Forsmark</strong> NPP<br />
unit one is a part <strong>of</strong> <strong>the</strong> <strong>Forsmark</strong> site which hosts all <strong>to</strong>ge<strong>the</strong>r 3 units with a <strong>to</strong>tal gross<br />
capacity <strong>of</strong> 3254MWe. The NPP is part <strong>of</strong> <strong>the</strong> Vattenfall Group and <strong>the</strong> site is situated on<br />
<strong>the</strong> east coast <strong>of</strong> Sweden, approximately 140 Kilometers north <strong>of</strong> S<strong>to</strong>ckholm.<br />
Vattenfall AB is <strong>the</strong> majority stakeholder with 66% <strong>of</strong> <strong>the</strong> shares, making <strong>Forsmark</strong>s<br />
Kraftgrupp AB (FKA) a subsidiary <strong>of</strong> Vattenfall AB. In addition, Mellansvensk<br />
Kraftgrupp owns 25.5% and E.on Karnkraft owns 8.5%.<br />
The purpose <strong>of</strong> <strong>the</strong> <strong>mission</strong> was <strong>to</strong> <strong>review</strong> operating practices in <strong>the</strong> areas <strong>of</strong> management<br />
organization and administration; training and qualifications; operations; maintenance;<br />
technical support (engineering); operating experience feedback including evaluation <strong>of</strong> <strong>the</strong><br />
25 July 2006 event; radiation protection; chemistry and emergency planning and<br />
preparedness. In addition, an exchange <strong>of</strong> technical experience and knowledge <strong>to</strong>ok place<br />
between <strong>the</strong> experts and <strong>the</strong>ir plant counterparts on how <strong>the</strong> common goal <strong>of</strong> excellence in<br />
<strong>operational</strong> <strong>safety</strong> could be fur<strong>the</strong>r pursued.<br />
The <strong>Forsmark</strong> OSART <strong>mission</strong> was <strong>the</strong> 145 th in <strong>the</strong> programme, which began in 1982.<br />
The <strong>team</strong> for <strong>Forsmark</strong> unit one OSART was composed <strong>of</strong> experts from Canada; Czech<br />
Republic; Finland; France; Germany; Japan; Russian Federation; Slovakia; Switzerland;<br />
United Kingdom, and <strong>the</strong> USA, <strong>to</strong>ge<strong>the</strong>r with <strong>the</strong> IAEA staff members and two observers<br />
from Sweden and one observer from Slovakia. The collective nuclear power experience <strong>of</strong><br />
<strong>the</strong> <strong>team</strong> was approximately 390 years, including <strong>the</strong> observers.<br />
Before visiting <strong>Forsmark</strong> unit one, <strong>the</strong> <strong>team</strong> studied information provided by <strong>the</strong> IAEA and<br />
<strong>the</strong> <strong>Forsmark</strong> plant <strong>to</strong> familiarize <strong>the</strong>mselves with <strong>the</strong> plant’s main features and operating<br />
performance, staff organization and responsibilities, and important programmes and<br />
procedures. During <strong>the</strong> <strong>mission</strong>, <strong>the</strong> <strong>team</strong> <strong>review</strong>ed many <strong>of</strong> <strong>the</strong> plant’s programmes and<br />
procedures in depth, examined indica<strong>to</strong>rs <strong>of</strong> <strong>the</strong> plant’s performance, observed work in<br />
progress and held in-depth discussions with plant personnel.<br />
Throughout <strong>the</strong> <strong>review</strong>, <strong>the</strong> exchange <strong>of</strong> information between <strong>the</strong> OSART experts and plant<br />
personnel was very open, pr<strong>of</strong>essional and productive. Emphasis was placed on assessing<br />
<strong>the</strong> effectiveness <strong>of</strong> <strong>operational</strong> <strong>safety</strong> ra<strong>the</strong>r than simply <strong>the</strong> content <strong>of</strong> programmes. The<br />
conclusions <strong>of</strong> <strong>the</strong> OSART <strong>team</strong> were based on <strong>the</strong> performance <strong>of</strong> <strong>the</strong> plant compared<br />
with IAEA Safety Standards and good international practices.<br />
1<br />
INTRODUCTION AND MAIN CONCLUSIONS
MAIN CONCLUSIONS<br />
The OSART <strong>team</strong> concluded that <strong>the</strong> managers and staff <strong>of</strong> <strong>Forsmark</strong> NPP are committed<br />
<strong>to</strong> improving <strong>the</strong> <strong>operational</strong> <strong>safety</strong> and reliability <strong>of</strong> <strong>the</strong>ir plant. This was clearly<br />
demonstrated by <strong>the</strong> fact that since <strong>the</strong> OSART prepara<strong>to</strong>ry meeting and seminar in June<br />
2007, <strong>the</strong> plant has introduced or extended several programmes contributing <strong>to</strong> improved<br />
<strong>operational</strong> <strong>safety</strong>. During this process, <strong>the</strong> plant has extensively used <strong>the</strong> OSART<br />
methodology for self assessment and <strong>the</strong> IAEA Safety Standards <strong>to</strong> benchmark <strong>the</strong>ir<br />
existing practices and <strong>to</strong> identify gaps and useful improvements. The <strong>team</strong> recognized that<br />
<strong>Forsmark</strong> management and staff are dedicated and knowledgeable, with a very<br />
pr<strong>of</strong>essional attitude. The plant is benefiting from an excellent work environment with<br />
open and interested staff. The management recently implemented several good<br />
programmes and initiatives <strong>to</strong> fur<strong>the</strong>r enhance <strong>operational</strong> <strong>safety</strong> including an operating<br />
experience process and indica<strong>to</strong>rs <strong>to</strong> help drive improvements.<br />
The <strong>team</strong> found good areas <strong>of</strong> performance, including <strong>the</strong> following:<br />
−<br />
−<br />
−<br />
−<br />
−<br />
−<br />
−<br />
−<br />
Very well structured management manual which supports communication <strong>of</strong><br />
management expectations and commitments.<br />
To use <strong>the</strong> training simula<strong>to</strong>r <strong>to</strong> describe complex events and <strong>to</strong> demonstrate <strong>the</strong><br />
work methods in <strong>the</strong> control room, following a disturbance, <strong>to</strong> <strong>the</strong> media and o<strong>the</strong>r<br />
key groups.<br />
Computerized moni<strong>to</strong>ring <strong>of</strong> <strong>safety</strong> functions and operating status checks<br />
Effective management <strong>of</strong> fire cells in order <strong>to</strong> prevent <strong>the</strong> spread <strong>of</strong> any fire and<br />
associated fumes.<br />
The TIGER procedure ensures that <strong>the</strong> Human-Machine-Interface design is<br />
incorporated in modernization projects in an appropriate manner.<br />
MATSTAB (a full 3-dimensional neutron model in combination with a <strong>the</strong>rmal<br />
hydraulic model) can provide information on core design for stability prediction<br />
and stability optimization.<br />
Structured cooperation with <strong>the</strong> original equipment manufacturer Westinghouse<br />
Electric Sweden for operating experience dissemination for <strong>the</strong> improvement <strong>of</strong><br />
<strong>safety</strong>.<br />
In <strong>the</strong> Chemistry area, <strong>the</strong> plant has optimized <strong>the</strong> oxygen content in <strong>the</strong> drain <strong>of</strong><br />
<strong>the</strong> pre-heaters by changing <strong>the</strong> ventilation from <strong>the</strong> pre-heaters <strong>to</strong> <strong>the</strong> condenser<br />
<strong>to</strong>ge<strong>the</strong>r with installation <strong>of</strong> a bypass flow through some pre-heaters. In addition,<br />
<strong>the</strong> plant has optimized <strong>the</strong> sulphate content in <strong>the</strong> coolant after <strong>the</strong> power upgrade.<br />
A number <strong>of</strong> proposals for improvements in <strong>operational</strong> <strong>safety</strong> were <strong>of</strong>fered by <strong>the</strong> <strong>team</strong>.<br />
The most significant proposals include <strong>the</strong> following:<br />
−<br />
−<br />
−<br />
−<br />
The plant should <strong>review</strong> responsibilities for <strong>the</strong> operating staff, considering both<br />
<strong>the</strong> individual unit and <strong>the</strong> combined site, <strong>to</strong> determine if transients or abnormal<br />
conditions can be properly managed during both design basis and beyond design<br />
basis events. In addition <strong>the</strong>re should be always one person on site capable <strong>of</strong><br />
declaring an emergency and notifying <strong>the</strong> <strong>of</strong>f-site authorities.<br />
The organisation should implement an independent high level <strong>safety</strong> <strong>review</strong> with<br />
responsibility <strong>to</strong> maintain <strong>safety</strong> accountability external <strong>to</strong> <strong>the</strong> operating<br />
organization.<br />
The plant should perform an analysis and, based on <strong>the</strong> result <strong>of</strong> <strong>the</strong> analysis, define<br />
<strong>the</strong> size <strong>of</strong> <strong>the</strong> minimum shift staff complement taking in<strong>to</strong> account abnormal<br />
operation scenarios involving fire and accident conditions.<br />
The plant should rigorously apply <strong>the</strong> control and <strong>review</strong> process <strong>of</strong> <strong>operational</strong>
−<br />
−<br />
−<br />
−<br />
−<br />
−<br />
documentation, emergency preparedness procedures and opera<strong>to</strong>rs aids.<br />
The plant should establish and implement <strong>the</strong> appropriate control <strong>of</strong> fire loads<br />
especially in <strong>the</strong> areas containing <strong>the</strong> <strong>safety</strong> systems.<br />
The plant event reporting criteria should be clearly communicated <strong>to</strong> all staff and<br />
contrac<strong>to</strong>rs <strong>to</strong> ensure adequate reporting levels.<br />
In <strong>the</strong> Operating Experience area, <strong>the</strong> plant should organize and implement a<br />
system for regular training and retraining <strong>of</strong> personnel involved in event root cause<br />
analysis and <strong>the</strong> Operating Experience Feedback process. It should provide clearly<br />
defined criteria for reporting <strong>of</strong> events which are less significant than events <strong>to</strong> be<br />
reported <strong>to</strong> <strong>the</strong> regula<strong>to</strong>ry authority. Also <strong>the</strong> plant should develop and implement a<br />
procedure for screening Operating Experience information.<br />
The plant should improve <strong>the</strong> organization and work practices <strong>to</strong> cover all aspects<br />
in order <strong>to</strong> limit <strong>the</strong> exposure <strong>of</strong> workers and <strong>the</strong> spread <strong>of</strong> any contamination.<br />
In <strong>the</strong> Chemistry area, <strong>the</strong> plant should implement clear chemistry management<br />
expectations for <strong>the</strong> chemistry department and implement appropriate chemistry<br />
specifications.<br />
The plant should create an emergency level “Alarm” that would apply <strong>to</strong> Unit<br />
disturbances that trigger protective actions for Unit personnel.<br />
Regarding <strong>the</strong> event on 25 July 2006:<br />
−<br />
−<br />
−<br />
At <strong>the</strong> time <strong>of</strong> <strong>the</strong> event, <strong>the</strong>re was a lack <strong>of</strong> an integrated <strong>operational</strong> experience<br />
feedback programme and Corrective Action Programme at <strong>Forsmark</strong>. This was<br />
coupled with <strong>the</strong> weak use <strong>of</strong> a systematic analysis methodology. While technical<br />
issues were investigated in-depth utilising <strong>the</strong> expertise <strong>of</strong> experienced and<br />
knowledgeable staff, underlying organisational issues <strong>to</strong>ok longer <strong>to</strong> recognise and<br />
were latterly requested by <strong>the</strong> regula<strong>to</strong>ry authority.<br />
The event was communicated <strong>to</strong> international organizations in an open and timely<br />
manner.<br />
The corrective actions from <strong>the</strong> plant investigation and those required by <strong>the</strong><br />
regula<strong>to</strong>ry authority were satisfac<strong>to</strong>rily addressed.<br />
<strong>Forsmark</strong> unit one NPP management expressed a determination <strong>to</strong> address <strong>the</strong> areas<br />
identified for improvement and indicated a willingness <strong>to</strong> accept a follow up visit in<br />
about eighteen months.
1. MANAGEMENT, ORGANIZATION AND ADMINISTRATION<br />
1.1 ORGANIZATION AND ADMINISTRATION<br />
<strong>Forsmark</strong> is a three unit power plant <strong>of</strong> Boiling Water Reac<strong>to</strong>rs. The original design was<br />
ASEA, now supported by Westinghouse. The <strong>Forsmark</strong> organization functions as an<br />
independent corporate organization with multiple owners. Majority ownership is held by<br />
<strong>the</strong> Vattenfall corporation.<br />
Units 1 and 2 are sister designs; however design fidelity has not been <strong>to</strong>tally maintained<br />
as each unit acted independently for many years. The organizational structure was<br />
recently changed <strong>to</strong> place a single unit manager over both units. Efforts are underway <strong>to</strong><br />
standardize both <strong>the</strong> best practices and best design elements with <strong>the</strong> desire <strong>to</strong> improve<br />
both units.<br />
Unit 3 was com<strong>mission</strong>ed in 1985, approximately five years after unit 1 and 2, and is a<br />
newer design. This unit has a single <strong>operational</strong> organization overseen by a single unit<br />
manager.<br />
Support functions for all <strong>the</strong> units is provided by common maintenance and technical<br />
services organizations. The organizational structure is clearly defined in <strong>the</strong> management<br />
manual and well publicized.<br />
The Final Safety Analysis <strong>Report</strong> (FSAR or SAR) is well maintained.<br />
Organisational charts are provided in <strong>the</strong> Quality and Management handbook (LOK).<br />
Support functions are included and well defined. Corporate reporting is shown on a<br />
separate organizational chart.<br />
Creation <strong>of</strong> a new Corporate Nuclear Group is in progress. While <strong>the</strong> functions <strong>of</strong> this<br />
new group are not well defined, reporting assignments are known. Opportunities on how<br />
best <strong>to</strong> use this group can be gained from benchmarking.<br />
Some responsibilities and authority <strong>of</strong> chartered committees are well defined; however,<br />
new committees are being formed and remain under development.<br />
Staffing and resources are adequate; however, <strong>the</strong> organization is experiencing some<br />
stress created by organizational improvement initiatives and major projects. As<br />
indicated by <strong>safety</strong> culture surveys, <strong>the</strong> employees are concerned about resources and<br />
have been since 2001. More discussion on this <strong>to</strong>pic will be provided in subsequent<br />
sections <strong>of</strong> this report.<br />
A cautious approach is being used for <strong>the</strong> creation <strong>of</strong> a new Vattenfall corporate<br />
oversight group <strong>to</strong> ensure site functions remain consistent with <strong>the</strong> overall responsibility<br />
for <strong>safety</strong>. The plant has very defined lines <strong>of</strong> responsibility. This division <strong>of</strong><br />
responsibility is well unders<strong>to</strong>od.<br />
The Shift Supervisors have <strong>the</strong> authority <strong>to</strong> take actions deemed necessary with <strong>the</strong> plant,<br />
but are not responsible for emergency plan implementation. Call-out situations are<br />
directed by <strong>the</strong> duty engineer when contacted by <strong>the</strong> applicable shift supervisor. Shift<br />
supervisors direct control board and field activities from <strong>the</strong>ir station in <strong>the</strong> control room.<br />
4<br />
MANAGEMENT, ORGANIZATION AND ADMINISTRATION
No plant personnel are on-site, at all times, with responsibility for oversight <strong>of</strong> a unit or<br />
<strong>the</strong> entire site until <strong>the</strong> duty engineer arrives, following notification. The <strong>team</strong> made a<br />
recommendation in this area.<br />
Backlog activities were checked in various organizations and meetings. These activities<br />
appear <strong>to</strong> be both unders<strong>to</strong>od and managed without impacting plant <strong>safety</strong>. The plant<br />
continues <strong>to</strong> experience a low attrition rate each year and has increased staffing since<br />
2003 by 16%. Staffing increases are expected <strong>to</strong> continue by an additional 11% until<br />
2010. Site average age is currently 46 years <strong>of</strong> age with normal retirement occurring at<br />
65. Loss <strong>of</strong> corporate knowledge is not a significant threat in <strong>the</strong> near or medium term.<br />
A significant percentage <strong>of</strong> all promotions occur from internal candidates. Increasing <strong>the</strong><br />
number <strong>of</strong> external experienced recruits would benefit <strong>the</strong> organization with new ideas<br />
and proven methods from previous experiences.<br />
Temporary supervisors are used during high activity periods. When necessary, <strong>the</strong> plant<br />
evaluates a candidate <strong>to</strong> perform <strong>the</strong>se duties <strong>to</strong> determine if minimum requirements are<br />
satisfied. Consideration <strong>of</strong> a more specific qualification process for temporary<br />
replacements would better serve <strong>the</strong> plant while ensuring that all activities are performed<br />
safely.<br />
The plant has a fitness for duty programme <strong>to</strong> ensure all employees are capable <strong>of</strong><br />
performing <strong>the</strong>ir duties error free. The <strong>team</strong> has recognized a good performance in this<br />
area.<br />
As previously noted, no Vattenfall corporate nuclear operating organization exists at this<br />
time. More Corporate Nuclear oversight is planned; however <strong>the</strong>se plans are only in <strong>the</strong><br />
early development stages. A new position <strong>of</strong> Chief Nuclear Officer (CNO) has been<br />
created. The CNO reports directly <strong>to</strong> <strong>the</strong> managing direc<strong>to</strong>r <strong>of</strong> Vattenfall. In addition, a<br />
new group has been formed within <strong>the</strong> Vattenfall production unit that will have nuclear<br />
<strong>safety</strong> competence. The new group will assist <strong>the</strong> plants and <strong>the</strong> management on <strong>the</strong><br />
corporate level.<br />
External challenge <strong>of</strong> <strong>the</strong> plants organization is an important element <strong>of</strong> avoiding<br />
complacency. While an onsite <strong>safety</strong> committee <strong>review</strong> is currently in-place, an<br />
additional high level committee is planned. However, current plans do not include use <strong>of</strong><br />
independent expertise which should be considered. A recommendation was made by <strong>the</strong><br />
<strong>team</strong> in this area.<br />
Staff services are defined and clearly shown on <strong>the</strong> associated organizational charts.<br />
Control structures are in place <strong>to</strong> ensure that contrac<strong>to</strong>rs and staff services activities are<br />
performed safely.<br />
The Swedish Nuclear Power Inspec<strong>to</strong>rate (SKI) and Swedish Radiation Protection<br />
Institute (SSI) both have a frequent presence on site, but do not appear <strong>to</strong> intervene<br />
directly in <strong>the</strong> management <strong>of</strong> <strong>safety</strong> which is in accordance with national practice.<br />
The threshold for reporting events is high. A Corrective Action Programme (CAP) is<br />
under development for full implementation later in 2008. As this programme develops,<br />
it will be important for <strong>the</strong> plant <strong>to</strong> lower <strong>the</strong> reporting threshold <strong>to</strong> allow a more focused<br />
examination <strong>of</strong> event precursors and worker behaviours. These efforts will permit<br />
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MANAGEMENT, ORGANIZATION AND ADMINISTRATION
problem correction at low levels before events occur.<br />
Significant public scrutiny has recently been experienced. The organization’s intent <strong>to</strong><br />
operate safely appears <strong>to</strong> have been reinforced with public statements from both<br />
<strong>Forsmark</strong> and Vattenfall on a number <strong>of</strong> occasions. A Municipal Safety Information<br />
Council is in place <strong>to</strong> improve communication with local <strong>of</strong>ficials and <strong>the</strong> public.<br />
Meetings with <strong>the</strong> council are held every second month <strong>to</strong> communicate recent<br />
developments. This forum provides plant management and <strong>the</strong> Swedish Nuclear Power<br />
Inspec<strong>to</strong>rate with a method <strong>to</strong> communicate <strong>safety</strong> and environmental issues.<br />
Communication with local <strong>of</strong>ficials has helped establish strong acceptance and trust with<br />
<strong>the</strong> public. The <strong>team</strong> recognised a good performance in this area.<br />
The Plant Safety Committee is a chartered group tasked with <strong>review</strong>ing and discussing<br />
significant <strong>safety</strong> issues. It is chaired by <strong>the</strong> President with membership by <strong>the</strong> senior<br />
management <strong>team</strong>.<br />
His<strong>to</strong>rically <strong>the</strong> plant appears <strong>to</strong> have had little trending <strong>of</strong> performance with only a<br />
limited number <strong>of</strong> management goals focused on <strong>safety</strong>. Following a recent benchmark<br />
effort, <strong>the</strong> plant has identified an additional 21 parameters <strong>to</strong> trend and moni<strong>to</strong>r plant<br />
performance. These indica<strong>to</strong>rs are being run on a trial basis but have not yet been widely<br />
published. Action plans are provided in cases where goals are being exceeded; however,<br />
<strong>the</strong> urgency being applied is questionable and needs more follow-up. The plant’s intent is<br />
<strong>to</strong> use <strong>the</strong> Quality Indica<strong>to</strong>rs <strong>to</strong> help identify important <strong>safety</strong> issues. The <strong>team</strong> has made<br />
a suggestion in this area.<br />
Weekly meetings are conducted with <strong>the</strong> President, <strong>review</strong>ing performance over <strong>the</strong><br />
previous week. These meetings do not provide senior management with an in-depth<br />
view <strong>of</strong> <strong>the</strong> organization’s or equipment performance. As <strong>the</strong> corrective action<br />
programme develops, opportunities will be available for management <strong>to</strong> moni<strong>to</strong>r<br />
behavioural level performance more closely. The plant is encouraged <strong>to</strong> continue this<br />
objective as a focus and drive for full implementation <strong>of</strong> <strong>the</strong> CAP as quickly as possible.<br />
The plant’s policy for managing change is focused <strong>to</strong>wards organizational changes. A<br />
change management policy governing lower level types <strong>of</strong> changes could help improve<br />
<strong>the</strong> organizations ability <strong>to</strong> manage even relatively small changes. This improvement<br />
also provides <strong>to</strong>ols for managers and organizations implementing change <strong>to</strong> ensure all<br />
appropriate actions are considered.<br />
1.2 MANAGEMENT ACTIVITIES<br />
The President’s policies, goals and objectives are clearly communicated down <strong>to</strong> <strong>the</strong> unit<br />
managers. Expectations are <strong>the</strong>n developed using <strong>the</strong> grandfa<strong>the</strong>r principle for each level<br />
<strong>of</strong> <strong>the</strong> organization below <strong>the</strong> unit managers. The grandfa<strong>the</strong>r principle ensures<br />
management at least one level <strong>of</strong> responsibility higher in <strong>the</strong> organization is involved as<br />
expectations are developed through <strong>the</strong> organization.<br />
Unit managers <strong>the</strong>n respond with letters detailing how <strong>the</strong>y will comply, forming a<br />
contract between <strong>the</strong>m and <strong>the</strong> President. However, <strong>the</strong> <strong>team</strong> identified that some goals<br />
are not well unders<strong>to</strong>od by all employees.<br />
The Safety and Environment Unit (FQ) is tasked with checking progress in this area. In<br />
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MANAGEMENT, ORGANIZATION AND ADMINISTRATION
addition, weekly performance <strong>review</strong> meetings between line organizations and <strong>the</strong><br />
President are held <strong>to</strong> moni<strong>to</strong>r performance and implementation <strong>of</strong> expectations.<br />
A system is established and implemented <strong>to</strong> recognize and appreciate <strong>the</strong> contribution <strong>of</strong><br />
individuals or groups in <strong>the</strong> achievement <strong>of</strong> established goals and objectives. Specific<br />
follow-up is provided during annual performance appraisals with individual contribu<strong>to</strong>rs.<br />
Several communication channels exist between management, including <strong>the</strong> President,<br />
and employees. Scheduled meetings, intranet forums, employee surveys and published<br />
articles are all used as methods <strong>of</strong> communication. The intranet reporting method was<br />
developed <strong>to</strong> allow both questions and identification <strong>of</strong> anonymous concerns. The <strong>team</strong><br />
has recognized a good performance in this area.<br />
A business plan does exist and contains actions that <strong>the</strong> plant has agreed <strong>to</strong> address. The<br />
plant hierarchy <strong>of</strong> priorities is defined. However, an element <strong>of</strong> resource allocation<br />
remains a <strong>to</strong>pic. Employee survey results indicate that employees believe <strong>the</strong>re is a<br />
resource allocation concern that needs <strong>to</strong> be addressed. Additionally, <strong>the</strong>re is a high<br />
<strong>to</strong>lerance <strong>of</strong> late actions and open issues for <strong>the</strong> plant. For example, procedure <strong>review</strong>s<br />
are required biannually and several examples <strong>of</strong> procedures, not in compliance, are<br />
known <strong>to</strong> exist. While plant staffing has increased, a gap between employee perceptions<br />
about <strong>safety</strong> culture and recent hiring practices are inconsistent with management<br />
initiatives being pursued. Plant management is encouraged <strong>to</strong> take more action <strong>to</strong><br />
understand why employees voice this concern and <strong>to</strong> ensure actions being taken are well<br />
communicated. Adequate resources are available <strong>to</strong> support training.<br />
Multiple systems are used <strong>to</strong> track commitments and corrective actions. The plant is<br />
developing a more integrated, but still graded approach, but it is not fully implemented at<br />
this time. Implementation <strong>of</strong> a common action tracking system would improve <strong>the</strong><br />
organizations ability <strong>to</strong> moni<strong>to</strong>r actions and eliminate fragmentation that can lead <strong>to</strong><br />
performance concerns.<br />
Organizational implementation <strong>of</strong> initiatives and tracking <strong>to</strong> goals is part <strong>of</strong> <strong>the</strong> agenda<br />
for weekly <strong>review</strong> meetings between line organizations and <strong>the</strong> Senior Management<br />
<strong>team</strong>. The Safety and Environment department is also tasked with checking compliance.<br />
As previously noted, quality indica<strong>to</strong>rs are being developed. While this will provide an<br />
improvement in moni<strong>to</strong>ring capability, it will not provide a concise overview <strong>of</strong> plant<br />
performance. When combined with <strong>the</strong> <strong>safety</strong> index, a better assessment is possible at<br />
<strong>the</strong> management level, but not at <strong>the</strong> working level. The <strong>safety</strong> index is not well<br />
unders<strong>to</strong>od by all employees. The <strong>team</strong> has made a suggestion in this area.<br />
The quality indica<strong>to</strong>rs are updated three times per year which may not be frequent<br />
enough <strong>to</strong> provide early indications <strong>of</strong> degrading performance. Action plans <strong>to</strong> correct<br />
deficient performance are not always pursued urgently which may leave <strong>the</strong> plant staff<br />
with <strong>the</strong> perception that <strong>the</strong> management is <strong>to</strong>lerant or satisfied with existing<br />
performance.<br />
The “no-blame culture” objective is thoroughly engrained and is benefiting <strong>safety</strong><br />
culture; however, it has eroded accountability. As discussed in o<strong>the</strong>r areas, more<br />
oversight from senior management could help ensure accountability for performance is<br />
maintained.<br />
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MANAGEMENT, ORGANIZATION AND ADMINISTRATION
No formal programme for human performance is currently in use at <strong>the</strong> plant. However,<br />
many elements <strong>of</strong> a focus on human performance are visible. Human fac<strong>to</strong>rs are<br />
considered during plant modifications and <strong>the</strong> STAR process is widely used. Continued<br />
focus in this area might warrant expansion <strong>of</strong> <strong>the</strong> various human performance <strong>to</strong>ols, plus<br />
education <strong>of</strong> how <strong>to</strong> identify human performance traps <strong>to</strong> benefit plant performance.<br />
Work hours are controlled and limited <strong>to</strong> minimize <strong>the</strong> potential for fatigue. SKI is also<br />
forceful in limiting work hour effects on <strong>the</strong> working environment <strong>of</strong> individuals.<br />
Facilities are clean and organized. Work environments are good.<br />
During backshift or <strong>of</strong>f-hour operation, no formal process for assessing personnel<br />
performance currently exists. Industry experience indicates such a programme is<br />
important and <strong>the</strong> plant is encouraged <strong>to</strong> <strong>review</strong> this practice <strong>to</strong> determine how<br />
management can be more aware <strong>of</strong> how activities are conducted when management is<br />
not present.<br />
Fault indications are being entered in<strong>to</strong> databases <strong>to</strong> provide fur<strong>the</strong>r input <strong>to</strong> <strong>the</strong><br />
Probabilistic Safety Analysis (PSA). The PSA is also used <strong>to</strong> determine <strong>the</strong> significance<br />
<strong>of</strong> plant <strong>safety</strong> issues when a Licence Event <strong>Report</strong> (LER) is warranted or when<br />
determined appropriate by <strong>the</strong> unit manager.<br />
Periodic <strong>safety</strong> <strong>review</strong>s are routinely conducted <strong>to</strong> verify assumptions in <strong>the</strong> PSA are<br />
consistent with actual plant performance. Equipment failure information is updated for<br />
<strong>the</strong> plant and provided <strong>to</strong> <strong>the</strong> o<strong>the</strong>r Nordic Plants for <strong>the</strong>ir use in PSA.<br />
However, PSA is not used for proactive <strong>review</strong>s. As discussed, it is used reactively,<br />
looking back in his<strong>to</strong>ry. Use <strong>of</strong> <strong>the</strong> PSA in a more live time manner as a management<br />
<strong>to</strong>ol could enhance decision making. The plant states that compliance with Technical<br />
Specifications is adequate. Continued use <strong>of</strong> existing deterministic <strong>review</strong>s, combined<br />
with more use <strong>of</strong> <strong>the</strong> probabilistic <strong>to</strong>ols would provide an even higher level <strong>of</strong> confidence<br />
that activities will not degrade <strong>safety</strong>. The plant is encouraged <strong>to</strong> consider <strong>the</strong> proactive<br />
use <strong>of</strong> PSA <strong>to</strong> complete a more thorough evaluation <strong>of</strong> plant activities.<br />
In addition <strong>to</strong> an extensive regula<strong>to</strong>ry body driven <strong>safety</strong> modernisation program, a<br />
company reac<strong>to</strong>r <strong>safety</strong> programme is utilised <strong>to</strong> address both technical and<br />
organisational action items. This is recognised by <strong>the</strong> <strong>team</strong> as a good performance.<br />
1.3 MANAGEMENT OF SAFETY<br />
The plant has a high level <strong>safety</strong> policy visible via a number <strong>of</strong> documents and it is well<br />
accepted by <strong>the</strong> plant staff. Goals and objective are published in a management manual.<br />
All eleven organizational units give <strong>the</strong>ir replies on how <strong>the</strong>y meet <strong>the</strong> quality<br />
requirements stipulated. The replies are given on a free format, where applicable<br />
instructions, procedures, etc., are referenced in order <strong>to</strong> facilitate providing more detailed<br />
information when required. Each reply must respond <strong>to</strong> all requirements placed on <strong>the</strong><br />
organizational unit and <strong>the</strong> reply is used in internal audits <strong>to</strong> ensure that all<br />
responsibilities are taken care <strong>of</strong>. Internal audits are performed <strong>to</strong> ensure field<br />
observations are consistent with <strong>the</strong> commitments made. Overall personal commitment,<br />
at least within <strong>the</strong> management chain, is improved by this structured approach. The <strong>team</strong><br />
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MANAGEMENT, ORGANIZATION AND ADMINISTRATION
ecognized a good performance in this area.<br />
The plant establishes goals based on improvements from <strong>the</strong> past and has made<br />
indica<strong>to</strong>rs consistent with WANO indica<strong>to</strong>rs. Vattenfall has reinforced <strong>the</strong>ir<br />
expectations <strong>of</strong> a strong nuclear <strong>safety</strong> policy. Vattenfall endorses and supports<br />
employee health improvements.<br />
The quality assurance organization is relied upon <strong>to</strong> ensure each organization at <strong>the</strong> plant<br />
is complying with <strong>the</strong>ir commitments <strong>to</strong> <strong>the</strong> management manual. O<strong>the</strong>r <strong>review</strong>s and<br />
audits are routinely performed; however, <strong>the</strong>y are primarily focused on compliance with<br />
little emphasis <strong>to</strong>wards performance or sustainability. Industry peers and external<br />
experts are not frequently used. To prevent stagnation <strong>of</strong> <strong>the</strong> organizations improvement<br />
initiatives, fur<strong>the</strong>r development in this area is encouraged.<br />
The plant workers have his<strong>to</strong>rically been insulated from external organizations. While<br />
some limited benchmarking has recently occurred, future plans are not well documented.<br />
The sites involvement in owners’ group activities is good, so future initiatives with<br />
benchmarking are encouraged <strong>to</strong> focus <strong>to</strong>wards improvements in less technical areas,<br />
such as processes, human and organizational performance.<br />
The plant may not always be aware <strong>of</strong> activities occurring in <strong>the</strong> switchyard. Without<br />
this awareness, nuclear <strong>safety</strong> implications for <strong>the</strong> activity or timing <strong>of</strong> <strong>the</strong> activity can<br />
not be evaluated by <strong>the</strong> plant. Interface between <strong>the</strong> plant and Svenska Kraftnät<br />
(Switchyard Opera<strong>to</strong>r) should be controlled, consistent with industry operating<br />
experience, should be based on pre-established pro<strong>to</strong>cols. The <strong>team</strong> made a suggestion<br />
in this area.<br />
Root cause analysis techniques have been infrequently used in <strong>the</strong> past. While more are<br />
being performed in 2008, more management attention will improve <strong>the</strong> plants ability <strong>to</strong><br />
prevent recurrence <strong>of</strong> undesired conditions and behaviours. Root cause analysis for a<br />
foreign material exclusion (FME) performance deficiency was determined <strong>to</strong> be<br />
necessary in December 2007 with a scheduled completion by April 2008. Delay in<br />
performing <strong>the</strong> analysis does not promote timely feedback or correction. While a<br />
number <strong>of</strong> process improvements have been implemented, <strong>the</strong> plant continues <strong>to</strong> have<br />
problems with control <strong>of</strong> FME.<br />
The plant <strong>safety</strong> committee <strong>review</strong>s corrective actions in some important areas like<br />
Significant Operating Experience <strong>Report</strong>s (SOER’s). A comprehensive CAP will also<br />
improve performance in this area. The plant, consistent with <strong>the</strong> SKI regulations, has<br />
embarked on a number <strong>of</strong> plant modernization programs. The <strong>team</strong> has recognized a<br />
good performance in this area.<br />
During <strong>the</strong> <strong>review</strong> period, <strong>the</strong> <strong>team</strong> captured what <strong>the</strong>y believe <strong>to</strong> be those characteristics,<br />
practices and attitudes that indicate <strong>the</strong> level <strong>of</strong> <strong>safety</strong> culture at <strong>the</strong> plant. To assist with<br />
<strong>the</strong> ongoing management efforts regarding <strong>safety</strong> culture at <strong>the</strong> plant, <strong>the</strong> <strong>team</strong> identified<br />
some facts which are related <strong>to</strong> <strong>safety</strong> culture.<br />
With respect <strong>to</strong> <strong>the</strong> positive aspects <strong>of</strong> <strong>safety</strong> culture, <strong>the</strong> <strong>team</strong> determined that <strong>the</strong> plant<br />
staff were very open in <strong>the</strong>ir discussions with <strong>the</strong> <strong>team</strong>. This openness was evident in all<br />
areas and is conducive <strong>to</strong> a good management/workforce relationship as well as <strong>the</strong>ir<br />
willingness <strong>to</strong> improve. A high degree <strong>of</strong> pr<strong>of</strong>essionalism was also apparent within <strong>the</strong><br />
9<br />
MANAGEMENT, ORGANIZATION AND ADMINISTRATION
shift staff along with a prudent and interrogative attitude.<br />
The staff expressed a high degree <strong>of</strong> satisfaction with <strong>the</strong> managerial approach adopted at<br />
<strong>the</strong> plant. Teamwork was considered <strong>to</strong> be very good with many opportunities for<br />
interactions between <strong>the</strong> staff and management.<br />
There were also some comments made with respect <strong>to</strong> <strong>the</strong> less positive aspects <strong>of</strong> <strong>safety</strong><br />
culture which were observed by <strong>the</strong> <strong>team</strong> during <strong>the</strong> <strong>review</strong>. It was felt that <strong>the</strong>re was an<br />
underlying belief that experience and length <strong>of</strong> service <strong>to</strong>ok precedence over a more<br />
formalized work ethic at <strong>the</strong> plant. Although experience is considered a vital component<br />
<strong>of</strong> work within <strong>the</strong> nuclear industry, it is encouraged <strong>to</strong> be complemented by <strong>the</strong><br />
appropriate documentation and work practices.<br />
Gaining associated international experience is vital in <strong>the</strong> continuing development <strong>of</strong> a<br />
company and its staff. It was considered that more staff exposure <strong>to</strong> international forums<br />
would be beneficial <strong>to</strong> <strong>the</strong> plant. This would <strong>the</strong>n allow additional benchmarking <strong>to</strong> take<br />
place and ensure that <strong>the</strong> plant is kept up-<strong>to</strong>-date with international practices and<br />
developments.<br />
It was observed that, in a number <strong>of</strong> instances, <strong>the</strong>re is no clear comprehension regarding<br />
what <strong>safety</strong> culture means <strong>to</strong> <strong>the</strong> workforce. Nuclear <strong>safety</strong> is <strong>the</strong> responsibility <strong>of</strong> all<br />
plant staff and this message is encouraged <strong>to</strong> be reinforced at every opportunity. Many<br />
<strong>safety</strong> culture initiatives and seminars have already taken place but <strong>the</strong>se need <strong>to</strong> be<br />
supported in <strong>the</strong> workplace by continual managerial repetition and publications.<br />
Performance indica<strong>to</strong>rs are an industry norm <strong>to</strong> inform <strong>the</strong> workforce and management<br />
on how well <strong>the</strong>y are achieving <strong>the</strong>ir objectives. Nuclear <strong>safety</strong> indica<strong>to</strong>rs are available<br />
at <strong>the</strong> plant but <strong>the</strong>y are sometimes unnecessarily complicated – simple indica<strong>to</strong>rs are an<br />
ideal way <strong>of</strong> relaying <strong>safety</strong> information <strong>to</strong> <strong>the</strong> staff and can give <strong>the</strong>m an indication on<br />
how <strong>to</strong> improve with respect <strong>to</strong> <strong>safety</strong> culture. The plant is encouraged <strong>to</strong> make <strong>the</strong><br />
indica<strong>to</strong>rs easily retrievable on <strong>the</strong> intranet and widely publicized on <strong>the</strong> plant.<br />
1.4 QUALITY ASSURANCE PROGRAMME<br />
The plant has a high reliance on <strong>the</strong> independence provided by <strong>the</strong> Safety and<br />
Environment Unit. This approach does assure an independent view <strong>of</strong> technical issues,<br />
but does not appear <strong>to</strong> provide external input <strong>to</strong> challenge <strong>the</strong> organization <strong>to</strong> ever<br />
improving standards. The quality assurance (QA) group is a small organization within<br />
<strong>the</strong> Safety and Environment Unit, consisting <strong>of</strong> a manager and two plant employees.<br />
Since <strong>the</strong>se individuals are not currently qualified <strong>to</strong> perform <strong>the</strong>ir responsibilities<br />
independently, <strong>the</strong> group is supplemented with a full time long-term consultant and a<br />
part-time long-term consultant. The organizations commitment <strong>to</strong> quality assurance is<br />
improved with <strong>the</strong> assignment <strong>of</strong> staff; however, <strong>the</strong> impression created could allow <strong>the</strong><br />
conclusion that quality assurance activities are not considered important by <strong>the</strong><br />
organization.<br />
An audit programme is established and <strong>the</strong> Quality Assurance Manager holds <strong>the</strong><br />
organization accountable <strong>to</strong> complete actions by agreed due dates. The plant can rely on<br />
QA involvement for compliance oversight. However, opportunities <strong>to</strong> use <strong>the</strong> QA<br />
organization for performance based insights are missed.<br />
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1.5 INDUSTRIAL SAFETY PROGRAMME<br />
Industrial <strong>safety</strong> is structured with a focus on employee health improvement and<br />
compliance with industrial <strong>safety</strong> rules. Regular meetings are conducted <strong>to</strong> keep senior<br />
management informed and <strong>to</strong> maintain a good relationship with <strong>the</strong> industrial <strong>safety</strong><br />
trade union delegates. These delegates have a number <strong>of</strong> responsibilities including<br />
moni<strong>to</strong>ring for adherence with <strong>safety</strong> rules during field activities. There are currently 28<br />
delegates, one <strong>of</strong> which fills <strong>the</strong> role <strong>of</strong> senior delegate. The senior delegate coordinates<br />
<strong>the</strong> oversight <strong>of</strong> <strong>the</strong> o<strong>the</strong>r delegates and acts as <strong>the</strong> primary interface with management.<br />
This individual is also very involved with providing <strong>the</strong> plant with information shared<br />
with o<strong>the</strong>r Swedish Nuclear Plants and <strong>the</strong> trade unions.<br />
Management support for correcting identified <strong>safety</strong> concerns is improving. Safety<br />
delegates believe <strong>the</strong>ir concerns consistently get management support and are confident<br />
in <strong>the</strong>ir ability <strong>to</strong> s<strong>to</strong>p work when conditions warrant. Middle management is held<br />
accountable <strong>to</strong> correct concerns.<br />
1.6 DOCUMENT AND RECORDS MANAGEMENT<br />
Records retention is consistent with <strong>the</strong> regulations and well organized. Procedure<br />
controls are in place and compliance with <strong>the</strong> requirements is not a concern. Record<br />
vaults are organized and tidy with no concern identified. The Safety Analysis <strong>Report</strong> is<br />
maintained as a living document with significant recent focus <strong>to</strong> ensure accuracy.<br />
Some issues were noted by <strong>the</strong> <strong>team</strong> with <strong>the</strong> control <strong>of</strong> opera<strong>to</strong>r aids and controlled<br />
document maintenance in <strong>the</strong> field. More discussion is provided in <strong>the</strong> Operations<br />
section <strong>of</strong> this report. In addition, a structured approach for end-users <strong>to</strong> validate use <strong>of</strong><br />
<strong>the</strong> most recent revision is not well controlled. Benchmarking <strong>of</strong> how o<strong>the</strong>r nuclear<br />
organizations deal with this situation could help eliminate <strong>the</strong> potential for future<br />
problems in this area.<br />
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DETAILED MANAGEMENT, ORGANIZATION AND ADMINISTRATION FINDINGS<br />
1.1 ORGANIZATION AND ADMINISTRATION<br />
1.1(1) Issue: No <strong>of</strong>f hours on-site supervisory position is present <strong>to</strong> determine if transients<br />
or abnormal conditions are properly managed considering both design basis and<br />
beyond design basis events and <strong>to</strong> declare an emergency.<br />
Shift supervisors are responsible for direct response <strong>of</strong> <strong>the</strong> operating crew when<br />
abnormal conditions exist at <strong>Forsmark</strong>. Each operating unit is staffed with one<br />
supervisor on <strong>the</strong> operating crew. His primary responsibility is <strong>to</strong> implement <strong>the</strong><br />
emergency operating procedures. This staffing arrangement does not leave adequate<br />
supervisory presence <strong>to</strong> provide oversight. In addition;<br />
• Emergency plan implementation or consideration for conditions affecting<br />
multiple units can distract <strong>the</strong> shift supervisor from this primary command and<br />
control function without <strong>the</strong> assistance <strong>of</strong> a unit supervisor <strong>to</strong> direct crew<br />
activities.<br />
• The shift supervisor is responsible for addressing issues on a unit and <strong>to</strong> make<br />
contact with <strong>the</strong> duty engineer, who may not be on-site. Implementation <strong>of</strong> <strong>the</strong><br />
emergency plan is not in <strong>the</strong> scope <strong>of</strong> authority <strong>of</strong> <strong>the</strong> shift supervisor.<br />
• The FSAR Chapter 2 clearly defines <strong>the</strong> shift supervisor as not in <strong>the</strong> <strong>operational</strong><br />
management.<br />
• The process for declaring an emergency and notifying <strong>of</strong>f-site authorities may<br />
result in unnecessary delays in <strong>the</strong> implementation <strong>of</strong> protective actions.<br />
Failure by an operating crew <strong>to</strong> identify parameters that are not expected <strong>to</strong> be affected<br />
by <strong>the</strong> event or <strong>the</strong> transient <strong>operational</strong> state could be neglected. Failure <strong>to</strong> declare an<br />
emergency in a timely manner could result in unnecessary overexposure following an<br />
accident.<br />
Recommendation: The plant should <strong>review</strong> responsibilities for <strong>the</strong> operating staff,<br />
considering both <strong>the</strong> individual unit and <strong>the</strong> combined site, <strong>to</strong> determine if transients<br />
or abnormal conditions can be properly managed during both design basis and beyond<br />
design basis events. In addition <strong>the</strong>re should be always one person on site capable <strong>of</strong><br />
declaring an emergency and notifying <strong>the</strong> <strong>of</strong>f-site authorities.<br />
Basis: GS-R-2; 4.23: “Each facility or practice in threat category I, II, III or IV shall<br />
have a person on <strong>the</strong> site at all times with <strong>the</strong> authority and responsibilities: <strong>to</strong> classify<br />
a nuclear or radiological emergency and upon classification promptly and without<br />
consultation <strong>to</strong> initiate an appropriate on-site response; <strong>to</strong> notify <strong>the</strong> appropriate <strong>of</strong>fsite<br />
notification point (see para. 4.22); and <strong>to</strong> provide sufficient information for an<br />
effective <strong>of</strong>f-site response. This person shall be provided with a suitable means <strong>of</strong><br />
alerting on-site response personnel and notifying <strong>the</strong> <strong>of</strong>f-site notification point.”<br />
NS-R-2; 2.32: “The operating organization shall establish <strong>the</strong> necessary organizational<br />
structure and shall assign responsibilities for managing emergencies. This shall<br />
include arrangements for: prompt recognition <strong>of</strong> emergencies; timely notification and<br />
alerting <strong>of</strong> response personnel; and provision <strong>of</strong> <strong>the</strong> necessary information <strong>to</strong> <strong>the</strong><br />
authorities, including timely notification and subsequent provision <strong>of</strong> information as<br />
required.”<br />
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GS-G-2.1; Appendix VI – Response Time Objectives, Threat Category I, Facility<br />
Level: “Identifying, notifying and activation (<strong>the</strong> objective is timed from <strong>the</strong> time at<br />
which conditions indicating that emergency conditions are detected): Classify <strong>the</strong><br />
emergency: < 15 min, Notify local authorities (PAZ and UPZ) after classification: <<br />
30 min.”<br />
Basis: NS-G-2.14 sec 3.1. “The shift supervisor should manage plant operations on<br />
each shift and should be responsible for <strong>the</strong> overall <strong>safety</strong> at <strong>the</strong> plant, protection and<br />
<strong>safety</strong> <strong>of</strong> personnel, coordination <strong>of</strong> plant activities ad performance for <strong>the</strong> assigned<br />
shift. The responsibilities typically should include supervision <strong>of</strong> <strong>the</strong> shift personnel<br />
and direct control <strong>of</strong> plant operations in accordance with <strong>the</strong> <strong>operational</strong> limits and<br />
conditions and operating procedures. In addition, <strong>the</strong> responsibilities <strong>of</strong> <strong>the</strong> shift<br />
supervisor should normally include <strong>the</strong> following:<br />
• During <strong>of</strong>f-hours, <strong>to</strong> assume <strong>the</strong> authority <strong>of</strong> <strong>the</strong> plant manager. The shift<br />
supervisor should be given <strong>the</strong> authority <strong>to</strong> resolve any problem that may affect <strong>the</strong><br />
safe operation <strong>of</strong> <strong>the</strong> plant.”<br />
NS-G-2.14 sec 3.2. “In multi-unit power plants, where one shift supervisor may be<br />
responsible for all units, o<strong>the</strong>r persons, designated as unit supervisors, should be made<br />
responsible <strong>to</strong> <strong>the</strong> shift supervisor for <strong>the</strong> operation <strong>of</strong> each unit.<br />
1.1(2) Issue: While internal <strong>safety</strong> committees provide a high level <strong>of</strong> confidence in <strong>the</strong> safe<br />
operation <strong>of</strong> <strong>the</strong> plant, no independent <strong>safety</strong> <strong>review</strong> is provided by a periodic external<br />
<strong>review</strong>.<br />
Information relative <strong>to</strong> this issue includes:<br />
• A Vattenfall corporate nuclear operating organization is currently being formed<br />
with <strong>the</strong> objective <strong>of</strong> providing independent <strong>review</strong> <strong>of</strong> plant <strong>safety</strong>. However, this<br />
organization is being developed and is not assisting with this function <strong>to</strong>day.<br />
• A high level independent <strong>safety</strong> <strong>review</strong> committee is planned but is in <strong>the</strong> early<br />
stages <strong>of</strong> development. No external membership is currently known <strong>to</strong> exist on<br />
this committee.<br />
• An on-site <strong>safety</strong> <strong>review</strong> committee does exist and functions <strong>to</strong> oversee plant<br />
<strong>safety</strong>; however, this committee consists <strong>of</strong> many senior managers assigned <strong>to</strong> <strong>the</strong><br />
site with no external membership.<br />
Without a formal and fully implemented process <strong>to</strong> ensure <strong>safety</strong> accountability is<br />
supported by arrangements that are independent <strong>of</strong> <strong>the</strong> pressures <strong>of</strong> plant operation,<br />
<strong>operational</strong> pressures can limit senior managements ability <strong>to</strong> detect early indications<br />
<strong>of</strong> performance degradation.<br />
Recommendation: The organisation should implement an independent high level<br />
<strong>safety</strong> <strong>review</strong> with responsibility <strong>to</strong> maintain <strong>safety</strong> accountability external <strong>to</strong> <strong>the</strong><br />
operating organization membership.<br />
Basis: NS-G-2.4 sec 5.18. “The operating organization should provide a means for<br />
independent <strong>safety</strong> <strong>review</strong>. The key <strong>to</strong> this process is <strong>the</strong> establishment <strong>of</strong> an<br />
objective internal self-evaluation programme supported by periodic external <strong>review</strong>s<br />
conducted by experienced industry peers using well established and proven processes.<br />
The principal objective is <strong>to</strong> ensure that, in those matters that are important <strong>to</strong> <strong>safety</strong>,<br />
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MANAGEMENT, ORGANIZATION AND ADMINISTRATION
<strong>safety</strong> accountability is supported by arrangements that are independent <strong>of</strong> <strong>the</strong><br />
pressures <strong>of</strong> plant operation. The <strong>safety</strong> <strong>review</strong> should be independent <strong>of</strong> plant<br />
operation, and should be conducted on a continuing basis <strong>to</strong> verify that plant<br />
management establishes verified and authorized practices and implements changes as<br />
required. The reports resulting from this activity should be formal and should be<br />
provided directly <strong>to</strong> <strong>the</strong> <strong>to</strong>p management <strong>of</strong> <strong>the</strong> operating organization. Particular<br />
attention should be paid <strong>to</strong> <strong>the</strong> feedback from experience.”<br />
1.1(3) Issue: Only a limited number <strong>of</strong> management goals are focused on <strong>operational</strong> <strong>safety</strong><br />
performance. Moni<strong>to</strong>ring methods can also be improved <strong>to</strong> ensure <strong>the</strong> plant is aware<br />
<strong>of</strong> progress <strong>to</strong>wards meeting established goals.<br />
The moni<strong>to</strong>ring and reporting on <strong>the</strong> performance <strong>of</strong> process’s can be improved with<br />
implementation <strong>of</strong> <strong>the</strong> Quality Indica<strong>to</strong>rs currently being developed as trial measures.<br />
The plant has started work <strong>to</strong> provide indica<strong>to</strong>rs as a <strong>to</strong>ol <strong>to</strong> help drive improvement;<br />
however, <strong>the</strong> <strong>team</strong> found <strong>the</strong> following facts during <strong>review</strong>.<br />
• Following a benchmarking effort, <strong>the</strong> plant identified 21 parameters <strong>to</strong> trend and<br />
moni<strong>to</strong>r plant performance. While several <strong>of</strong> <strong>the</strong>se indica<strong>to</strong>rs have been<br />
developed on a trial basis, <strong>the</strong> full implementation is not scheduled until May.<br />
• Based on <strong>the</strong> trial development <strong>of</strong> <strong>the</strong>se Quality Indica<strong>to</strong>rs, several undesired<br />
performance areas were identified. In December 2007, it was determined<br />
appropriate <strong>to</strong> perform a root cause in one area. This root cause analysis is not<br />
scheduled <strong>to</strong> complete until April <strong>of</strong> 2008 due <strong>to</strong> o<strong>the</strong>r priorities.<br />
• The 21 quality indica<strong>to</strong>rs were created in Oc<strong>to</strong>ber, published in November with<br />
<strong>the</strong> next update scheduled in May. Currently, 5 have no data, 2 are green, 4<br />
yellow and 11 are red. The thought process was <strong>to</strong> make <strong>the</strong>m challenging. These<br />
are very new and are a good idea; however, updates only 3 times per year may not<br />
drive <strong>the</strong> improvements desired. Some specific data from individual indica<strong>to</strong>rs is<br />
provided:<br />
o Fuel leaks at <strong>Forsmark</strong> are most frequently caused by debris fretting. This<br />
combined with <strong>the</strong> results <strong>of</strong> <strong>the</strong> FME quality indica<strong>to</strong>r where 25% <strong>of</strong> all<br />
FME inspections discover foreign material indicates problems with FME<br />
continue <strong>to</strong> exist.<br />
o Each unit as a large number <strong>of</strong> temporary modifications, some approaching<br />
five years in age. The December indica<strong>to</strong>r shows approximately 110. This<br />
is a current focus area for <strong>the</strong> plant and progress has been made in recent<br />
months.<br />
o 60% <strong>of</strong> maintenance procedures did not satisfy <strong>the</strong> requirement <strong>to</strong> <strong>review</strong><br />
every 2 years.<br />
Goals and strategic targets set for <strong>the</strong> operating crews have just two <strong>of</strong> nine focused on<br />
<strong>operational</strong> <strong>safety</strong> issues. The remainder are more focused on business oriented<br />
objectives. The <strong>team</strong> observed <strong>the</strong> following facts during <strong>the</strong> <strong>review</strong>:<br />
• One <strong>of</strong> <strong>the</strong> <strong>operational</strong> <strong>safety</strong> focused goals is <strong>to</strong> avoid INES 2 and higher events,<br />
which is not a challenging goal.<br />
• A second one is <strong>to</strong> reach <strong>safety</strong> index higher than 3, however, plant personnel are<br />
not sufficiently familiar with <strong>the</strong> <strong>safety</strong> index <strong>to</strong> understand how <strong>the</strong>ir actions can<br />
influence <strong>the</strong> goal.<br />
• Operational staff during interviews referred mainly <strong>to</strong> <strong>the</strong> general plant vision <strong>to</strong><br />
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MANAGEMENT, ORGANIZATION AND ADMINISTRATION
safely operate <strong>the</strong> plant and <strong>to</strong> <strong>safety</strong> as an overriding priority. They were rarely<br />
aware <strong>of</strong> any specific goals.<br />
Untimely moni<strong>to</strong>ring and a delayed response <strong>to</strong> process indica<strong>to</strong>rs can lead <strong>to</strong><br />
degradation <strong>of</strong> plant performance. A full understanding <strong>of</strong> <strong>the</strong> entire work force <strong>of</strong><br />
how <strong>the</strong>y can help <strong>the</strong> station achieve <strong>safety</strong> goals is also necessary.<br />
Suggestion: The plant should consider expanding <strong>the</strong> number <strong>of</strong> management goals<br />
and <strong>the</strong> moni<strong>to</strong>ring methods used for improving <strong>the</strong> focus on <strong>operational</strong> <strong>safety</strong><br />
performance.<br />
Basis: GS-R-3 sec 3.11. “Senior management shall ensure that <strong>the</strong> implementation<br />
<strong>of</strong> <strong>the</strong> plans is regularly <strong>review</strong>ed against <strong>the</strong>se objectives and that actions are taken <strong>to</strong><br />
address deviations from <strong>the</strong> plans where necessary.”<br />
1.1(a) Good Practice: Structuring <strong>the</strong> management manual in such a way that <strong>the</strong><br />
requirements for each unit are described in one chapter <strong>of</strong> <strong>the</strong> management manual.<br />
Responses by <strong>the</strong> units on how <strong>the</strong>y will meet <strong>the</strong>se requirements are described in an<br />
adjacent chapter. This structure aids in communicating expectations and commitments<br />
<strong>to</strong> <strong>the</strong> plant staff.<br />
It is important <strong>to</strong> <strong>safety</strong> for <strong>the</strong> organization <strong>to</strong> be committed <strong>to</strong> <strong>the</strong> requirements.<br />
Thereby, <strong>the</strong> personal engagement can be improved supporting fulfilment <strong>of</strong> <strong>the</strong><br />
expectations.<br />
The plant has structure <strong>the</strong> management manual in<strong>to</strong> four main chapters:<br />
1. Management principles<br />
a. Company structure<br />
b. Vision and company <strong>mission</strong><br />
c. Management philosophy<br />
d. Policies<br />
e. Management expectations<br />
2. Organization<br />
a. Responsibilities<br />
b. Definitions <strong>of</strong> management levels<br />
c. Safety management principles<br />
d. Delegation<br />
e. Authorities<br />
f. Organization charts<br />
3. Quality requirements<br />
4. Replies from <strong>the</strong> individual units on how <strong>the</strong>y meet <strong>the</strong> quality<br />
requirements.<br />
In chapter 4, all eleven organizational units give <strong>the</strong>ir replies on how <strong>the</strong>y meet <strong>the</strong><br />
quality requirements stipulated in chapter 3. The replies are given on a free format,<br />
where applicable instructions, procedures, etc., are referenced in order <strong>to</strong> facilitate<br />
more detailed information when required.<br />
Each reply must respond <strong>to</strong> all requirements placed on <strong>the</strong> organizational unit and <strong>the</strong><br />
reply is used in internal audits <strong>to</strong> ensure that all responsibilities are taken care <strong>of</strong>.<br />
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Internal audits are performed <strong>to</strong> ensure field observations are consistent with <strong>the</strong><br />
commitments made.<br />
Overall personal commitment <strong>to</strong> <strong>the</strong> requirements set up by <strong>the</strong> company is<br />
significantly improved by this structured approach.<br />
1.3 MANAGEMENT OF SAFETY<br />
1.3(1) Issue: Switchyard activities are not fully evaluated by plant personnel.<br />
Switchyard maintenance and operations without appropriate <strong>review</strong>, controls and<br />
communications have created a number <strong>of</strong> issues at nuclear power stations. Lessons<br />
from <strong>the</strong>se events demonstrate <strong>the</strong> need for close interface between nuclear units and<br />
switchyard opera<strong>to</strong>rs <strong>to</strong> ensure activities are adequately assessed for impact <strong>to</strong> nuclear<br />
<strong>safety</strong>.<br />
O<strong>the</strong>r information relevant <strong>to</strong> this issue:<br />
• SOER 99-01 was issued <strong>to</strong> notify nuclear plants <strong>of</strong> operating experience<br />
related <strong>to</strong> operation and maintenance activities in electrical switchyards. The<br />
recommendations from this document have been <strong>review</strong>ed and open issues<br />
identified.<br />
• Multiple events have been encountered at <strong>the</strong> plant initiated by perturbations in<br />
<strong>the</strong> switchyard resulting from operating activities.<br />
Activities occurring in electrical switchyards and through <strong>the</strong> trans<strong>mission</strong> system<br />
have a potential, if errors or malfunctions occur, <strong>to</strong> impact <strong>safety</strong> <strong>of</strong> nuclear units.<br />
Nuclear units are not only a supplier <strong>of</strong> electricity but also a vital cus<strong>to</strong>mer.<br />
Suggestion: The plant should consider establishing a structured evaluation process<br />
for activities with <strong>the</strong> potential <strong>to</strong> impact electrical power trans<strong>mission</strong> <strong>to</strong> or from <strong>the</strong><br />
plant.<br />
Basis: NS-G-2.4 sec 3.1. “In establishing <strong>the</strong> structure <strong>of</strong> <strong>the</strong> operating organization,<br />
consideration should be given <strong>to</strong> <strong>the</strong> management functions in <strong>the</strong> following areas:<br />
• Operating functions, which include executive decision making and actions for<br />
<strong>the</strong> operation <strong>of</strong> a plant, both in <strong>operational</strong> states and in accident conditions.<br />
• Supporting functions, which include obtaining from both on-site and <strong>of</strong>f-site<br />
organizations <strong>the</strong> technical and administrative services and facilities necessary<br />
<strong>to</strong> perform operating functions.”<br />
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2. TRAINING AND QUALIFICATIONS<br />
2.1 TRAINING POLICY AND ORGANIZATION<br />
The Human Resources Department has a very important function for <strong>the</strong> training policy<br />
and organization. It facilitates <strong>the</strong> process <strong>to</strong> confirm that each employee gets adequate<br />
training <strong>to</strong> fulfill <strong>the</strong> requirements <strong>of</strong> <strong>the</strong> position. The Human Resources Department<br />
supports <strong>the</strong> competence supply efforts in <strong>the</strong> plant. Methods and processes are well<br />
developed <strong>to</strong> establish good relationships with contrac<strong>to</strong>rs and <strong>the</strong> public education<br />
system. Methods for initial and continuing training are suitably described in <strong>the</strong> Strategic<br />
Competence Planning Process (STRAKO) and are reflected in <strong>the</strong> Systematic Approach<br />
<strong>to</strong> Training (SAT) methodology. The plant process is based on <strong>the</strong> IAEA document<br />
“Nuclear power Plant Personnel Training and its Evaluation Guidebook – TRS 380”.<br />
The Human Resource Process was established in 2001. The process shows a skill<br />
programme <strong>of</strong> high standard. Kärnkraftsäkerhet och Utbildning (KSU, contrac<strong>to</strong>r for<br />
skill) training policies and programs are compatible with current practices at <strong>Forsmark</strong>.<br />
All skill levels are individually defined in <strong>the</strong> STRAKO and annual assessments <strong>of</strong> <strong>the</strong><br />
qualifications are provided. This practice supports fairness and shows an adequate,<br />
transparent policy. The training evaluation is formalized. A generic standard is<br />
established for each occupation and if a specific position requires special skills,<br />
additional training modules are provided. Training sessions are adequately planned and<br />
recorded in a database (SAP). All documents are archived. SAP can produce various<br />
statistics on <strong>the</strong> training courses as well as <strong>the</strong> output <strong>of</strong> his<strong>to</strong>rical training records.<br />
However, <strong>the</strong> <strong>team</strong> observed that <strong>the</strong> results were not developed and published as<br />
training indica<strong>to</strong>rs <strong>to</strong> confirm and assess <strong>the</strong> efficiency <strong>of</strong> <strong>the</strong> training. The <strong>team</strong> provided<br />
a suggestion in this area.<br />
All rules for goals, objectives and management oversight are adequately established in<br />
<strong>the</strong> Human Resource Process. It also requires a debriefing after every training session.<br />
The management <strong>the</strong>reby gains direct feedback on <strong>the</strong> quality and effectiveness <strong>of</strong> <strong>the</strong><br />
course.<br />
The Human Resources Department has overall training process responsibilities. One<br />
exception is <strong>the</strong> training process for operations management and engineers on duty (VHI)<br />
which is handled by <strong>the</strong> Department for Safety and Environment. The responsibilities <strong>of</strong><br />
both departments are well supported.<br />
NSMI (Nordic Generation Safety Management Institute) is <strong>the</strong> advanced <strong>safety</strong><br />
management programme intended for <strong>the</strong> <strong>operational</strong> management level 1, 2 and 3 and<br />
for managers in certain functions. The purpose <strong>of</strong> <strong>the</strong> programme is <strong>to</strong> give <strong>the</strong><br />
participants a broad understanding for <strong>safety</strong> work <strong>to</strong> support <strong>the</strong>ir acting in unexpected<br />
situations where <strong>the</strong>y have <strong>to</strong> make decisions in <strong>operational</strong> and <strong>safety</strong> issues. The<br />
programme has been completed for <strong>the</strong> President, unit managers and operation managers.<br />
The plant has tu<strong>to</strong>rs, including contrac<strong>to</strong>rs, who provide training for its employees. The<br />
basic Radioprotection training at <strong>the</strong> plant was good. At <strong>the</strong> University <strong>of</strong> Uppsala, a<br />
tu<strong>to</strong>r enhanced <strong>the</strong> lesson with self-created interactive Excel-Spreadsheets.<br />
Westinghouse, <strong>the</strong> contrac<strong>to</strong>r for maintenance, provided good training on mock-ups <strong>of</strong><br />
<strong>the</strong> plant, supported by learning objectives and <strong>the</strong>oretical lessons. The conduct <strong>of</strong> this<br />
training is considered a good performance by <strong>the</strong> <strong>team</strong>.<br />
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The Human Resources Department is well supported by management and allocates<br />
sufficient resources <strong>to</strong> meet requirements. It performs an internal self assessment<br />
regularly <strong>to</strong> improve <strong>the</strong> process. The <strong>team</strong> recognized that deviations from <strong>the</strong> annual<br />
training goals are discussed and inputs from <strong>the</strong> o<strong>the</strong>r plant’s management or feedbacks<br />
from <strong>the</strong> training courses are well implemented in new tasks.<br />
The implementation <strong>of</strong> <strong>the</strong> administrative policy is guaranteed due <strong>to</strong> SAP and <strong>the</strong><br />
Competence Management Process. Responsibilities are suitably regulated in <strong>the</strong> Human<br />
Resource process. Never<strong>the</strong>less, o<strong>the</strong>r departments participate in important decision<br />
making processes. The needs <strong>of</strong> every plant department are adequately described in <strong>the</strong><br />
STRAKO process. Gap analysis was performed effectively before planning fur<strong>the</strong>r work.<br />
If <strong>the</strong> attendance <strong>of</strong> a worker at prescribed training is not evident, <strong>the</strong>n <strong>the</strong> reasons will<br />
be discussed in <strong>the</strong> annual assessment.<br />
The Human Resources Department is responsible for <strong>the</strong> quality control <strong>of</strong> external<br />
training. Sessions are supervised by random audits carried out by <strong>the</strong> plant person<br />
responsible for <strong>the</strong> area.<br />
2.2 TRAINING FACILITIES, EQUIPMENT AND MATERIAL<br />
The <strong>team</strong> observed that numerous multifunctional training rooms were available. These<br />
can be used for training purposes, classrooms or individual study, workshop training or<br />
meeting rooms. Training rooms were well equipped.<br />
The plant utilizes interactive training courses on actual plant equipment for industrial<br />
<strong>safety</strong> training, fuel handling, foreign material exclusion and industrial <strong>safety</strong> on<br />
electrical and mechanical work. A formalized programme for retraining staff on<br />
labora<strong>to</strong>ry instruments does not exist. However, <strong>the</strong> Chemistry Department possesses a<br />
procedure <strong>to</strong> ensure well documented on-<strong>the</strong>-job-training on chemical instruments.<br />
Workshops for <strong>the</strong> maintenance department are well equipped. For special tasks e.g. fuel<br />
service work, Westinghouse transfers its own equipment <strong>to</strong> <strong>the</strong> plant.<br />
Annually, <strong>the</strong> plant creates an inven<strong>to</strong>ry <strong>of</strong> needs for <strong>the</strong> full scope simula<strong>to</strong>r. All<br />
relevant changes and modifications on and for <strong>the</strong> plant are discussed between KSU and<br />
<strong>the</strong> plant, four times a year. Modifications are implemented <strong>to</strong> keep <strong>the</strong> training facility<br />
realistic. This process ensures that KSU have a constantly updated simulation-system.<br />
Adequate testing phases for new LCD-Displays are performed <strong>to</strong> validate planned<br />
changes before implementing <strong>the</strong>m on site.<br />
The full-scope simula<strong>to</strong>r F1 for <strong>Forsmark</strong> Unit 1 and Unit 2 adequately supports a wide<br />
range <strong>of</strong> training capabilities from abnormal up <strong>to</strong> emergency events. Unit 1 is <strong>the</strong> main<br />
reference and shows practically no differences <strong>to</strong> Unit 2. The shutdown panel is used in<br />
emergency scram situations when <strong>the</strong> main control room (MCR) is not available. On <strong>the</strong><br />
full-scope simula<strong>to</strong>r, <strong>the</strong> shut down panel is not installed. In <strong>the</strong> basic training course, it<br />
is well described. However, when on-<strong>the</strong>-job, no formal retraining exists on how and<br />
when this panel should be used.<br />
Training facilities in <strong>the</strong> full-scope simula<strong>to</strong>r are enhanced by different instruc<strong>to</strong>r aids<br />
e.g. video-system, audio recorder, computer based technical information and access <strong>to</strong><br />
KSU´s network. The <strong>team</strong> recognised a good practice with respect <strong>to</strong> <strong>the</strong> plant utilising<br />
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<strong>the</strong> simula<strong>to</strong>r <strong>to</strong> demonstrate work methods <strong>to</strong> <strong>the</strong> media and o<strong>the</strong>r key groups.<br />
KSU provides well updated training programs. These are adequately recorded and allow<br />
retrieval possibility. Fur<strong>the</strong>rmore, every programme is <strong>review</strong>ed by <strong>the</strong> evaluation <strong>to</strong>ol<br />
“Delta Plus”. Quality control is performed for an adequate adult learning experience.<br />
Real time walk-throughs for all lessons and <strong>review</strong>s <strong>of</strong> student’s and tu<strong>to</strong>r’s material are<br />
satisfac<strong>to</strong>rily established. Recently, a real time data viewer (RDV, a graphical debugging<br />
<strong>to</strong>ol), which was originally designed for development, was adapted as an aid for <strong>the</strong><br />
simula<strong>to</strong>r instruc<strong>to</strong>rs and <strong>the</strong>ir preparations. It has also been used in training courses.<br />
2.3 QUALITY OF THE TRAINING PROGRAMMES<br />
The Human Resource Competence Management uses a special process <strong>to</strong> qualify <strong>the</strong><br />
results <strong>of</strong> <strong>review</strong>ing training programs. The Human Resource Process itself provides a<br />
good basis for knowledge and skill.<br />
The principal results <strong>of</strong> probabilistic <strong>safety</strong> assessment <strong>of</strong> <strong>the</strong> plant, showing <strong>the</strong><br />
importance <strong>of</strong> plant systems in preventing damage or severe accidents, are not included<br />
in <strong>the</strong> shift supervisors training program.<br />
Adequate independent qualifying <strong>review</strong>s <strong>of</strong> <strong>the</strong> training plans and activities are given by<br />
feedback from <strong>the</strong> attendees. The Human Resource Process provides an annual<br />
assessment between management and <strong>the</strong> employees. In <strong>the</strong>se audits, training activities<br />
and qualifications are discussed and modifications are considered if needed. KSU<br />
performs internal audits using its own instruc<strong>to</strong>rs.<br />
The adequacy <strong>of</strong> training programs for field opera<strong>to</strong>rs is also assessed by KSU.<br />
The <strong>team</strong> fur<strong>the</strong>rmore observed good systematic training approaches initiated by<br />
Westinghouse for <strong>the</strong> maintenance personnel. The personnel practice on a mock-up <strong>of</strong><br />
<strong>the</strong> plant. This process ensures that <strong>the</strong> trainees have good practical experience.<br />
Quality control, content and scope <strong>of</strong> simula<strong>to</strong>r training are well covered by using two<br />
methods. Firstly, before a training course is conducted with <strong>the</strong> shift group,<br />
representatives from <strong>the</strong> plant and o<strong>the</strong>r instruc<strong>to</strong>rs validate <strong>the</strong> program. The second<br />
method is provided by <strong>the</strong> trained group itself. In <strong>the</strong> follow-up assessments after <strong>the</strong><br />
simula<strong>to</strong>r training, <strong>the</strong> shift group is given <strong>the</strong> possibility <strong>to</strong> give feedback on <strong>the</strong><br />
training. With this method, quality is optimised.<br />
Some training subjects in <strong>the</strong> basic training for all employees are required at regular<br />
intervals e.g. fire protection every four years, respira<strong>to</strong>ry protective equipment every two<br />
years. O<strong>the</strong>r requirements are included in <strong>the</strong> training program.<br />
2.4 TRAINING PROGRAMS FOR CONTROL ROOM OPERATORS AND SHIFT<br />
SUPERVISORS<br />
The first step for <strong>the</strong> initial training programme for control room opera<strong>to</strong>rs and shift<br />
supervisors is an authorization exam for <strong>the</strong> field opera<strong>to</strong>r. The training programme for a<br />
turbine opera<strong>to</strong>r contains training modules such as: <strong>the</strong>rmo hydraulics, general plant<br />
knowledge, plant dynamics, simula<strong>to</strong>r training and On-Job-Training (OJT). Ano<strong>the</strong>r<br />
programme is required <strong>to</strong> get a reac<strong>to</strong>r opera<strong>to</strong>r authorization. Starting with a<br />
satisfac<strong>to</strong>rily completed authority exam as a turbine opera<strong>to</strong>r, supplementary courses in<br />
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technical specification documents, reac<strong>to</strong>r physics, emergency preparedness, core <strong>the</strong>ory<br />
and intensive simula<strong>to</strong>r training follow. To get a shift supervisor authorization,<br />
additional courses are needed. Core requirements are: leadership training, emergency<br />
procedures and simula<strong>to</strong>r training. Again, an authority exam must be successfully<br />
completed.<br />
The retraining programme for control room opera<strong>to</strong>rs provides a good mix <strong>of</strong> <strong>the</strong>oretical<br />
training in <strong>the</strong> classroom and practical training on <strong>the</strong> simula<strong>to</strong>r. In <strong>the</strong> classroom, plant<br />
modifications, operating experience and observations from previous training are<br />
considered in different ways, as lectures or <strong>team</strong> work presentations. On <strong>the</strong> simula<strong>to</strong>r,<br />
training subjects are based on abnormal and emergency accident management. KSU has<br />
a spreadsheet with all recurring simula<strong>to</strong>r training tasks (1-6 year cycle). Important<br />
elements are retrained more frequently. The retraining covers plant systems as well as<br />
overall fault instructions (ÖSI) unit fault instructions (ASI) and system-wide operating<br />
instructions (SDI).<br />
KSU provides training courses <strong>of</strong> a high quality standard. Training materials are<br />
generally well prepared. These contain detailed information and are constructed in<br />
accordance with adult learning standards. Reviewed papers were <strong>of</strong> good quality,<br />
containing pictures, schematics, and diagrams. All documents are printed in color and<br />
distributed <strong>to</strong> <strong>the</strong> trainees.<br />
The exercise guide for <strong>the</strong> instruc<strong>to</strong>rs describes all actions in each simula<strong>to</strong>r training<br />
scenario and is well documented. In <strong>the</strong> follow-up meeting after <strong>the</strong> retraining, <strong>the</strong><br />
simula<strong>to</strong>r instruc<strong>to</strong>rs and <strong>the</strong> shift <strong>team</strong> evaluate recognized weak areas in performance<br />
as well as good practices. In an intensive dialogue, all occurrences are discussed <strong>to</strong><br />
ensure successful performance for assigned duties for <strong>the</strong> shift <strong>team</strong>. For MCR staff, <strong>the</strong><br />
training programme is improved in real time sessions (pilot course). The requirements <strong>to</strong><br />
pass retraining include passing a <strong>the</strong>ory test with >80% score and attending for a<br />
minimum <strong>of</strong> 80% <strong>of</strong> <strong>the</strong> time.<br />
The <strong>team</strong> observed simula<strong>to</strong>r retraining. The programme is well conducted on <strong>the</strong> full<br />
scope simula<strong>to</strong>r, with <strong>the</strong>ory in <strong>the</strong> classroom. The actual scenario was adequate and well<br />
managed by <strong>the</strong> participants. The shift group use <strong>the</strong> 3-way communication method and<br />
<strong>the</strong> STAR principle is well established. A few areas for improvement were observed<br />
during <strong>the</strong> training: <strong>the</strong> responsibility <strong>of</strong> an extra shift supervisor was not clear, however<br />
corrective action was taken by <strong>the</strong> instruc<strong>to</strong>r.<br />
2.5 TRAINING PROGRAMS FOR FIELD OPERATORS<br />
Initial training for field opera<strong>to</strong>rs is broken down in<strong>to</strong> several tasks. It starts with a kick<strong>of</strong>f<br />
group dynamic meeting with <strong>team</strong>-building exercises. The course includes five skill<br />
areas for: administrative training, operating principles knowledge, technical training,<br />
component training and finally, plant knowledge.<br />
Under <strong>the</strong> conduct <strong>of</strong> <strong>the</strong> shift group and experienced field opera<strong>to</strong>rs, each trainee passes<br />
on-<strong>the</strong>-job training and walk-throughs. During <strong>the</strong>se, <strong>the</strong> shift supervisor acts as a<br />
men<strong>to</strong>r. KSU is responsible for on-<strong>the</strong>-job training <strong>of</strong> field opera<strong>to</strong>rs and must ensure its<br />
effectiveness. Also, <strong>the</strong> shadow training method is well established. After finishing <strong>the</strong><br />
training period and passing <strong>the</strong> final authority exam, <strong>the</strong> employee achieves field<br />
opera<strong>to</strong>r status.<br />
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A Graphic Simula<strong>to</strong>r is a useful <strong>to</strong>ol for opera<strong>to</strong>rs. Only Unit 3 has direct access <strong>to</strong> such<br />
a simula<strong>to</strong>r. Ano<strong>the</strong>r Graphic Simula<strong>to</strong>r for Unit1/2 is placed in Studsvik (Headquarter<br />
KSU) and is used only for development. The <strong>team</strong> encourages <strong>the</strong> plant <strong>to</strong> install a<br />
graphic simula<strong>to</strong>r for units 1 and 2 as this would improve training, <strong>safety</strong> culture and<br />
familiarity with routine tasks.<br />
2.6 TRAINING PROGRAMS FOR MAINTENANCE PERSONNEL<br />
Individual training subjects for maintenance personnel are developed in <strong>the</strong> STRAKO<br />
process that outlines all training requirements. All job related inputs are used for training<br />
development and are supported by <strong>the</strong> line organization.<br />
For specific knowledge, training is undertaken on a mock-up <strong>of</strong> <strong>the</strong> plant owned by<br />
Westinghouse. This model <strong>of</strong>fers a good learning environment for <strong>the</strong> development <strong>of</strong><br />
specific knowledge and skills. The mock-up allows sufficient training on most critical<br />
work sequences, especially from <strong>the</strong> ALARA standpoint. Classroom training and<br />
practical training are well balanced.<br />
2.7 TRAINING PROGRAMS FOR TECHNICAL PLANT SUPPORT PERSONNEL<br />
For employees, work specifics and <strong>the</strong> needs <strong>of</strong> every plant department are adequately<br />
addressed in <strong>the</strong> STRAKO process. However, <strong>the</strong> SAT methodology for Technical<br />
Support staff training is only currently under development.<br />
Last year, <strong>the</strong> plant hired 18 trainees. During <strong>the</strong> eighteen month trainee program, <strong>the</strong>se<br />
young people are trained at <strong>the</strong> plant <strong>to</strong> meet <strong>the</strong> requirements <strong>of</strong> <strong>the</strong> following sections:<br />
electrical systems, nuclear <strong>safety</strong> or project management. The programme activities are<br />
mainly held at <strong>the</strong> plant but also at <strong>the</strong> Uppsala University.<br />
Trainees are annually interviewed in assessments by management. Management validate<br />
<strong>the</strong> satisfac<strong>to</strong>ry performance <strong>of</strong> <strong>the</strong> trainee. Job related inputs are compared with a<br />
defined standard for <strong>the</strong> position. This systematic gap analysis <strong>of</strong> job requirements<br />
ensures an adequate training development.<br />
2.8 TRAINING PROGRAMS FOR MANAGEMENT AND SUPERVISORY<br />
PERSONNEL<br />
The <strong>team</strong> observed that <strong>the</strong> managers possess many well established skills. The<br />
management planning process and <strong>the</strong> training programme are well described. The main<br />
purpose <strong>of</strong> <strong>the</strong> Managing Planning Process is <strong>to</strong> secure <strong>the</strong> supply <strong>of</strong> future leaders at<br />
different management levels. Fur<strong>the</strong>rmore <strong>the</strong> purpose is <strong>to</strong> promote <strong>safety</strong> and<br />
assessment <strong>of</strong> potentials. These requirements are explained in <strong>the</strong> “Management’s<br />
Expectations and our Leadership criteria” document.<br />
Management pr<strong>of</strong>iles are satisfac<strong>to</strong>rily handled with <strong>the</strong> STRAKO process. The<br />
requirements are described in <strong>the</strong> plant document “The role <strong>of</strong> managers at FKA”. This<br />
document deals with <strong>the</strong> role <strong>of</strong> <strong>the</strong> manager and leader, <strong>the</strong> required behaviours <strong>of</strong><br />
managers, <strong>safety</strong> thinking and general competences.<br />
Fundamentals such as problem solving, decision making and leadership are adequately<br />
addressed in <strong>the</strong> VCMP-Course (Vattenfall Core Management Program). Additional<br />
management courses are provided for experienced managers e.g. “Management<br />
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Development Programme for Potential upper Management”.<br />
Key line managers participate in training. In special cases, <strong>the</strong> President is present and<br />
speaks <strong>to</strong> <strong>the</strong> trainees.<br />
The plant has ongoing activities divided in<strong>to</strong> three modules. The first module,<br />
Management Expectations is addressed <strong>to</strong> all managers and employees. The second<br />
module is a self-made module “Streng<strong>the</strong>n <strong>the</strong> leadership”. This module begins with a<br />
questionnaire taken before individual interviews. All managers are asked about <strong>safety</strong><br />
culture behaviours or setting goals for work. This evaluation highlights <strong>the</strong> present<br />
situation in <strong>the</strong> plant. A third activity is <strong>the</strong> Safety Dialogue Seminar. The target groups<br />
are all managers and employees. They build up cross functional groups in <strong>the</strong>se seminars.<br />
The first pilot project was successfully completed in January 2008. The overall goal is <strong>to</strong><br />
streng<strong>the</strong>n <strong>the</strong> <strong>safety</strong> culture. The <strong>team</strong> identified this area as a good performance.<br />
2.9 TRAINING PROGRAMS FOR TRAINING GROUP PERSONNEL<br />
Instruc<strong>to</strong>rs at <strong>the</strong> plant are typically recruited on <strong>the</strong> basis <strong>of</strong> <strong>the</strong>ir technical knowledge<br />
and experience at <strong>the</strong> actual working position. They usually act as on-<strong>the</strong>-job trainers. In<br />
<strong>the</strong> Chemistry Department for example, <strong>the</strong> <strong>team</strong> observed that on-<strong>the</strong>-job training is<br />
performed by an experienced employee. A policy for <strong>the</strong> training <strong>of</strong> external instruc<strong>to</strong>rs<br />
is currently under development.<br />
Simula<strong>to</strong>r instruc<strong>to</strong>rs are employed by KSU. All instruc<strong>to</strong>rs are mainly recruited from <strong>the</strong><br />
<strong>operational</strong> staff at <strong>the</strong> plant. Academic background is not a primary consideration. The<br />
Competence Pr<strong>of</strong>ile out <strong>of</strong> <strong>the</strong> STRAKO process defines <strong>the</strong> training requirement.<br />
Every instruc<strong>to</strong>r comes with a long experience as a shift worker (mainly shift supervisor)<br />
and good plant and technical knowledge. For external instruc<strong>to</strong>rs and part time<br />
instruc<strong>to</strong>rs, KSU uses <strong>the</strong> same criteria as for its internal personnel <strong>to</strong> ensure high quality<br />
teaching.<br />
KSU attests that its instruc<strong>to</strong>rs have a high pr<strong>of</strong>iciency, although no formal programme<br />
for qualification exists. These instruc<strong>to</strong>rs are evaluated on <strong>the</strong>ir performance in different<br />
ways. During each retraining course, <strong>the</strong> instruc<strong>to</strong>r is observed by a manager <strong>of</strong> <strong>the</strong><br />
operation department. At <strong>the</strong> end <strong>of</strong> a retraining session, <strong>the</strong> instruc<strong>to</strong>r and <strong>the</strong> training<br />
group discuss <strong>the</strong> training with each o<strong>the</strong>r in a follow-up assessment. Fur<strong>the</strong>rmore, KSU<br />
has an advisory committee which is responsible for <strong>the</strong> quality control and good<br />
performance <strong>of</strong> its instruc<strong>to</strong>rs.<br />
When weaknesses are detected in an instruc<strong>to</strong>r, <strong>the</strong> plant simula<strong>to</strong>r manager or <strong>the</strong><br />
advisory board directly initiates corrective actions. If one area <strong>of</strong> competence is weak,<br />
<strong>the</strong> instruc<strong>to</strong>r is required <strong>to</strong> take supplementary courses and improve his competence.<br />
Fur<strong>the</strong>rmore in <strong>the</strong> annual assessment between <strong>the</strong> management and <strong>the</strong> instruc<strong>to</strong>r,<br />
possible weaknesses or deviations from <strong>the</strong> expected standard are discussed.<br />
2.10 GENERAL EMPLOYEE TRAINING<br />
Several new employees have been hired due <strong>to</strong> retirements. To keep a high training<br />
standard, a business strategy was developed in <strong>the</strong> Strategic Competence Planning<br />
System. The plant supports a high school on site. The aim <strong>of</strong> this initiative is <strong>to</strong> get<br />
highly educated students ready for future employment.<br />
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The <strong>team</strong> observed that <strong>the</strong> Human Resource Process provides <strong>to</strong> all new employees,<br />
high quality general and basic training education, covering knowledge about <strong>the</strong><br />
operation process, organization, industrial <strong>safety</strong>, radioprotection, environmental training<br />
and fire protection. This basic course explains <strong>the</strong> plant administrative controls as well as<br />
<strong>the</strong> approach for <strong>the</strong> performance <strong>of</strong> safer work. In addition, <strong>the</strong> regular retraining<br />
ensures a comprehensive understanding <strong>of</strong> <strong>the</strong> requirements.<br />
The plant provides training and retraining covering practical training in industrial <strong>safety</strong><br />
and radiation protection for each employee, all temporary personnel and contrac<strong>to</strong>rs.<br />
Fur<strong>the</strong>rmore, a special ALARA requirement for difficult work during <strong>the</strong> outage is a task<br />
in a separate document. This document includes a full description <strong>of</strong> <strong>the</strong> analysis <strong>to</strong><br />
assess risks, hazards, <strong>safety</strong> culture aspects, working rules and eventually up <strong>to</strong> <strong>the</strong><br />
description <strong>of</strong> how <strong>to</strong> work on a mock-up.<br />
The basic training for all employees includes training in first aid and rescue for accidents<br />
as well as training on alarm rules.<br />
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DETAILED TRAINING AND QUALIFICATIONS FINDINGS<br />
2.1 TRAINING POLICY AND ORGANIZATION<br />
2.1(1) Issue: Even though most training <strong>to</strong>ols are <strong>of</strong> a fairly high quality, some training<br />
documents, instructions, routines and analyses are incomplete.<br />
• The HR department does not develop and publish training indica<strong>to</strong>rs <strong>to</strong><br />
confirm and assess efficiency <strong>of</strong> <strong>the</strong> training.<br />
• SAT methodology for Technical support staff training is currently under<br />
development.<br />
• During <strong>the</strong> simula<strong>to</strong>r training, responsibility <strong>of</strong> an extra shift supervisor was<br />
not clear. However, corrective action was taken by <strong>the</strong> instruc<strong>to</strong>r.<br />
• In <strong>the</strong> general training for Radiation Protection, a film was shown. However<br />
some incorrect examples exist in <strong>the</strong> movie.<br />
• Specific retraining how <strong>to</strong> restart manually UPS was not performed.<br />
• Policy for <strong>the</strong> training <strong>of</strong> external instruc<strong>to</strong>rs is currently under development<br />
• The shutdown panel is well described in <strong>the</strong> basic training course, however<br />
on <strong>the</strong> job, no formal practical retraining exists on how and when this panel<br />
should be used.<br />
• The principal results <strong>of</strong> probabilistic <strong>safety</strong> assessment <strong>of</strong> <strong>the</strong> plant, showing<br />
<strong>the</strong> importance <strong>of</strong> plant systems in preventing damage or severe accidents, are<br />
not included in <strong>the</strong> shift supervisors training programs.<br />
Without complete and thorough training documents, instructions, routines and<br />
publishing indica<strong>to</strong>rs, <strong>the</strong> plant cannot maintain <strong>the</strong> current high level <strong>of</strong> training.<br />
Suggestion: The plant should consider completing all training documents,<br />
instructions, routines and analyses <strong>to</strong> <strong>the</strong> required standards.<br />
Basis: NS-G-2.8 Par 3.3, 5.27, 7.8(1), 5.5, 5.20, 4.3, 4.37, 4.36<br />
Par. 3.3. “Before undertaking any <strong>safety</strong> related work, staff should demonstrate<br />
<strong>the</strong> appropriate knowledge, skills and attitudes <strong>to</strong> ensure <strong>safety</strong> under a variety <strong>of</strong><br />
conditions relating <strong>to</strong> <strong>the</strong>ir duties. …”<br />
Par. 5.27 “Personnel involved in chemistry, radiation protection, nuclear<br />
engineering or o<strong>the</strong>r technical functions should undergo qualification and receive<br />
training as appropriate <strong>to</strong> <strong>the</strong>ir jobs and responsibilities. Their training should be<br />
determined by a systematic approach as described in paras 5.16–5.26 for opera<strong>to</strong>rs<br />
and maintenance personnel. ”<br />
Par. 7.8(1) “The shift member(s) designated <strong>to</strong> directly supervise operation <strong>of</strong> <strong>the</strong><br />
plant or <strong>of</strong> <strong>the</strong> unit and who decides on <strong>safety</strong> related measures during normal<br />
operation, incidents or accidents, gives commands <strong>to</strong> <strong>the</strong> shift and is responsible<br />
for <strong>the</strong> safe performance <strong>of</strong> <strong>the</strong> unit (that is, <strong>the</strong> shift supervisor and <strong>the</strong> deputy<br />
shift supervisor, who may take over <strong>the</strong>se functions).<br />
Par. 5.5 “All persons likely <strong>to</strong> be occupationally exposed <strong>to</strong> ionizing radiation —<br />
that is, not only radiation protection staff — should receive suitable training in (a)<br />
radiation risks and (b) <strong>the</strong> technical and administrative means <strong>of</strong> preventing undue<br />
exposure and applying <strong>the</strong> ALARA (as low as reasonably achievable) principle.”<br />
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Par. 5.20 “Field opera<strong>to</strong>rs should receive training commensurate with <strong>the</strong>ir duties<br />
and responsibilities. All personnel in this category should have detailed<br />
knowledge <strong>of</strong> <strong>the</strong> <strong>operational</strong> features <strong>of</strong> <strong>the</strong> plant and hands-on experience. This<br />
knowledge should cover both <strong>the</strong> control rooms and <strong>the</strong> plant as a whole”<br />
Par. 4.3 “The training policy should be known, unders<strong>to</strong>od and supported by all<br />
persons concerned. Plant department managers and <strong>the</strong> plant training manager<br />
should be involved in developing <strong>the</strong> training policy and implementing<br />
procedures, as a way <strong>of</strong> facilitating <strong>the</strong>ir acceptance <strong>of</strong> <strong>the</strong> policy”<br />
Par. 4.37 “Plant emergency response using emergency operating procedures<br />
(EOPs) should be practiced in <strong>the</strong> simula<strong>to</strong>r, <strong>to</strong> provide operating personnel with<br />
<strong>the</strong> necessary knowledge and skills <strong>to</strong> demonstrate competent emergency actions.<br />
…”<br />
Par. 4.36. “Supplementary training should be provided for those staff members<br />
who are required <strong>to</strong> perform specialized duties in <strong>the</strong> event <strong>of</strong> an accident. For<br />
example, <strong>to</strong>pics such as nuclear <strong>safety</strong> analysis, applicable codes, standards and<br />
regulations, information on evaluated <strong>safety</strong> margins <strong>of</strong> <strong>the</strong> plant, symp<strong>to</strong>m<br />
oriented procedures and accident management measures should be covered. The<br />
principal results <strong>of</strong> any probabilistic <strong>safety</strong> assessment <strong>of</strong> <strong>the</strong> plant, showing <strong>the</strong><br />
importance <strong>of</strong> plant systems in preventing damage or severe accidents, should be<br />
included in <strong>the</strong> training programs”<br />
2.2 TRAINING FACILITIES, EQUIPMENT AND MATERIAL<br />
2.2(a) Good practice: To use <strong>the</strong> training simula<strong>to</strong>r <strong>to</strong> describe complex events and <strong>to</strong><br />
demonstrate <strong>the</strong> work methods in <strong>the</strong> control room following a disturbance, <strong>to</strong> <strong>the</strong> media<br />
and o<strong>the</strong>r key groups.<br />
A problem in communications in nuclear power is <strong>to</strong> be able <strong>to</strong> describe clearly complex<br />
events and <strong>the</strong> design <strong>of</strong> <strong>the</strong> <strong>safety</strong> systems that manage <strong>the</strong> events <strong>to</strong> people outside <strong>the</strong><br />
nuclear power industry. Fur<strong>the</strong>rmore, it is difficult <strong>to</strong> present a picture <strong>of</strong> <strong>the</strong> orderly<br />
work methods in <strong>the</strong> control room during a disturbance by merely describing <strong>the</strong>m.<br />
There is a full scope simula<strong>to</strong>r at <strong>Forsmark</strong> which is used <strong>to</strong> conduct training and<br />
refresher training for different categories <strong>of</strong> operations personnel. This simula<strong>to</strong>r is an<br />
identical copy <strong>of</strong> <strong>the</strong> <strong>Forsmark</strong> 1 control room. It has been on <strong>the</strong> site since 2001 and is<br />
operated by KSU (Nuclear Training & Safety Center) at <strong>the</strong> <strong>Forsmark</strong> site.<br />
After <strong>the</strong> July 25, 2006 event at <strong>Forsmark</strong> <strong>the</strong> media published and broadcast a number <strong>of</strong><br />
inaccurate descriptions <strong>of</strong> <strong>the</strong> situation in <strong>the</strong> control room during <strong>the</strong> disturbance and <strong>of</strong><br />
<strong>the</strong> impact <strong>of</strong> <strong>the</strong> disturbance on various surveillance systems.<br />
The plant invited journalists in <strong>to</strong> <strong>the</strong> simula<strong>to</strong>r <strong>to</strong> witness a simulation <strong>of</strong> <strong>the</strong> event,<br />
providing <strong>the</strong>m with a much clearer picture <strong>of</strong> <strong>the</strong> sequence <strong>of</strong> events, which surveillance<br />
systems were affected and which were intact as well as <strong>the</strong> orderly work methods <strong>of</strong> <strong>the</strong><br />
control room personnel, which were in turn a result <strong>of</strong> <strong>the</strong> training and refresher training<br />
on <strong>the</strong> same simula<strong>to</strong>r. Fur<strong>the</strong>rmore, it was made clear how <strong>the</strong> <strong>safety</strong> systems are<br />
designed, with redundant features and so forth. This effort contributed much <strong>to</strong><br />
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presenting a more balanced picture <strong>of</strong> <strong>the</strong> July 25 th event which had been described in <strong>the</strong><br />
media as a potential core meltdown.<br />
O<strong>the</strong>r groups have visited <strong>the</strong> simula<strong>to</strong>r later <strong>to</strong> see <strong>the</strong> same run-through. Among o<strong>the</strong>rs,<br />
SKI, <strong>the</strong> local <strong>safety</strong> board, <strong>the</strong> county administrative board’s emergency preparedness<br />
organization and many national politicians have seen <strong>the</strong> simulation. Their perception <strong>of</strong><br />
<strong>the</strong> July 25 th event has also become much more balanced.<br />
A contributing fac<strong>to</strong>r in <strong>the</strong> success <strong>of</strong> presenting a more balanced picture is that <strong>the</strong><br />
personnel who work as instruc<strong>to</strong>rs in <strong>the</strong> simula<strong>to</strong>r are good teachers who are able <strong>to</strong><br />
describe clearly complicated situations and relationships <strong>to</strong> <strong>the</strong> layman.<br />
This positive outcome has resulted in <strong>Forsmark</strong> including <strong>the</strong> simula<strong>to</strong>r as a<br />
communication resource in <strong>the</strong>ir emergency equipment.<br />
26<br />
TRAINING AND QUALIFICATIONS
3. OPERATIONS<br />
3.1 ORGANIZATION AND FUNCTIONS<br />
The Operations organization and responsibilities are well defined in <strong>the</strong> procedure F12-I-<br />
0001 “Assignment <strong>of</strong> responsibilities and distribution <strong>of</strong> work within F12” as well as<br />
delegations in procedure F12-I-0002, “Delegation <strong>of</strong> authorities from F12”. They are<br />
properly communicated and unders<strong>to</strong>od by <strong>the</strong> appropriate level <strong>of</strong> operation managers.<br />
Goals and objectives are defined in <strong>the</strong> document F12-2007-0113 “Activity Plan for<br />
2008-2010 at F12” which is <strong>the</strong>n fur<strong>the</strong>r defined in one document per Unit (e.g. F12-<br />
2008-0102). Specific and measurable goals are set for <strong>the</strong> plant and operations<br />
management level for short term and intermediate periods. However, <strong>the</strong> <strong>team</strong><br />
recommended fur<strong>the</strong>r improvements in this area.<br />
The Operations’ managers are frequently present in <strong>the</strong> field. They have open discussions<br />
with <strong>the</strong> <strong>operational</strong> staff members and are recognized by <strong>the</strong>ir staff. Unit Managers take<br />
responsibility for long term activities <strong>to</strong> relieve Shift Supervisors (SS) <strong>of</strong> this<br />
administrative work. The Shift Supervisors recognized <strong>the</strong> presence <strong>of</strong> an additional<br />
crew member with SS qualification as very effective help <strong>to</strong> reduce <strong>the</strong>ir administrative<br />
tasks. They recognize <strong>the</strong> goal <strong>to</strong> increase <strong>the</strong> number <strong>of</strong> shift crew members as a very<br />
positive step in this matter. Off shift operation personnel support <strong>the</strong> shift <strong>team</strong>s in<br />
several fields like training, planning <strong>of</strong> activities related <strong>to</strong> surveillance testing and<br />
modifications, personnel planning, management <strong>of</strong> keys and work authorization process.<br />
In some periods <strong>of</strong> time <strong>the</strong> maximum authorized overtime limits are used, specifically<br />
during outages periods.<br />
The Shift Supervisor is not identified as having <strong>the</strong> authority <strong>of</strong> <strong>the</strong> plant manager during<br />
<strong>of</strong>f hours. He has <strong>to</strong> call <strong>the</strong> Engineer on duty or Operations manager for problems in<br />
connection with safe operation. The authority allocated <strong>to</strong> <strong>the</strong> Shift Supervisor is not<br />
commensurate with his responsibilities. In <strong>the</strong> Safety Analysis <strong>Report</strong> (SAR) Chapter 2<br />
he is not identified as being in <strong>the</strong> <strong>operational</strong> management and consequently <strong>the</strong>re is no<br />
continuous oversight <strong>of</strong> <strong>the</strong> units. However, though he has authority <strong>to</strong> solve problems<br />
that may impair <strong>the</strong> safe operation <strong>of</strong> <strong>the</strong> unit, <strong>of</strong>f hours, no one on site has an oversight<br />
<strong>of</strong> <strong>the</strong> <strong>safety</strong> <strong>of</strong> <strong>the</strong> whole site.<br />
The Operations Department initiated regular self assessment sessions for each shift crew<br />
as <strong>the</strong> closing part <strong>of</strong> <strong>the</strong>ir seven week shift cycle at F1 and F2 units at <strong>the</strong> end <strong>of</strong> 2007<br />
and at F3 unit earlier in 2007. Some shift crews have not conducted this activity yet.<br />
Once effectively implemented, this activity is a very positive step <strong>to</strong>wards improving<br />
Operations performance.<br />
Units at <strong>the</strong> plant are independent by design and also by <strong>the</strong> <strong>operational</strong> organization, so<br />
<strong>the</strong>re should not be any effects on o<strong>the</strong>r units during emergencies. However, <strong>the</strong> recent<br />
organizational changes focused on merging some <strong>operational</strong> activities <strong>of</strong> F1 and F2<br />
units <strong>to</strong> <strong>the</strong> so called F12 structure, can be challenging in this respect. The plant is<br />
encouraged <strong>to</strong> consider <strong>the</strong> application <strong>of</strong> techniques <strong>to</strong> prevent human errors deriving<br />
from a merged organization.<br />
Two procedures define internal coordination and interfaces with o<strong>the</strong>r groups (F1-I-350<br />
“Operational meetings” and F-I-1115 “Operational <strong>review</strong> meeting”). There are<br />
<strong>operational</strong> <strong>review</strong> meetings and daily <strong>review</strong> meetings in <strong>the</strong> morning during which <strong>the</strong><br />
conditions <strong>of</strong> <strong>the</strong> unit are stated from <strong>the</strong> nuclear <strong>safety</strong> and production points <strong>of</strong> view.<br />
There are also weekly coordination meetings and a monthly company <strong>safety</strong> committee.<br />
The plant is encouraged <strong>to</strong> conduct more effective daily meetings in order <strong>to</strong> increase <strong>the</strong><br />
27<br />
OPERATIONS
availability <strong>of</strong> <strong>the</strong> Shift Supervisor for <strong>operational</strong> activities.<br />
The Shift Supervisor does not supervise <strong>the</strong> coordination <strong>of</strong> o<strong>the</strong>r departments’ activities<br />
and can not control <strong>the</strong> operating objectives for <strong>the</strong> shift. Such activities are <strong>the</strong><br />
responsibility <strong>of</strong> <strong>the</strong> Unit Operation Manager.<br />
Before resuming shift work after three weeks <strong>of</strong>f shift and starting a new seven week<br />
shift cycle, <strong>the</strong> shift <strong>team</strong> spends a half day (known as “Little d day”) for getting back <strong>to</strong><br />
duty. It covers technical experience feedback from <strong>the</strong> past three weeks and from all<br />
three units, <strong>safety</strong> concerns, <strong>the</strong> coming two weeks programme and also management and<br />
human resource issues. This is also a dedicated time for <strong>the</strong> shift <strong>to</strong> be with <strong>the</strong>ir<br />
managers and discuss various <strong>to</strong>pics. The <strong>team</strong> considers this as a good performance.<br />
The plant already has a programme <strong>to</strong> increase <strong>the</strong> number <strong>of</strong> shift crew members from<br />
6-7 <strong>to</strong> 7-8 individuals, which is a positive plant management activity in this matter.<br />
Operation Managers take care <strong>of</strong> <strong>the</strong> appropriate balance between experienced and new<br />
incoming staff members for each shift crew. The plant faces some difficulties in<br />
attracting and hiring new young personnel in field opera<strong>to</strong>r positions, which is<br />
considered as <strong>the</strong> starting position in <strong>the</strong> shift crew. For emergency situations, if referring<br />
<strong>to</strong> <strong>the</strong> existing technical specifications, shift staffing level is sufficient <strong>to</strong> respond <strong>to</strong> and<br />
face emergency situations. However, in some situations <strong>the</strong> <strong>team</strong> considers this situation<br />
is not adequate and provides a recommendation <strong>to</strong> <strong>the</strong> plant in this area.<br />
A rigorous “fitness for duty” program, covering initial entrance tests and random tests for<br />
alcohol and drugs consumption is implemented. Moreover, every three years “on shift”<br />
personnel must undergo a medical examination <strong>to</strong> confirm <strong>the</strong>ir capacity for such shift<br />
work. Regular personnel performance <strong>review</strong>s are conducted by shift supervisors and<br />
<strong>operational</strong> managers at <strong>the</strong> end <strong>of</strong> each seven week shift cycle, on a yearly basis and<br />
<strong>the</strong>n every three years in order <strong>to</strong> renew <strong>the</strong> <strong>operational</strong> licence.<br />
The shift supervisor and radiation protection groups <strong>of</strong> all three units report <strong>the</strong> key<br />
aspects <strong>of</strong> <strong>operational</strong> activities and events <strong>of</strong> various logbooks in<strong>to</strong> <strong>the</strong> DIGILOG which<br />
is an information system available <strong>to</strong> everyone at <strong>the</strong> site. Entries consist <strong>of</strong> important<br />
information that has occurred during <strong>the</strong> past 24 hours, actions taken <strong>to</strong> support<br />
maintenance or radiation protection activities and information from <strong>the</strong> daily morning<br />
meeting. A search <strong>of</strong> <strong>the</strong> database can be initiated by system number, keywords or date.<br />
The <strong>team</strong> recognizes this as a good performance.<br />
3.2 OPERATIONS FACILITIES AND OPERATOR AIDS<br />
The lighting is generally <strong>of</strong> very good quality in all areas <strong>of</strong> <strong>the</strong> plant and more<br />
specifically in <strong>the</strong> main control room. The plant is equipped with adequate<br />
communication means, which are properly used. The use <strong>of</strong> mobile phones is restricted<br />
in some areas.<br />
There is a clear panel policy applied in <strong>the</strong> MCR. There is an aid <strong>to</strong> localization <strong>of</strong><br />
alarms on <strong>the</strong> panels. However, <strong>the</strong>re is no prioritization <strong>of</strong> alarm, which could make<br />
opera<strong>to</strong>rs confused in case <strong>of</strong> perturbation or incident. The <strong>team</strong> encourages <strong>the</strong> plant <strong>to</strong><br />
prioritize <strong>the</strong> alarms.<br />
There are several computers which provide all necessary information concerning plant<br />
performance. A video system allows opera<strong>to</strong>rs <strong>to</strong> visualize <strong>the</strong> various plant areas which<br />
are not accessible during power operations.<br />
Moni<strong>to</strong>ring functions for <strong>safety</strong> functions (BSF) and computerised operating status<br />
checking (DDK) are s<strong>of</strong>tware-based and present operating status, component status and<br />
process parameter information. The functions present deviations from expected status or<br />
28<br />
OPERATIONS
value. The <strong>team</strong> considers this as a good practice.<br />
Main control room and shutdown panel facilities assure habitability <strong>of</strong> <strong>the</strong> work spaces in<br />
compliance with appropriate documents.<br />
The emergency shut down panel is available for Units 1&2. Unit 3 is equipped with two<br />
emergency shutdown panels, well separated from <strong>the</strong> main control room, with adequate<br />
communication means fed by batteries. Necessary procedures and communication <strong>to</strong>ols<br />
are available in <strong>the</strong> shut down panel room.<br />
Generally good cleanliness, housekeeping and adequate labelling <strong>of</strong> equipment were<br />
observed at <strong>the</strong> plant areas. There are first aid kits distributed in many places at <strong>the</strong> plant<br />
with adequate numbers <strong>of</strong> breathing apparatus provided <strong>to</strong> <strong>the</strong> shift personnel. Personnel<br />
pass medical examinations and receive training on use <strong>of</strong> <strong>the</strong> apparatus.<br />
In general, isolated equipment is clearly identified in <strong>the</strong> field. Equipment isolations for<br />
<strong>the</strong> administrative locking (system which have <strong>to</strong> be in a defined configuration for <strong>safety</strong><br />
reasons) are not tagged though <strong>the</strong>y are locked effectively and checked periodically.<br />
3.3 OPERATING RULES AND PROCEDURES<br />
Operational Limits and Conditions (OLC) are clearly defined in chapter 3 <strong>of</strong> Technical<br />
Specifications (STF). They are applicable at various modes during <strong>the</strong> start-up activities<br />
after a refuelling outage and/or shutdown for maintenance. There are very effective<br />
controls and procedures <strong>to</strong> ensure compliance <strong>to</strong> OLC before a change <strong>of</strong> reac<strong>to</strong>r mode.<br />
Opera<strong>to</strong>rs and Shift Supervisors are well trained and knowledgeable about OLCs. Any<br />
deviation has <strong>to</strong> be reported <strong>to</strong> <strong>the</strong> regula<strong>to</strong>r and properly documented through an<br />
appropriate report. However, during <strong>the</strong> <strong>review</strong>, <strong>the</strong> entries in<strong>to</strong> OLC were logged as any<br />
o<strong>the</strong>r record in <strong>the</strong> SS logbook and were not highlighted for easy identification. In Daily<br />
Review Sheets, only <strong>the</strong> identification <strong>of</strong> <strong>the</strong> associated system relevant <strong>to</strong> <strong>the</strong> OLC was<br />
recorded and no additional information relative <strong>to</strong> <strong>the</strong> time limits was included. Exact<br />
entry and exit times for <strong>safety</strong> system unavailability can help prevent an unsafe condition<br />
caused by inadequate plant staff awareness and is an important parameter for<br />
probabilistic risk assessment. The <strong>team</strong> encourages <strong>the</strong> plant <strong>to</strong> improve in this area.<br />
Procedures are clearly written, unders<strong>to</strong>od and supported with appropriate references.<br />
They are available in <strong>the</strong> main control room, work authorization room and o<strong>the</strong>r plant<br />
areas. There is an adequate method <strong>to</strong> report and document procedure deficiencies; a fast<br />
administrative process is applied with hand written authorized changes in <strong>the</strong> procedures<br />
in urgent situations. The plant <strong>operational</strong> procedures are regularly <strong>review</strong>ed on a two<br />
yearly basis <strong>to</strong> ensure <strong>the</strong>y are up-<strong>to</strong>-date. However, <strong>the</strong> <strong>team</strong> observed <strong>the</strong> potential for<br />
improvement and provided a recommendation in this area.<br />
Emergency Operating Procedures are clearly written and easily accessible by any <strong>of</strong> <strong>the</strong><br />
opera<strong>to</strong>rs. There are event-based procedures for <strong>the</strong> opera<strong>to</strong>rs and symp<strong>to</strong>m-based<br />
procedures for <strong>the</strong> Shift Supervisor. Such a combination does not have any adverse<br />
impact on <strong>the</strong> management <strong>of</strong> such operating conditions. However, <strong>the</strong>re are no<br />
symp<strong>to</strong>m-based emergency procedures for shutdown conditions. The plant is encouraged<br />
<strong>to</strong> develop and implement <strong>the</strong>se procedures.<br />
3.4 CONDUCT OF OPERATIONS<br />
Opera<strong>to</strong>rs are attentive and responsive <strong>to</strong> plant conditions. The system and component<br />
status changes are appropriately authorized. The plant system operating procedures<br />
contain <strong>the</strong> alarm response information. There is a policy on <strong>the</strong> use <strong>of</strong> alarm response<br />
procedures established by <strong>the</strong> plant. However, <strong>the</strong> policy is not fully implemented and<br />
29<br />
OPERATIONS
<strong>the</strong> plant is encouraged <strong>to</strong> improve in this area.<br />
Shift turnover is well organized and conducted: <strong>the</strong>re is a quiet atmosphere; <strong>to</strong>urs <strong>of</strong> <strong>the</strong><br />
panels are made by <strong>the</strong> opera<strong>to</strong>rs <strong>of</strong> both in-coming and out-going shifts at each level.<br />
The shift crew briefing is conducted immediately after <strong>the</strong> turnover. He briefing is led by<br />
<strong>the</strong> Shift Supervisor, each shift crew member reports <strong>to</strong> SS and receives instruction from<br />
<strong>the</strong> SS concerning <strong>the</strong> shift program. The access <strong>to</strong> <strong>the</strong> control room is limited and<br />
controlled by <strong>the</strong> SS.<br />
The surveillance programme is well defined by chapter 4 <strong>of</strong> <strong>the</strong> STF and well managed<br />
through <strong>the</strong> FENIX database in term <strong>of</strong> schedule and results follow-up. The shift<br />
supervisor verifies all surveillance testing results before input in<strong>to</strong> <strong>the</strong> FENIX database.<br />
Results <strong>of</strong> tests performed by o<strong>the</strong>r departments are also handed <strong>to</strong> <strong>the</strong> Shift Supervisor<br />
in a timely manner. The maximum <strong>to</strong>lerance <strong>of</strong> 30% in terms <strong>of</strong> surveillance test<br />
scheduling is strictly followed. Any deviation requires reporting <strong>to</strong> <strong>the</strong> regula<strong>to</strong>r.<br />
However, <strong>the</strong> <strong>team</strong> suggested some fur<strong>the</strong>r improvements in <strong>the</strong> surveillance test<br />
procedures, in addition <strong>to</strong> already planned modifications.<br />
The policy in <strong>the</strong> plant is that periodic tests should be performed during <strong>the</strong> afternoon<br />
shift, when possible. No tests are scheduled in <strong>the</strong> night shift which is appropriate as <strong>the</strong><br />
attention <strong>of</strong> opera<strong>to</strong>rs is lower during <strong>the</strong>se periods.<br />
The field opera<strong>to</strong>r rounds are divided in<strong>to</strong> different areas: Reac<strong>to</strong>r, Turbine and O<strong>the</strong>r<br />
facilities and cover <strong>the</strong> <strong>operational</strong> rooms in <strong>the</strong> plant. Rounds are scheduled accordingly.<br />
The <strong>team</strong> observed field opera<strong>to</strong>rs with high pr<strong>of</strong>essionalism, having a prudent and<br />
interrogative attitude as regard <strong>to</strong> hazards as well as consideration for <strong>the</strong> importance <strong>of</strong><br />
<strong>the</strong> equipment as regard <strong>to</strong> nuclear <strong>safety</strong>.<br />
Industrial <strong>safety</strong> deficiencies are systematically reported by <strong>the</strong> field opera<strong>to</strong>rs as it is part<br />
<strong>of</strong> <strong>the</strong> normal patrol. Specific patrols are dedicated <strong>to</strong> plant cleanliness and<br />
housekeeping.<br />
Provisions are made for <strong>the</strong> performance <strong>of</strong> verifications in <strong>the</strong> procedure F12-I-0001:<br />
Shift engineer and opera<strong>to</strong>rs shall be in <strong>the</strong> field three times/shift period. However, <strong>the</strong><br />
<strong>team</strong> has not observed this practice while being on site and encourages <strong>the</strong> plant <strong>to</strong><br />
streng<strong>the</strong>n this activity.<br />
The shift has several appropriate and efficient <strong>to</strong>ols <strong>to</strong> work with during disturbed<br />
operations. Problems are communicated between shifts during <strong>the</strong> shift turnover and shift<br />
briefing and <strong>to</strong> o<strong>the</strong>r departments through <strong>the</strong> FENIX database as well as during <strong>the</strong> daily<br />
meeting. The requirements are stated in <strong>the</strong> procedure F-I-1034 “Operation pr<strong>of</strong>iciency”.<br />
An overall <strong>operational</strong> readiness scheme is used <strong>to</strong> verify that all necessary checks and<br />
tests are performed before <strong>the</strong> plant is taken in<strong>to</strong> operation after refuelling outage or a<br />
maintenance shutdown. All <strong>the</strong>se requirements are followed with <strong>the</strong> support <strong>of</strong> <strong>the</strong><br />
Start-up Activity Diagram (green pen diagram). The diagram is a primary <strong>to</strong>ol used by<br />
<strong>the</strong> operations personnel and gives a quick and easy means for transmitting information<br />
<strong>to</strong> all concerned parties. The <strong>team</strong> considers this procedure as a good performance.<br />
There are adequate procedures and requirements <strong>to</strong> restart <strong>the</strong> unit after a reac<strong>to</strong>r scram.<br />
The decision <strong>to</strong> start-up <strong>the</strong> plant is made by <strong>the</strong> President who gives delegation <strong>to</strong> <strong>the</strong><br />
production unit manager <strong>to</strong> start <strong>the</strong> unit when certain conditions are met. Immediately<br />
before start-up, <strong>the</strong>re is an <strong>operational</strong> meeting, where <strong>the</strong> fulfilment <strong>of</strong> <strong>the</strong>se conditions<br />
is checked.<br />
3.5 WORK AUTHORIZATIONS<br />
The work authorization process is properly described in <strong>the</strong> plant procedures. Roles,<br />
30<br />
OPERATIONS
esponsibilities and authorities are well defined and unders<strong>to</strong>od by plant personnel. The<br />
plant developed its own s<strong>of</strong>tware application FENIX <strong>to</strong> effectively run and control <strong>the</strong><br />
work authorization process. By this application, all work permits and access permits <strong>to</strong><br />
any unit work is authorized and managed.<br />
There are well equipped, spacious and well organized work areas prepared <strong>to</strong> handle <strong>the</strong><br />
work authorization process. The shift operation personnel are adequately supported by<br />
daily supporting staff in <strong>the</strong> work authorization process administration, especially during<br />
<strong>the</strong> outages. A special list <strong>of</strong> all ongoing work permits and access permits is prepared<br />
daily before <strong>the</strong> morning <strong>operational</strong> <strong>review</strong> meeting.<br />
There is an appropriate key control system, strictly managed by <strong>the</strong> SS and <strong>of</strong>f shift<br />
operations personnel. Isolation tags are properly used <strong>to</strong> mark all equipment isolation<br />
points during maintenance in <strong>the</strong> field. The shift crew personnel are aware <strong>of</strong> plant<br />
systems and equipment out <strong>of</strong> service.<br />
There is a shutdown risk programme fully integrated in<strong>to</strong> <strong>the</strong> preventive maintenance<br />
programme. Mainly, <strong>the</strong> deterministic approach is used <strong>to</strong> define <strong>the</strong> minimum required<br />
configuration <strong>of</strong> available <strong>safety</strong> systems during power operation and during outages.<br />
The probabilistic approach is not applied for this purpose.<br />
Modifications and temporary modifications (TM) are adequately controlled by operations<br />
personnel. Temporary modifications are properly implemented in <strong>the</strong> field. The MCR<br />
staff is aware <strong>of</strong> all temporary modifications currently implemented in <strong>the</strong> unit. However,<br />
<strong>the</strong> <strong>team</strong> encourages <strong>the</strong> plant <strong>to</strong> improve <strong>the</strong> management and administrative tasks<br />
related <strong>to</strong> temporary modifications such as timely closure <strong>of</strong> TM, no hand written notes<br />
and drawings in TM approval sheets and <strong>the</strong> strict application <strong>of</strong> <strong>the</strong> approval process <strong>of</strong><br />
TM.<br />
Preliminary hardware modifications are marked well in advance, before implementation,<br />
in red colour in<strong>to</strong> <strong>operational</strong> drawings. This gives <strong>the</strong> <strong>operational</strong> shift crew and o<strong>the</strong>r<br />
<strong>operational</strong> staff enough time <strong>to</strong> <strong>review</strong>, comment and become familiar with future<br />
modifications. The <strong>team</strong> considers this <strong>to</strong> be a good performance.<br />
3.6 FIRE PREVENTION AND PROTECTION PROGRAMME<br />
The overall management <strong>of</strong> <strong>the</strong> fire prevention and fire protection programme is good<br />
and well organized at <strong>the</strong> plant. Adequate fixed fire protection systems are installed;<br />
portable fire fighting equipment is available at <strong>the</strong> plant and well maintained. The<br />
maintenance <strong>of</strong> fire barriers <strong>to</strong> isolate <strong>the</strong> fire cells is very efficient. A state-<strong>of</strong>-<strong>the</strong>-art fire<br />
detection system is implemented at <strong>the</strong> plant facilities. There was ninety one fire alarms<br />
recorded in 2006 from which only sixteen were false alarms. All required fire protection<br />
components are included in <strong>the</strong> plant surveillance programme and are regularly tested.<br />
The <strong>team</strong> recognized <strong>the</strong> management <strong>of</strong> fire cells in <strong>the</strong> plant as a good practice.<br />
The plant fire protection programme is effectively supported by a pr<strong>of</strong>essional, on-site,<br />
adequately equipped fire brigade, run by a contracting company. The same company is in<br />
charge <strong>of</strong> fire extinguishers and breathing apparatus maintenance and inspections. Five<br />
fully qualified and well trained pr<strong>of</strong>essional fire fighters are present at all times at <strong>the</strong><br />
site.<br />
Adequate <strong>the</strong>oretical and practical initial training is provided <strong>to</strong> shift crew members, who<br />
assist <strong>the</strong> fire brigade in case <strong>of</strong> fire. In addition, fur<strong>the</strong>r assistance <strong>to</strong> <strong>the</strong> plant is<br />
provided, if necessary, by <strong>the</strong> <strong>of</strong>f-site pr<strong>of</strong>essional fire brigade located nearby in<br />
Östhammar.<br />
31<br />
OPERATIONS
There are regular walk downs carried out by on-site fire brigade personnel in order <strong>to</strong><br />
check <strong>the</strong> fire load in <strong>the</strong> plant areas. However, <strong>the</strong> <strong>team</strong> recommended fur<strong>the</strong>r<br />
improvements in <strong>the</strong> control <strong>of</strong> combustible materials in <strong>the</strong> plant areas.<br />
There are fire drills conducted by <strong>the</strong> on-site fire brigade, jointly with designated<br />
<strong>operational</strong> staff, on a yearly basis. However, during <strong>the</strong> <strong>team</strong> <strong>review</strong>, <strong>the</strong> drill scheduling<br />
did not ensure equal opportunities for all shift crews <strong>to</strong> take part within a specific period<br />
<strong>of</strong> time. The <strong>team</strong> encourages <strong>the</strong> plant <strong>to</strong> consider better scheduling <strong>of</strong> joint fire drills.<br />
3.7 MANAGEMENT OF ACCIDENT CONDITIONS<br />
There are clearly described roles and responsibilities during emergency situations at <strong>the</strong><br />
plant. The shift personnel are regularly trained <strong>to</strong> cope with plant accident conditions on<br />
realistic scenarios during full-scope simula<strong>to</strong>r training. The event-based abnormal<br />
operating procedures, symp<strong>to</strong>m-based emergency procedures and severe accident<br />
management guidelines (SAMG) are developed and implemented with plant staff being<br />
adequately trained on <strong>the</strong>ir use.<br />
There is clear link between symp<strong>to</strong>m-based emergency procedures and severe accident<br />
management guidelines. SAMG are supported by <strong>the</strong> necessary hardware installations, so<br />
<strong>the</strong> plant can efficiently cope with beyond design basis accidents. In addition, a technical<br />
handbook (THAL) has been developed for <strong>the</strong> senior management level, <strong>to</strong> manage<br />
severe plant conditions.<br />
The shift crew is supported by an on-call engineer on duty and supporting emergency<br />
groups. The use <strong>of</strong> emergency procedures is practiced by <strong>the</strong> shift crew during <strong>the</strong> first<br />
day <strong>of</strong> each seven week shift cycle. There are regular monthly drills provided <strong>to</strong><br />
engineers on duty and annual site emergency drills with activation <strong>of</strong> <strong>the</strong> whole plant<br />
emergency organization. However, <strong>the</strong> shift crew composition can be, in some<br />
emergency cases, inadequate – see chapter 3.1 Organization and Functions.<br />
There is a comprehensive database with technical information on unit conditions<br />
available <strong>to</strong> supporting groups throughout <strong>the</strong> plant computer network application.<br />
Several independent communication means are available <strong>to</strong> shift personnel and<br />
supporting plant personnel.<br />
32<br />
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DETAILED OPERATIONS FINDINGS<br />
3.1 ORGANIZATION AND FUNCTION<br />
3.1(1) Issue: The plant has not been in a position <strong>to</strong> demonstrate on which basis <strong>the</strong><br />
minimum <strong>team</strong> has been sized.<br />
The <strong>team</strong> observed <strong>the</strong> following facts during <strong>the</strong> <strong>review</strong>:<br />
• During a 2006 incident, <strong>the</strong> shift supervisor requested <strong>the</strong> support <strong>of</strong> three<br />
opera<strong>to</strong>rs from Unit 2 according <strong>to</strong> <strong>the</strong> procedure (First Check) if <strong>the</strong><br />
supervisor identifies <strong>the</strong> need <strong>of</strong> extra personnel due <strong>to</strong> insufficient staff in a<br />
field (Electrical Field Opera<strong>to</strong>r)<br />
• In some situations where actions have <strong>to</strong> be performed in <strong>the</strong> switchyard<br />
and/or in <strong>the</strong> controlled area simultaneously with a fire, <strong>the</strong> existing staff can<br />
not perform all necessary actions.<br />
• There is no permanent independent evaluation <strong>of</strong> unit <strong>safety</strong> parameters during<br />
abnormal conditions,<br />
• No actual basis for <strong>the</strong> sizing <strong>of</strong> <strong>the</strong> existing shift <strong>team</strong> could be located.<br />
In such situations where multiple units could be affected (e.g. general black out) or with<br />
<strong>the</strong> complication <strong>of</strong> one incident combined with a fire, <strong>the</strong> plant would face difficulties in<br />
safely managing each unit.<br />
Recommendation: The plant should perform an analysis and based on <strong>the</strong> result <strong>of</strong> <strong>the</strong><br />
analysis define <strong>the</strong> size <strong>of</strong> <strong>the</strong> minimum shift staff complement taking in<strong>to</strong> account<br />
abnormal operation scenarios involving fire and accident conditions.<br />
Basis: NS-G-2.2 ; par I.38. Plant staffing<br />
The plant personnel required <strong>to</strong> be on duty for <strong>the</strong> various <strong>operational</strong> states should be<br />
specified and shall be sufficient <strong>to</strong> implement <strong>the</strong> necessary emergency procedures. The<br />
minimum staffing required for <strong>the</strong> control room should be stated, including <strong>the</strong> necessary<br />
qualifications for <strong>the</strong>ir duties.<br />
NS-G-2.4; par 6.14, Staffing arrangements should take in<strong>to</strong> account:<br />
• <strong>the</strong> minimum number <strong>of</strong> persons necessary for performing all functions with<br />
respect <strong>to</strong> plant operation and emergency situations, with a view <strong>to</strong> avoiding<br />
excessive loads being placed on individuals;<br />
• <strong>the</strong> need, particularly in <strong>the</strong> case <strong>of</strong> remotely located plants, for adequate<br />
expertise, special equipment and spare parts <strong>to</strong> be available locally for dealing<br />
with emergency situations until such time as <strong>the</strong>y are augmented from <strong>of</strong>f-site<br />
sources;<br />
NS-G-2.14, Conduct <strong>of</strong> Operations, Personnel Resources and Qualification<br />
par. 2.10. The operations manager should ensure that an adequate number <strong>of</strong> competent<br />
staff is available at all times <strong>to</strong> operate <strong>the</strong> plant safely in both normal and abnormal<br />
plant conditions. There should be sufficient numbers <strong>of</strong> <strong>operational</strong> staff, so that <strong>the</strong>y<br />
may be periodically released <strong>to</strong> meet training and development requirements. A long<br />
term staff succession plan should be in place, supported by career development <strong>review</strong>s,<br />
associated action plans and recruitment plans. These <strong>review</strong>s should aim <strong>to</strong> foster<br />
continuous improvement and learning.<br />
par 2.11. The shift crews should be staffed in a way that <strong>the</strong>re is a sufficient number <strong>of</strong><br />
authorized opera<strong>to</strong>rs and o<strong>the</strong>r staff for <strong>the</strong> reliable accomplishment <strong>of</strong> assigned tasks<br />
based on normal and abnormal operation scenarios which consider also fire and accident<br />
33<br />
OPERATIONS
conditions. Special attention should be paid <strong>to</strong> ensure that staffing levels provide<br />
adequate redundancy and diversity <strong>of</strong> <strong>the</strong> competence needed both in normal and<br />
abnormal situations.<br />
3.3 OPERATING RULES AND PROCEDURES<br />
3.3(a) Good Practice – Computerized Moni<strong>to</strong>ring <strong>of</strong> Safety Functions (BSF) and<br />
Operating Status Checks (DDK)<br />
How does it work?<br />
BSF - The computer compiles <strong>the</strong> status <strong>of</strong> <strong>safety</strong> systems using pre-defined parameters<br />
and limits. When a deviation in <strong>the</strong> BSF exists, an audible alarm is actuated and an alarm<br />
annuncia<strong>to</strong>r identifies <strong>the</strong> issue <strong>to</strong> <strong>the</strong> operating staff. The BSF-panel is divided in<strong>to</strong> five<br />
function-areas and is presented by each train:<br />
• Reactivity A B C D<br />
• Core cooling A B C D<br />
• Barriers A B C D<br />
• Heat sink A B C D<br />
• Electrical systems A B C D<br />
DDK - The computer also has a function <strong>to</strong> check parameters against plant status. There<br />
are more than 700 parameters checked within this program. Deviations are identified on a<br />
computer screen. Six plant modes are available:<br />
• Check before start-up<br />
• Check before 100 °C<br />
• Check before 286 °C<br />
• Check before 8%<br />
• Check before 54%<br />
• Check at 108%<br />
Who can use it?<br />
When an alarm is indicated by <strong>the</strong> BSF <strong>the</strong> opera<strong>to</strong>r is made aware <strong>of</strong> a deviation from<br />
normal status. The opera<strong>to</strong>r can <strong>the</strong>n quickly check where <strong>the</strong> specific deviation exists.<br />
The DDK is used at least once every day and is presented <strong>to</strong> operations management<br />
during <strong>the</strong> daily <strong>review</strong> meeting. When complemented with results <strong>of</strong> surveillance<br />
tests recorded in FENIX, it is also used prior <strong>to</strong> changing <strong>the</strong> reac<strong>to</strong>r <strong>operational</strong> mode<br />
<strong>to</strong> ensure compliance with Operational Limits and Conditions and that all <strong>operational</strong><br />
parameters are within normal limits.<br />
What improvements are achieved?<br />
The BSF indication provides an easy way <strong>to</strong> check deviations that might exist with<br />
<strong>safety</strong> systems and <strong>to</strong> determine which functions may be threatened. The DDK make it<br />
easy <strong>to</strong> have an overall check that all parameters are within expected values and<br />
limits. Safety parameters can be checked in a few seconds.<br />
3.3(1) Issue: The control and <strong>review</strong> process <strong>of</strong> <strong>operational</strong> documentation,<br />
emergency preparedness procedures and opera<strong>to</strong>rs aids at <strong>the</strong> plant is not rigorously<br />
applied.<br />
The <strong>team</strong> observed <strong>the</strong> following facts during <strong>the</strong> <strong>review</strong>:<br />
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OPERATIONS
• The periodical <strong>review</strong>s <strong>of</strong> plant drawings posted in field locations are not evident.<br />
o There is a periodic check-up <strong>of</strong> drawings every 6 month, but <strong>the</strong> field<br />
observations identified drawings more than 20 years old in F3 MCR without<br />
any record <strong>of</strong> periodical <strong>review</strong> appearing on <strong>the</strong> drawing.<br />
o There was <strong>the</strong> procedure No. 1.962 A which includes <strong>the</strong> copy <strong>of</strong> two extra<br />
drawings at F1, DG A control room. The drawings were obviously very old,<br />
<strong>the</strong>y were authorized many years ago and never <strong>review</strong>ed since; in some parts<br />
<strong>the</strong>y were not clear enough <strong>to</strong> read.<br />
• There were several sets <strong>of</strong> unit <strong>operational</strong> drawings distributed in <strong>the</strong> plant. These<br />
locations include areas like <strong>the</strong> MCR, MCR meeting room, work authorization<br />
area, etc. In <strong>the</strong> F1 <strong>operational</strong> department administration area <strong>the</strong>re was one set <strong>of</strong><br />
drawings in <strong>the</strong> rack, <strong>the</strong> rack was labelled as uncontrolled documentation.<br />
However, <strong>the</strong> drawings were not marked as uncontrolled copies and could be<br />
mixed with controlled copies in o<strong>the</strong>r unit work places.<br />
• There is a list <strong>of</strong> drawings required at some workplaces (F3, DG B control room),<br />
however, <strong>the</strong>re is no list <strong>of</strong> <strong>operational</strong> procedures required in <strong>the</strong>se workplaces.<br />
• Some <strong>of</strong> <strong>the</strong> controlled documents are out <strong>of</strong> date. For example:<br />
o Allman del, Ansvar, Organisation och Verksamhet, Kärnkraftverkens<br />
Gemensamma Beredskapsstyrka (“Support from o<strong>the</strong>r plants”), last updated<br />
2004-06-24, contains phone numbers (home, mobile, work) <strong>of</strong> persons who<br />
retired. This is apparently an obsolete version that has not been replaced by <strong>the</strong><br />
current version from 2006.<br />
o Operativa Stöddokument F1/2, contains mention “shall be updated by 2007-<br />
12-31”<br />
o Beredskap planerade övningar och utbildningar 2007 “calendar <strong>of</strong> training and<br />
exercises for 2007”.<br />
• Phone list is more than seven months old, yet <strong>the</strong> phone numbers should be<br />
checked twice a year.<br />
o Document Operative pärm, updated in 2007-06-08<br />
o Note that <strong>the</strong> numbers in this document may be correct, <strong>the</strong> date on <strong>the</strong><br />
document has not been changed each time <strong>the</strong> phone numbers were checked.<br />
• Some <strong>of</strong> <strong>the</strong> controlled documents contain handwritten corrections without initials<br />
and <strong>the</strong>y are not captured in <strong>the</strong> electronic version. For example Document F-I-315<br />
Rev 2, 2006-12-28, page 8. “Procedure for operation <strong>of</strong> equipment”.<br />
• There were unauthorized opera<strong>to</strong>rs aids (diagrams) observed attached <strong>to</strong> <strong>the</strong> panels<br />
at plant MCRs. Although some <strong>of</strong> <strong>the</strong>m were <strong>the</strong> copies <strong>of</strong> <strong>the</strong> part <strong>of</strong> <strong>the</strong> latest<br />
version <strong>of</strong> SAR (Safety Analysis <strong>Report</strong>) or o<strong>the</strong>r procedures, <strong>the</strong>y were obviously<br />
uncontrolled documentation.<br />
• Numerous opera<strong>to</strong>rs’ aids (pink sheets on cardboard) with no obvious authorization<br />
were observed in room 1D02.41 (11-414-P1 and 12-414-P3).<br />
The use <strong>of</strong> uncontrolled or unauthorized <strong>operational</strong> documentation can lead <strong>to</strong><br />
<strong>operational</strong> events due <strong>to</strong> referencing <strong>of</strong> incorrect or out-<strong>of</strong>-date information.<br />
Recommendation: The plant should rigorously apply <strong>the</strong> control and <strong>review</strong> process <strong>of</strong><br />
<strong>operational</strong> documentation, emergency preparedness procedures and opera<strong>to</strong>rs aids.<br />
Basis: NS-G-2.4, The Operating Organisation for NPPs, par. 6.75. Documentation<br />
should be controlled in a consistent, compatible manner throughout <strong>the</strong> plant and <strong>the</strong><br />
operating organization. This includes <strong>the</strong> preparation, change, <strong>review</strong>, approval, release<br />
and distribution <strong>of</strong> documentation. Lists and procedures for <strong>the</strong>se functions should be<br />
prepared and controlled.<br />
DS347 Draft 3 – Conduct <strong>of</strong> Operations, par. 6.17. The opera<strong>to</strong>r aids control system<br />
should prevent <strong>the</strong> use <strong>of</strong> unauthorized opera<strong>to</strong>r aids and o<strong>the</strong>r supportive materials such<br />
35<br />
OPERATIONS
as unauthorized instructions or labels <strong>of</strong> any kind on <strong>the</strong> equipment, local panels, boards<br />
and measurement devices within <strong>the</strong> work areas. The aids should be placed in close<br />
proximity <strong>to</strong> where <strong>the</strong>y are expected <strong>to</strong> be used and posted aids should not obscure<br />
instruments or controls.<br />
par. 6.18. The control system for opera<strong>to</strong>r aids should ensure that opera<strong>to</strong>r aids contain<br />
correct information, which has been <strong>review</strong>ed and approved by a competent authority. In<br />
addition all opera<strong>to</strong>r aids should be <strong>review</strong>ed periodically <strong>to</strong> determine if <strong>the</strong>y are still<br />
needed, if <strong>the</strong> information in <strong>the</strong>m has changed or been updated, or if <strong>the</strong>y should be<br />
permanently incorporated in some manner.<br />
3.4 CONDUCT OF OPERATION<br />
3.4(1) Issue: Although <strong>the</strong> plant has a plan <strong>to</strong> improve <strong>the</strong> conduct <strong>of</strong> surveillance test<br />
procedures, some additional changes can be applied.<br />
The <strong>team</strong> observed <strong>the</strong> following facts during <strong>the</strong> <strong>review</strong>:<br />
• The final acceptance or non-acceptance <strong>of</strong> surveillance test results should be<br />
noted by a responsible operation’s staff member on<strong>to</strong> <strong>the</strong> test cover sheet.<br />
However, currently no clear acceptance criteria are provided on <strong>the</strong> test cover<br />
sheet or surveillance test procedure.<br />
• Surveillance test procedures are step by step procedures with an expectation<br />
each step be signed by <strong>the</strong> responsible individual immediately following<br />
completion <strong>of</strong> <strong>the</strong> step. However:<br />
o no responsible individual is designated <strong>to</strong> conduct each step in <strong>the</strong><br />
surveillance test procedure.<br />
o a summary <strong>of</strong> which staff members are necessary <strong>to</strong> conduct <strong>the</strong><br />
o<br />
surveillance test is not provided.<br />
most <strong>of</strong> <strong>the</strong> procedures do not use <strong>the</strong> table format, so in some cases <strong>the</strong><br />
signature does not clearly indicate which step was actually conducted.<br />
• The test No. 14.10.1.040A <strong>to</strong> check <strong>the</strong> au<strong>to</strong>matic back-up for system No. 576<br />
consists <strong>of</strong> two independent procedures, one for maintenance and one for<br />
operations personnel. There are no links included in <strong>the</strong>se procedures <strong>to</strong> ensure<br />
good work coordination between involved personnel.<br />
• During <strong>the</strong> test <strong>of</strong> system No. 1 320-1 <strong>the</strong> opera<strong>to</strong>r checked, verified and<br />
cleared <strong>the</strong> summary alarm indications <strong>of</strong> unit critical <strong>safety</strong> functions placed<br />
in <strong>the</strong> 1KA8 panel. However, <strong>the</strong>se steps were not mentioned in <strong>the</strong><br />
surveillance test procedure.<br />
Precise, detailed and unique surveillance test procedures with clearly identified<br />
acceptance criteria can ensure that potential human failures are avoided during <strong>the</strong> test<br />
conduct and acceptability <strong>of</strong> <strong>the</strong> test results is uniquely verified by responsible personnel.<br />
Suggestion: The plant should consider fur<strong>the</strong>r detailed improvements <strong>to</strong> <strong>the</strong> surveillance<br />
test procedures in addition <strong>to</strong> <strong>the</strong> planned improvements.<br />
Basis: NS-G-2.4 – Conduct <strong>of</strong> Operations, par. 5.19. Departments o<strong>the</strong>r than <strong>the</strong><br />
operations department may be assigned responsibilities by <strong>the</strong> plant <strong>to</strong> develop <strong>the</strong><br />
individual surveillance test procedures, specify <strong>the</strong> appropriate frequency <strong>of</strong> testing,<br />
complete some <strong>of</strong> <strong>the</strong> testing and identify acceptance criteria. The operations department<br />
should be responsible for <strong>the</strong> scheduling and accomplishment <strong>of</strong> tests that involve<br />
equipment operation, <strong>of</strong> <strong>the</strong> <strong>review</strong> <strong>of</strong> completed test reports <strong>to</strong> ensure completeness and<br />
<strong>of</strong> verification that <strong>the</strong> test results meet <strong>the</strong> approved acceptance criteria.<br />
Surveillance results should be <strong>review</strong>ed for long term trends that may indicate a<br />
deteriorating situation.<br />
36<br />
OPERATIONS
NS-G-2.6 – Maintenance, Surveillance and In-service Inspection in Nuclear Power<br />
Plants, par. 5.3. Acceptance criteria and actions <strong>to</strong> be taken if acceptance criteria cannot<br />
be met should be clearly specified in <strong>the</strong> procedures.<br />
3.6 FIRE PREVENTION AND PROTECTION PROGRAMME<br />
3.6(a) Good Practice – Effective management <strong>of</strong> fire cells<br />
Fire cells moni<strong>to</strong>ring - Fire cells divide <strong>the</strong> unit in<strong>to</strong> separate compartments in order <strong>to</strong><br />
prevent <strong>the</strong> spread <strong>of</strong> fire and fumes. In order <strong>to</strong> moni<strong>to</strong>r <strong>the</strong> integrity <strong>of</strong> <strong>the</strong> fire cells,<br />
each door in <strong>the</strong> fire cell is moni<strong>to</strong>red and an alarm is tripped if a door is open <strong>to</strong>o long.<br />
(Fig. 1) This feature ensures a high standard for fire cells integrity, even during outage.<br />
Anyone who is in <strong>the</strong> plant and discovers an open fire cell door must close it. If this is<br />
not possible, <strong>the</strong> Shift Supervisor must be informed immediately.<br />
Fire cells service openings - During work, service openings are used whenever possible.<br />
When in use <strong>the</strong>se are sealed by seal bags specially designed for this purpose. (Fig. 2)<br />
This feature ensures that <strong>the</strong> fire cells are closed even during work in plant<br />
(Fig. 1) (Fig. 2)<br />
Adaptive Fire Alarm Detec<strong>to</strong>rs - The fire alarm detec<strong>to</strong>rs system can be adapted (with<br />
increased or reduced sensitivity) <strong>to</strong> <strong>the</strong> actual work situation in specific plant rooms.<br />
Changes can be accomplished via a PC s<strong>of</strong>tware application, e.g.: when hot work is<br />
performed or a transportation vehicle enters in<strong>to</strong> <strong>the</strong> plant. The fire alarm detec<strong>to</strong>rs are<br />
always ready <strong>to</strong> moni<strong>to</strong>r fire status; <strong>the</strong>re is no need <strong>to</strong> switch <strong>the</strong>m <strong>of</strong>f completely. The<br />
sensitivity <strong>of</strong> <strong>the</strong> fire alarm moni<strong>to</strong>ring system is specified by <strong>the</strong> fire protection foreman<br />
when issuing <strong>the</strong> directive for fire protection measures as part <strong>of</strong> work authorisation<br />
process.<br />
3.6(1) Issue: The plant did not establish and implement <strong>the</strong> appropriate controls <strong>to</strong><br />
manage <strong>the</strong> amount <strong>of</strong> combustible materials (fire loads) in <strong>the</strong> plant areas.<br />
The <strong>team</strong> observed <strong>the</strong> following facts during <strong>the</strong> <strong>review</strong>:<br />
• There are regular walk-downs by on-site fire brigade personnel in order <strong>to</strong><br />
check <strong>the</strong> fire load in <strong>the</strong> plant areas. In general, acceptable fire loading was<br />
observed in <strong>the</strong> plant areas; however, <strong>the</strong> current general fire load rule (max 25<br />
l <strong>of</strong> combustible liquid in <strong>the</strong> room) is not strictly applied:<br />
o <strong>the</strong>re is no limitation for non-liquid flammable materials<br />
o 200 l oil drum and 200 l drum with glycol were s<strong>to</strong>red in <strong>the</strong> unit 1, DG A<br />
37<br />
OPERATIONS
and C rooms<br />
o significant amounts <strong>of</strong> paper documents and o<strong>the</strong>r combustible materials<br />
were placed at work places at <strong>the</strong> back side <strong>of</strong> unit 1 MCR<br />
• In several plant areas <strong>the</strong> <strong>team</strong> observed no compliance with <strong>the</strong> plant policy<br />
which gives limitation <strong>to</strong> <strong>the</strong> s<strong>to</strong>rage <strong>of</strong> combustible liquids in <strong>the</strong> fire cells,<br />
recommends <strong>to</strong> unpack equipments or consumables before taking <strong>the</strong>m in<strong>to</strong> <strong>the</strong><br />
controlled area (wood, plastic and paper packaging, …)<br />
Without clear fire load limits for plant areas <strong>the</strong> control <strong>of</strong> combustible materials will not<br />
be effective.<br />
Recommendation: The plant should establish and implement <strong>the</strong> appropriate control <strong>of</strong><br />
fire loads, especially in <strong>the</strong> areas containing <strong>the</strong> <strong>safety</strong> systems.<br />
Basis: NS-G-2.1 Fire Safety in <strong>the</strong> Operation <strong>of</strong> NPPs, par. 2.12. “Procedures should be<br />
established for <strong>the</strong> purpose <strong>of</strong> ensuring that amounts <strong>of</strong> combustible materials (<strong>the</strong> fire<br />
load) and <strong>the</strong> numbers <strong>of</strong> ignition sources be minimized in areas containing items<br />
important <strong>to</strong> <strong>safety</strong> and in adjacent areas that may present a risk <strong>of</strong> exposure <strong>to</strong> fire for<br />
items important <strong>to</strong> <strong>safety</strong>.”<br />
par. 6.5. “Administrative controls should be established and implemented <strong>to</strong> ensure that<br />
areas important <strong>to</strong> <strong>safety</strong> are inspected periodically in order <strong>to</strong> evaluate <strong>the</strong> general fire<br />
loading and plant housekeeping conditions, and <strong>to</strong> ensure that means <strong>of</strong> exit and access<br />
routes for manual fire fighting are not blocked. Administrative controls should also be<br />
effected <strong>to</strong> ensure that <strong>the</strong> actual fire load is kept within permissible limits.”<br />
38<br />
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4. MAINTENANCE<br />
4.1 ORGANISATION AND FUNCTIONS<br />
The maintenance policies <strong>of</strong> <strong>Forsmark</strong> are clearly stated in an instruction and are suitably<br />
distributed <strong>to</strong> all maintenance workers.<br />
Appropriate goals, objectives and performance indica<strong>to</strong>rs are established for maintenance<br />
and improved performance has resulted. The indica<strong>to</strong>rs include <strong>safety</strong>, production<br />
results, productive upgrades and organizational effects.<br />
Evaluating and revising <strong>the</strong> policy can be undertaken in accordance with a specific<br />
instruction.<br />
Maintenance programmes are adequate and maintained current with industry practices<br />
and are based on suppliers/manufacturers recommendations, experience from operation,<br />
maintenance and experience from o<strong>the</strong>r Swedish nuclear power plants.<br />
The Maintenance Department is staffed by highly motivated, qualified and experienced<br />
personnel. The department is led by <strong>the</strong> Maintenance Manager and <strong>the</strong>re are over 200<br />
full time employees which is considered sufficient for <strong>the</strong> role <strong>of</strong> <strong>the</strong> department. This<br />
number increases <strong>to</strong> approximately 800 personnel during an outage. The department has<br />
seven sections for <strong>the</strong> following functions: Electrical, Installation Workshop & Technical<br />
Service, I&C, Mechanical, Planning, Radiation Protection & Industrial Safety and<br />
Maintenance engineering. The responsibilities and authorities within <strong>the</strong> maintenance<br />
sections are clearly defined in an instruction. There is a commitment <strong>to</strong> sustain and<br />
develop <strong>safety</strong> culture within <strong>the</strong> department.<br />
There is an interface between all <strong>the</strong> Swedish nuclear power plants on various<br />
maintenance activities. This is well defined and is working well on a number <strong>of</strong> fronts<br />
including <strong>the</strong> exchange <strong>of</strong> information regarding component faults.<br />
The interface between operations and maintenance is well established and meetings are<br />
held regularly such as <strong>the</strong> daily planning meeting and various outage meetings. A formal<br />
maintenance-operations agreement meeting is scheduled annually.<br />
The interface with contrac<strong>to</strong>rs is effective and is structured in an effective manner. The<br />
plant has many years <strong>of</strong> experience with <strong>the</strong> contrac<strong>to</strong>rs such as ISS (technical support),<br />
Westinghouse (reac<strong>to</strong>r service, I&C), and Als<strong>to</strong>m (turbine services).<br />
The qualification and experience level requirements for <strong>the</strong> maintenance staff are<br />
adequately described in <strong>the</strong> document which contains <strong>the</strong> training programme for<br />
maintenance contrac<strong>to</strong>rs and plant personnel. Contrac<strong>to</strong>rs comply with <strong>the</strong>se plant<br />
instructions concerning <strong>the</strong> qualification <strong>of</strong> <strong>the</strong>ir staff and consultants. Contrac<strong>to</strong>rs<br />
undergo <strong>the</strong> same basic training as plant personnel. The pr<strong>of</strong>iciency <strong>of</strong> all staff is<br />
determined by <strong>the</strong> supervisor and managers on a regular basis.<br />
The maintenance staff clearly demonstrated that <strong>the</strong>y possessed a very good working<br />
knowledge <strong>of</strong> current practices and procedures.<br />
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4.2 MAINTENANCE FACILITIES AND EQUIPMENT<br />
The current maintenance facilities have been recognized by <strong>the</strong> plant <strong>to</strong> have limitations<br />
with respect <strong>to</strong> space. A new 2000 m2 workshop and s<strong>to</strong>rage facility is under<br />
construction where diesels and large pumps can be maintained. It will be ready for use in<br />
<strong>the</strong> autumn <strong>of</strong> 2008.<br />
The LWR-Centre in Västerås has training facilities (with mock-ups) for maintenance<br />
personnel, particularly with respect <strong>to</strong> <strong>the</strong> main circulation pumps and reac<strong>to</strong>r inner parts.<br />
There is also a maintenance training centre in Barsebäck where training for employees<br />
and contrac<strong>to</strong>rs will commence in March 2008.<br />
Tools and equipment are maintained when <strong>the</strong>y are returned after use if required. Plant<br />
components removed are only maintained if it is economically viable <strong>to</strong> perform <strong>the</strong><br />
maintenance. Plant equipment is controlled and segregated <strong>to</strong> prevent its use if it is<br />
unserviceable.<br />
Measuring and test equipment are adequately calibrated and controlled <strong>to</strong> ensure<br />
accuracy and traceability.<br />
Decontamination <strong>of</strong> components is performed in <strong>the</strong> decontamination centre e.g.<br />
gasblasting for main circulation pumps cleaning, ultrasonics for smaller non-greasy parts,<br />
chemical and brush cleaning <strong>of</strong> reac<strong>to</strong>r main flange bolts.<br />
Remote controlled equipment is used for <strong>the</strong> welding machine for operation inside pipes,<br />
a remote controlled TV robot for inspection on <strong>the</strong> inside <strong>of</strong> pipes and clamshell<br />
equipment for cutting pipes. This is considered satisfac<strong>to</strong>ry.<br />
Chemicals used by maintenance are approved and classified according <strong>to</strong> a specific<br />
instruction and are classified and labelled in<strong>to</strong> five groups. Chemicals are s<strong>to</strong>red in<br />
appropriate lockers.<br />
The register for <strong>to</strong>ols is connected <strong>to</strong> <strong>the</strong> maintenance system. This allows <strong>the</strong><br />
opportunity <strong>to</strong> check which <strong>to</strong>ol has been used in every specific occasion and if <strong>the</strong><br />
reference <strong>to</strong>ol is calibrated at <strong>the</strong> correct interval. The <strong>team</strong> considers this as a good<br />
performance.<br />
4.3 MAINTENANCE PROGRAMMES<br />
The correct balance <strong>of</strong> resources is assigned <strong>to</strong> each facet <strong>of</strong> <strong>the</strong> maintenance programme<br />
and management allocates resources according <strong>to</strong> <strong>the</strong> needs <strong>of</strong> this programme. The<br />
scope and frequencies associated with <strong>the</strong> preventative maintenance programme are<br />
based on <strong>the</strong> appropriate regula<strong>to</strong>ry guidance, supplier recommendations, operation and<br />
maintenance experience and industry experience. Regula<strong>to</strong>ry requirements are contained<br />
in <strong>the</strong> associated SKI regulations.<br />
Activities, in <strong>the</strong> main, are completed in a timely manner and extensions are only granted<br />
when authorized by management. They are tracked using <strong>the</strong> FENIX maintenance<br />
management database. All information on completed activities is transferred <strong>to</strong> <strong>the</strong> plant<br />
archives.<br />
If <strong>the</strong>re is lack <strong>of</strong> resources, <strong>the</strong> list <strong>of</strong> priorities <strong>of</strong> <strong>the</strong> president is used by <strong>the</strong> managers<br />
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<strong>to</strong> allocate fur<strong>the</strong>r resources.<br />
The effectiveness <strong>of</strong> <strong>the</strong> programme is periodically evaluated by management and<br />
upgraded based on experience.<br />
Maintenance his<strong>to</strong>ry records are accurate and kept up <strong>to</strong> date. Managers approve<br />
completed work before <strong>the</strong> measure is archived.<br />
The effectiveness <strong>of</strong> <strong>the</strong> predictive maintenance programme in improving equipment<br />
reliability and availability is periodically <strong>review</strong>ed. The maintenance system is kept<br />
current with respect <strong>to</strong> internal experience and external contrac<strong>to</strong>rs' experience.<br />
Identified equipment degradation is reported promptly for correction. When equipment<br />
degradation is detected, a corrective maintenance work order is initiated according <strong>to</strong> <strong>the</strong><br />
appropriate procedure.<br />
Good predictive maintenance techniques are used and <strong>the</strong>se are comparable with industry<br />
practice. These include fixed vibration moni<strong>to</strong>ring which is used for <strong>the</strong> main circulation<br />
pumps, turbines and genera<strong>to</strong>rs, portable vibration moni<strong>to</strong>ring which is used for rotating<br />
equipment such as pumps and mo<strong>to</strong>rs, <strong>the</strong>rmographic moni<strong>to</strong>ring which is used for <strong>the</strong><br />
identification <strong>of</strong> hot surfaces, <strong>the</strong>rmal and water leakages and oil samples taken for<br />
example from <strong>the</strong> turbine lubrication system, transformers and <strong>the</strong> feed water pumps<br />
systems.<br />
The plant uses REM (reliability experience maintenance) which is a systematic analysis<br />
which takes experience in<strong>to</strong> account regarding <strong>the</strong> maintenance <strong>of</strong> equipment.<br />
The principles, methods and assessment procedures is <strong>review</strong>ed by SKI and is in<br />
accordance with its directives as contained in <strong>the</strong> Regulation Code <strong>of</strong> <strong>the</strong> Swedish<br />
Nuclear Power Inspec<strong>to</strong>rate regarding mechanical devices in Nuclear Facilities. The<br />
Swedish utilities have, in a cooperation programme, interpreted <strong>the</strong> code in<strong>to</strong> a series <strong>of</strong><br />
documents called PAKT, where <strong>the</strong> requirements are described in more detail. <strong>Forsmark</strong><br />
has produced its own instructions from <strong>the</strong>se documents. The production units are<br />
responsible for <strong>the</strong> application <strong>of</strong> <strong>the</strong> requirements.<br />
A number <strong>of</strong> procedures exist which adequately describe <strong>the</strong> necessary actions <strong>to</strong> be<br />
taken.<br />
Mechanical devices are qualitatively classified at <strong>Forsmark</strong> in<strong>to</strong> three inspection groups<br />
(A, B & C) for directing <strong>the</strong> extent and aim <strong>of</strong> <strong>the</strong> in-service inspection, as required by<br />
<strong>the</strong> Code. There is also a Group F for prescribed inspection areas.<br />
The Code states that <strong>the</strong> non-destructive testing <strong>of</strong> <strong>the</strong> reac<strong>to</strong>r vessel and mechanical<br />
devices which are in inspection group F, A and B shall be carried out with inspection<br />
systems which are qualified <strong>to</strong> detect, characterize and also size <strong>the</strong> defect. The licensee<br />
shall attend so that such qualification is supervised by a body which has an independent<br />
and neutral position and <strong>the</strong> necessary competence. The Swedish utilities founded SQC<br />
(Swedish Qualification Centre) for this purpose and are <strong>the</strong>refore self-accredited. This is<br />
approved by SKI.<br />
The results <strong>of</strong> ISI (In Service Inspections) can ei<strong>the</strong>r be in <strong>the</strong> form <strong>of</strong> a pro<strong>to</strong>col or a<br />
report. The document describes all <strong>the</strong> existing basis and conditions for <strong>the</strong> inspection<br />
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and <strong>the</strong> results <strong>of</strong> <strong>the</strong> inspection. All NDE (Non-Destructive Examination) reports at <strong>the</strong><br />
plant are <strong>review</strong>ed by a Level III competent person.<br />
If <strong>the</strong> labora<strong>to</strong>ry reports an indication over <strong>the</strong> acceptance limit, <strong>the</strong>n sizing and<br />
characterization <strong>of</strong> <strong>the</strong> defect is commenced. Decisions are <strong>the</strong>n taken on whe<strong>the</strong>r <strong>to</strong><br />
repair or not, time schedules etc. If a failure is discovered during operation, <strong>the</strong>n actions<br />
<strong>to</strong> be taken are immediately discussed between all concerned parties.<br />
The frequencies <strong>of</strong> inspections are based on structural integrity analyses. A<br />
computerized aid is now used <strong>to</strong> determine <strong>the</strong>se frequencies.<br />
The plant has its own limit on <strong>the</strong> number <strong>of</strong> corrective maintenance work backlogs<br />
which is less than 1000 work orders per unit. Currently, Unit one is above this figure and<br />
corrective actions around this issue are ongoing.<br />
As Guides for identification <strong>of</strong> ageing degradations, <strong>Forsmark</strong> uses NRC Gall reports,<br />
EPRI documents, Westinghouse documents and information from OEM (Original<br />
Equipment Manufacturing), mainly ABB. All individually applied mechanism are<br />
<strong>the</strong>reafter <strong>review</strong>ed by a <strong>team</strong> <strong>of</strong> specialist for each main group, building (concrete,<br />
concrete reinforcement etc.) mechanical (rubber, plastic, copper, aluminium etc) and<br />
electrical/I&C (copper aluminium, PVC, rubber, plastic etc).<br />
Information on components which are susceptible <strong>to</strong> ageing is compiled. Only class 1-3<br />
components and electrical function class 1E or 2E are included. No differentiation is<br />
made between active or passive components and all <strong>safety</strong> components are analyzed.<br />
The plant has electrical power moni<strong>to</strong>ring for performance-based maintenance on<br />
isolation valves and control rod drives and <strong>team</strong> considered that this is good practice.<br />
The Maintenance Department has developed an Action Plan <strong>to</strong> enhance <strong>the</strong>ir activities.<br />
The Plan is based on analysis <strong>of</strong> <strong>the</strong> “60 point bullet list” developed after <strong>the</strong> 25/7/2006<br />
event, Root Cause Analysis conducted on underlying maintenance issues identified from<br />
<strong>the</strong> event and <strong>the</strong> results <strong>of</strong> three maintenance management seminars. The Action Plan is<br />
being progressed and includes activities <strong>to</strong> reduce <strong>the</strong> Technical documentation backlog,<br />
manage ageing <strong>of</strong> equipment and reduce <strong>the</strong> backlog <strong>of</strong> registering new equipment and<br />
including it in <strong>the</strong> preventive maintenance programme. It was noted that actions<br />
identified for maintenance from <strong>the</strong> “60 point bullet list” have been completed.<br />
4.4. PROCEDURES, RECORDS AND HISTORY<br />
A policy on <strong>the</strong> use <strong>of</strong> procedures exists and is implemented accordingly. Procedures,<br />
work instructions, and <strong>the</strong>ir revisions are properly controlled. The revision <strong>of</strong> instructions<br />
is undertaken every two years.<br />
A backlog <strong>of</strong> 380 maintenance document <strong>of</strong> grade 1 currently exists. A recovery<br />
programme is ongoing and <strong>the</strong> backlog is planned <strong>to</strong> diminish by June 2008. A project<br />
manager is in charge <strong>of</strong> this recovery project and he has a staff <strong>of</strong> up <strong>to</strong> fifteen<br />
experienced persons who work on this project part-time.<br />
The content <strong>of</strong> all o<strong>the</strong>r procedures <strong>review</strong>ed was found <strong>to</strong> be technically correct with<br />
clear acceptance criteria.<br />
Procedures for <strong>the</strong> preparation <strong>of</strong> work orders are clear, concise and contain adequate<br />
information. Procedures and work instructions are periodically updated according <strong>to</strong> <strong>the</strong><br />
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appropriate procedure and reflect in-house and industry operating experience.<br />
Temporary changes are adequately controlled and minimized. All changes are marked in<br />
<strong>the</strong> procedure/drawing and a satisfac<strong>to</strong>ry process is <strong>the</strong>n implemented <strong>to</strong> make <strong>the</strong><br />
required permanent change <strong>to</strong> <strong>the</strong> procedure/drawing.<br />
A sample <strong>of</strong> some maintenance his<strong>to</strong>ry files were <strong>review</strong>ed and found <strong>to</strong> be accurate,<br />
current and include sufficient detail for important plant systems and equipment. These<br />
his<strong>to</strong>rical records were easily retrievable and properly secured.<br />
4.5 CONDUCT OF MAINTENANCE WORK<br />
All <strong>the</strong> maintenance work which was <strong>review</strong>ed by <strong>the</strong> <strong>team</strong> was performed according <strong>to</strong><br />
<strong>the</strong> approved work orders and instructions by competent and pr<strong>of</strong>essional personnel.<br />
Adequate resources were available at all <strong>the</strong> worksites.<br />
Where work in <strong>the</strong> controlled area was undertaken, <strong>the</strong> plant programme for ALARA<br />
principles was used and put in<strong>to</strong> effect according <strong>to</strong> <strong>the</strong> relevant instruction.<br />
With regard <strong>to</strong> <strong>the</strong> number <strong>of</strong> fuel damage events at <strong>the</strong> plant, a FME (foreign material<br />
exclusion) programme was launched in 2001. The main goal <strong>of</strong> <strong>the</strong> FME programme was<br />
<strong>to</strong> reduce/eliminate <strong>the</strong> risk <strong>of</strong> getting foreign material in<strong>to</strong> <strong>the</strong> primary and turbine<br />
systems. Preventive actions include <strong>the</strong> installation <strong>of</strong> cyclone filters in <strong>the</strong> feed water<br />
system <strong>of</strong> unit 2. O<strong>the</strong>r initiatives include an Instruction on Cleanness Requirements for<br />
Work and Work Preparations and On-site Check list for FME preventive actions. Basic<br />
training on FME is given for all, available online and also used for training contrac<strong>to</strong>r<br />
maintenance personnel.<br />
The tagging system is used correctly and good <strong>safety</strong> practices are evident. Managers and<br />
supervisors effectively moni<strong>to</strong>r and guide work. Contrac<strong>to</strong>rs follow <strong>the</strong> plants’ controlled<br />
procedures and standards.<br />
Post maintenance/modification testing is carried out in a satisfac<strong>to</strong>ry manner.<br />
4.6 MATERIAL CONDITIONS<br />
The plant policy is that <strong>the</strong> material condition <strong>of</strong> <strong>the</strong> plant should be maintained in such a<br />
way that its safe, reliable and efficient operation can be ensured. Standards are identified<br />
satisfac<strong>to</strong>rily at <strong>the</strong> plant but <strong>the</strong> actual implementation <strong>of</strong> <strong>the</strong> required standards and<br />
instructions is not in accordance with management expectations.<br />
The <strong>team</strong> was made aware that two instances <strong>of</strong> through-wall leaks occurred on a system<br />
418 pipeline on Unit One, as a result <strong>of</strong> flow assisted corrosion, in December 2007 and<br />
January 2008. The pipeline had been inspected eight years ago and was programmed <strong>to</strong><br />
be inspected again in June 2008. The inspection <strong>of</strong> similar pipes was taken, repairs<br />
undertaken and per<strong>mission</strong> <strong>to</strong> restart <strong>the</strong> turbine was received from <strong>the</strong> third party control<br />
body. All pipework in this system for each unit will be inspected in <strong>the</strong> next scheduled<br />
outages.<br />
Regular system walkdowns by management are done <strong>to</strong> <strong>the</strong> power plant and work places.<br />
Walkdowns are scheduled and have a given frequency, depending on <strong>the</strong> position <strong>of</strong> <strong>the</strong><br />
manager.<br />
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A number <strong>of</strong> leaks were identified and some have been in existence and <strong>to</strong>lerated for a<br />
long period <strong>of</strong> time and <strong>the</strong> <strong>team</strong> made a suggestion in this area.<br />
4.7 WORK CONTROL<br />
Corrective and preventive work is efficiently planned and scheduled in <strong>the</strong> maintenance<br />
planning system FENIX. Three weeks before preventive maintenance work is <strong>to</strong> be<br />
carried out, <strong>the</strong> system au<strong>to</strong>matically generates a work order, including all related<br />
information that is required (calibration cards, material requisition for replacement parts<br />
etc).<br />
Authorizations required for implementation <strong>of</strong> <strong>the</strong> work are clearly described and printed<br />
in a separate form e.g. work permit/work authorization, radiation protection and<br />
industrial <strong>safety</strong> instruction and fire protection instruction.<br />
Work prioritizing is efficiently performed in <strong>the</strong> morning maintenance and operations<br />
meeting. Scheduling for daily preventive and corrective work is also done at this<br />
meeting.<br />
Temporary repairs are minimized with less than 5 temporary repairs being done annually.<br />
Outage planning is integrated in<strong>to</strong> <strong>the</strong> FENIX work control process.<br />
Contrac<strong>to</strong>rs are effectively managed by agreements.<br />
Suggestions for modifications are made by <strong>the</strong> production and maintenance unit.<br />
Modifications are <strong>review</strong>ed weekly at <strong>the</strong> maintenance meeting.<br />
ALARA is part <strong>of</strong> <strong>the</strong> planning and conduct <strong>of</strong> work. The Industrial <strong>safety</strong> and Radiation<br />
Protection Department is part <strong>of</strong> <strong>the</strong> maintenance unit.<br />
Post maintenance <strong>review</strong>s improve maintenance effectiveness. Audits are performed<br />
every year in different maintenance areas.<br />
4.8 SPARE PARTS AND MATERIALS<br />
The responsibility for procurement rests with <strong>the</strong> Service and Facilities Department on<br />
<strong>the</strong> request <strong>of</strong> <strong>the</strong> Maintenance Department. Receipt inspection is conducted initially by<br />
<strong>the</strong> contrac<strong>to</strong>r ISS <strong>to</strong> ensure that <strong>the</strong> correct quantity and that <strong>the</strong> correct product is<br />
received – <strong>the</strong> information is input in<strong>to</strong> <strong>the</strong> SAP R/3 program. Acceptance inspection is<br />
undertaken by <strong>the</strong> Spare Parts Officer and Quality Control <strong>to</strong> ensure that <strong>the</strong> correct<br />
functional and quality item is received and this information is also input in<strong>to</strong> SAP. No<br />
procedure currently exists for <strong>the</strong> job function <strong>of</strong> Spare Parts Officer and also no<br />
procedure for <strong>the</strong> repair <strong>of</strong> spare parts, o<strong>the</strong>r than I&C.<br />
The necessary technical and quality assurance standards are confirmed by this acceptance<br />
inspection process.<br />
It is considered that <strong>the</strong> control <strong>of</strong> receipt <strong>of</strong> spare parts is effectively and efficiently<br />
organized.<br />
Commercial grade parts go through a satisfac<strong>to</strong>ry process for certifying new spare parts.<br />
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Quality assessment is adequately applied in this process.<br />
Adequate material management facilities exist for <strong>the</strong> s<strong>to</strong>rage <strong>of</strong> spare parts. Fur<strong>the</strong>r<br />
s<strong>to</strong>rage facilities will be constructed during 2008 and 2009 in anticipation <strong>of</strong> s<strong>to</strong>ck level<br />
increases owing <strong>to</strong> <strong>the</strong> planned power upgrade modifications.<br />
A new s<strong>to</strong>rage strategy has been adopted for new spares from January 2008. Four levels<br />
(A, B, C&D) <strong>of</strong> s<strong>to</strong>rage environmental conditions have been formulated ranging from <strong>the</strong><br />
requirements for materials which are extremely sensitive <strong>to</strong> environmental influences (A)<br />
<strong>to</strong> Level D which is for materials which can be s<strong>to</strong>red outdoors.<br />
Upon receipt <strong>of</strong> a spare part, <strong>the</strong> item, with its receipt date, are logged in<strong>to</strong> SAP. A shelf<br />
life is <strong>the</strong>n allocated <strong>to</strong> <strong>the</strong> item depending on manufacturers recommendations etc. A<br />
regular interrogation <strong>of</strong> <strong>the</strong> database is conducted <strong>to</strong> determine which items are about <strong>to</strong><br />
exceed <strong>the</strong>ir shelf life. When <strong>the</strong> <strong>team</strong> performed an interrogation <strong>of</strong> <strong>the</strong> 217 items due<br />
for disposal in 2008, as <strong>the</strong>y had exceeded <strong>the</strong>ir predetermined shelf life, <strong>the</strong> first two<br />
items were found <strong>to</strong> have exceeded <strong>the</strong>ir shelf life by one and three years.<br />
Hazardous materials are identified at <strong>the</strong> receipt inspection stage, having been<br />
appropriately labelled by <strong>the</strong> supplier. Such materials are s<strong>to</strong>red in designated areas<br />
Small items which do not pass <strong>the</strong> acceptance inspection are placed on a very narrow<br />
shelf in close proximity <strong>to</strong> <strong>the</strong> inspection area. This is not considered <strong>to</strong> be sufficient<br />
separation from those items which are considered as acceptable. Larger items which<br />
cannot be placed on <strong>the</strong> shelf are s<strong>to</strong>red on <strong>the</strong> floor and a note attached <strong>to</strong> <strong>the</strong> item.<br />
There are no demarcated areas for such non-conforming or damaged items.<br />
It was stated that, during <strong>the</strong> 27 years <strong>of</strong> operation <strong>of</strong> <strong>the</strong> plant, <strong>the</strong>re has only been one<br />
time when operation was affected due <strong>to</strong> <strong>the</strong> lack <strong>of</strong> spare parts and this had been due <strong>to</strong><br />
an LP ro<strong>to</strong>r having been dropped from a crane and <strong>the</strong> resulting damaged turbine blades<br />
were not in s<strong>to</strong>ck.<br />
It is recognized by <strong>the</strong> plant that full traceability <strong>of</strong> <strong>safety</strong> related spare parts is not<br />
evident where <strong>the</strong> item does not have a specific identifier – if a batch were found <strong>to</strong> be<br />
faulty, <strong>the</strong>n all <strong>the</strong> components which had <strong>the</strong> spare utilized would have <strong>to</strong> have <strong>the</strong><br />
faulty spare replaced.<br />
All spare parts are labelled prior <strong>to</strong> being placed in s<strong>to</strong>rage and <strong>the</strong> information includes<br />
date, order number, part number, description and s<strong>to</strong>rage location.<br />
S<strong>to</strong>ck levels are kept at a level that considers past requirements, delivery times and<br />
<strong>safety</strong>. The current s<strong>to</strong>ck levels indicate that <strong>the</strong>re are 220000 spare parts in s<strong>to</strong>ck.<br />
Items made <strong>of</strong> rubber are not accepted as return parts. The <strong>team</strong> found some areas in <strong>the</strong><br />
plant where apparently surplus spare parts were observed <strong>to</strong> be s<strong>to</strong>red/placed.<br />
Access <strong>to</strong> <strong>the</strong> s<strong>to</strong>rage location is controlled.<br />
QA audits are performed on a regular basis but it is considered that <strong>the</strong>se audits are<br />
limited <strong>to</strong> <strong>the</strong> documentation relating <strong>to</strong> spare parts – more emphasis should be placed on<br />
<strong>the</strong> physical s<strong>to</strong>rage and s<strong>to</strong>rage environment. The staff has initiated an informal selfassessment<br />
<strong>of</strong> <strong>the</strong>ir work and workplace and consideration should be given <strong>to</strong><br />
formalizing this self-assessment process.<br />
The control and surveillance <strong>of</strong> spare parts for maintenance is not sufficiently robust and<br />
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<strong>the</strong> <strong>team</strong> made a suggestion in this area.<br />
4.9 OUTAGE MANAGEMENT<br />
An outage organizational chart is available and clearly delineates <strong>the</strong> individual<br />
responsibilities.<br />
Planning meetings are held on a regular basis prior <strong>to</strong> <strong>the</strong> start <strong>of</strong> <strong>the</strong> outage. These<br />
meetings cover organization, scope <strong>of</strong> activities, current status <strong>of</strong> schedules, progress <strong>of</strong><br />
preparations and experiences from previous outages.<br />
During <strong>the</strong> outage, up <strong>to</strong> twelve individual meetings are held daily ranging from<br />
‘Operational Managers Planning Meeting’ <strong>to</strong> ‘Shift Supervisors Planning Meeting’.<br />
Contrac<strong>to</strong>rs are supervised by plant personnel.<br />
A waste reduction programme is adequately applied at <strong>the</strong> plant.<br />
The requirements <strong>of</strong> Operating Technical Specifications are adequately addressed but<br />
<strong>the</strong>re is no methodical, structured approach <strong>to</strong> determining <strong>the</strong> risk associated with<br />
outage activities. Currently a meeting is convened <strong>of</strong> experienced engineers and all<br />
activities are discussed and <strong>the</strong> items <strong>of</strong> high risk are subjectively identified.<br />
Restart <strong>of</strong> <strong>the</strong> unit following an outage is comprehensively addressed and is subject <strong>to</strong><br />
authorization from <strong>the</strong> President.<br />
An Outage Review <strong>Report</strong> is produced which adequately addresses all outage aspects<br />
and any follow-up items.<br />
Experiences during <strong>the</strong> outage are collected on forms and <strong>the</strong> involved staff is<br />
encouraged <strong>to</strong> complete <strong>the</strong>se forms with any findings <strong>the</strong>y may make. These forms are<br />
collected and relevant information is feedback in<strong>to</strong> <strong>the</strong> outage process.<br />
Long term planning has been a part <strong>of</strong> <strong>the</strong> scheduling <strong>of</strong> <strong>the</strong> plant since 2004 and<br />
nowadays adequately caters for outages up <strong>to</strong> four years ahead. A simple matrix system<br />
is utilized <strong>to</strong> predict <strong>the</strong> critical path <strong>of</strong> <strong>the</strong> outage.<br />
The production unit manager has overall responsibility for <strong>the</strong> outage and is also<br />
responsible for <strong>the</strong> <strong>safety</strong> status <strong>of</strong> <strong>the</strong> unit and <strong>the</strong> operations related activities in <strong>the</strong><br />
plant. The outage project manager is responsible for ensuring that maintenance outage<br />
activities are performed with <strong>the</strong> specified quality and within <strong>the</strong> planned time.<br />
The production unit manager is also responsible for appointing personnel responsible for<br />
granting work permits, personnel for <strong>the</strong> operation <strong>of</strong> plant modifications and appointing<br />
<strong>of</strong>ficials for isolation valve testing.<br />
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DETAILED MAINTENANCE FINDINGS<br />
4.3 MAINTENANCE PROGRAMMES<br />
4.3(a) Good Practice: The plant has electrical power moni<strong>to</strong>ring for performance-based<br />
maintenance on isolation valves and control rod drives online, (SODEM).<br />
An online computerized electrical power measuring system is optimal for moni<strong>to</strong>ring<br />
performance <strong>of</strong> isolation valves and control rod drives. The electrical power measuring<br />
system can be used for tracking changes from a fingerprint curve or as an indica<strong>to</strong>r <strong>of</strong><br />
increased friction that may affect <strong>the</strong> operability <strong>of</strong> <strong>the</strong> valves.<br />
The Plant uses such a system for measuring electrical power demand by mo<strong>to</strong>r-operated<br />
isolation valves. The computerized system is triggered at each individual operation <strong>of</strong> <strong>the</strong><br />
valves or control rods.<br />
In <strong>the</strong> valve moni<strong>to</strong>ring system, <strong>the</strong> alarm levels are calculated for each individual valve.<br />
The alarm levels are based on <strong>the</strong> valve calculations in <strong>the</strong> SAR. The curves are analyzed<br />
on a regular basis and <strong>the</strong> maintenance engineers make recommendations for<br />
maintenance action during outage. Written procedures provide assistance with analysis<br />
and adjustment <strong>of</strong> alarm levels. The performance analyses also enable operability<br />
assessments for <strong>the</strong> mo<strong>to</strong>r operated isolation valves.<br />
The valve moni<strong>to</strong>ring system is used for troubleshooting on both valves and actua<strong>to</strong>rs. It<br />
also enables identification <strong>of</strong> mechanical errors, e.g. increased friction, bent stem and if<br />
<strong>the</strong> actua<strong>to</strong>r is fitted <strong>of</strong>f centre <strong>of</strong> <strong>the</strong> valve.<br />
Alarms from <strong>the</strong> control rod moni<strong>to</strong>ring system are used in combination with o<strong>the</strong>r<br />
moni<strong>to</strong>ring systems <strong>to</strong> evaluate <strong>the</strong> status <strong>of</strong> <strong>the</strong> control rod drives and collect data for<br />
maintenance actions during outage.<br />
4.6 MATERIAL CONDITIONS<br />
4.6(1) Issue: A number <strong>of</strong> leaks were identified and some have been in existence and<br />
<strong>to</strong>lerated for a long period <strong>of</strong> time.<br />
There were a number <strong>of</strong> components which are indicating leakage and <strong>the</strong>se<br />
include:<br />
• Level 3 12-415 E309 Oil leaks have been occurring for over a year – no<br />
remedial action taken.<br />
• Room 1.S1.13 Valve 767 W401 leaking and encrusted with solids.<br />
• Diesel genera<strong>to</strong>rs A and B. Two plastic containers collecting oil leakage –<br />
plastic containers have been in place for over a year - oil also in surrounding<br />
area.<br />
• Oil leaks in 12-415 P301, P302 – feedwater pumps.<br />
• Several oil leaks in 11-414 P1-P3.<br />
• Valve 711V164 was leaking fluid on<strong>to</strong> <strong>the</strong> floor.<br />
Visible leakage is a sign <strong>of</strong> poor material condition which can lead <strong>to</strong><br />
unavailability <strong>of</strong> <strong>safety</strong> related equipment and also increase <strong>the</strong> fire risk in <strong>the</strong> case<br />
<strong>of</strong> oil leakages.<br />
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Suggestion: Consideration should be given <strong>to</strong> enhancing <strong>the</strong> current material condition<br />
initiative <strong>to</strong> ensure that all leakages from components are timely and effectively repaired.<br />
IAEA Basis:<br />
DS347 Conduct <strong>of</strong> Operations at Nuclear Power Plants<br />
4.35 Personnel assigned <strong>the</strong> task <strong>of</strong> carrying out rounds should be made responsible for<br />
verifying that operating equipment and standby equipment operate within normal<br />
parameters. They should take note <strong>of</strong> equipment that is deteriorating and <strong>of</strong> fac<strong>to</strong>rs<br />
affecting environmental conditions, such as water and oil leaks, burned out light bulbs<br />
and changes in building temperature or <strong>the</strong> cleanliness <strong>of</strong> <strong>the</strong> air. Any problems noted<br />
with equipment should be promptly communicated <strong>to</strong> <strong>the</strong> control room personnel and<br />
corrective actions should be initiated.<br />
4.8 SPARE PARTS AND MATERIALS<br />
4.8(1) Issue: The control and surveillance <strong>of</strong> spare parts for maintenance is not<br />
sufficiently robust.<br />
There are deficiencies within <strong>the</strong> spare parts section which should be improved<br />
such as:<br />
• The control system for spares contains items which should have been discarded<br />
• There is inadequate segregation <strong>of</strong> non-conforming items<br />
• QA audits on <strong>the</strong> section are documentation focused<br />
• There is not full traceability <strong>of</strong> some <strong>safety</strong> related equipment<br />
• Instructions do not exist for <strong>the</strong> position and responsibilities <strong>of</strong> Spare Parts<br />
Officer and no instruction for ‘The repair <strong>of</strong> spare parts’.<br />
Inadequate control <strong>of</strong> spare parts could result in inoperability <strong>of</strong> <strong>safety</strong> systems should<br />
deficient or inappropriate spare parts be utilized.<br />
Suggestion: The plant should consider enhancing <strong>the</strong> current control and surveillance <strong>of</strong><br />
spare parts.<br />
IAEA Basis:<br />
NS-G-2.6<br />
8.32 The operating organization should ensure that s<strong>to</strong>rage facilities <strong>of</strong>fer adequate space<br />
and provide for <strong>the</strong> secure retention <strong>of</strong> s<strong>to</strong>cks in suitable environmental conditions, in<br />
order <strong>to</strong> prevent deterioration.<br />
8.37 Items that have a limited shelf life should, if not used, be replaced at <strong>the</strong> appropriate<br />
time in order <strong>to</strong> ensure suitability for <strong>the</strong> expected function when <strong>the</strong>y are needed.<br />
8.51 Defective items,…., should be repaired in accordance with established<br />
procedures….<br />
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5. TECHNICAL SUPPORT<br />
5.1 ORGANIZATION AND FUNCTIONS<br />
Technical support (TS) tasks are assigned <strong>to</strong> <strong>the</strong> TS unit and o<strong>the</strong>r related units, e.g.<br />
maintenance unit, production unit and <strong>the</strong> common facilities unit. The responsibilities<br />
and assignments <strong>of</strong> each department <strong>of</strong> <strong>the</strong> TS unit and relevant units are clearly<br />
documented in LOK and FT-I-001 (Instruction for TS unit work).<br />
All <strong>the</strong> departments <strong>of</strong> <strong>the</strong> TS unit, except <strong>the</strong> project management department, have a<br />
role as specialists within <strong>the</strong>ir own area <strong>of</strong> expertise. They adequately provide <strong>the</strong><br />
technical investigations, analysis and assessments for a broad range <strong>of</strong> different<br />
assignments from <strong>the</strong> production units (clients).<br />
Considering <strong>the</strong> features <strong>of</strong> <strong>the</strong> assignments, <strong>the</strong> TS unit incorporates a matrix<br />
organization in performing project tasks, with <strong>the</strong> aim <strong>of</strong> improving efficiency and<br />
effectiveness.<br />
The TS unit has set up <strong>the</strong> interdisciplinary engineering department (FTT) <strong>to</strong> facilitate<br />
technical issues in interdisciplinary analysis <strong>of</strong> plant functions and nuclear <strong>safety</strong>. One<br />
important task is <strong>to</strong> create conditions for future plant renewals through <strong>the</strong> analysis <strong>of</strong><br />
design requirements and nuclear <strong>safety</strong>.<br />
In addition <strong>to</strong> <strong>the</strong> fundamental organization, <strong>the</strong> TS unit has set up a management <strong>team</strong><br />
which functions as a decision-making forum and ensures that engineering issues are<br />
addressed and <strong>the</strong> decision-making is taken collectively in an effective and efficient<br />
manner. The <strong>team</strong> is comprised <strong>of</strong> <strong>the</strong> TS unit manager, unit department managers and<br />
employees for coordination <strong>of</strong> <strong>the</strong> TS unit.<br />
The TS unit makes special efforts <strong>to</strong> limit <strong>the</strong> number <strong>of</strong> direct subordinates <strong>of</strong> subunits,<br />
in order that each manager can maintain sufficient oversight in <strong>the</strong> manager role, because<br />
<strong>the</strong> assignments cover a broad range <strong>of</strong> competence areas. The TS unit conducts an<br />
annual <strong>review</strong> <strong>of</strong> competence and resource status <strong>of</strong> each department and <strong>the</strong> entire TS<br />
unit. Based on <strong>the</strong> <strong>review</strong> result, <strong>the</strong> staffing can be changed appropriately <strong>to</strong> ensure <strong>the</strong><br />
necessary staffing for each department <strong>of</strong> <strong>the</strong> TS unit.<br />
The system <strong>to</strong> improve each individual’s competence and skill is properly established in<br />
<strong>the</strong> plant. The competence and skill requirements for each position <strong>of</strong> <strong>the</strong> TS unit are<br />
clearly documented and registered in <strong>the</strong> strategic competence system (STRAKO). The<br />
gap between actual skills and requirements for each individual is identified at an annual<br />
performance <strong>review</strong> and a development plan is formulated based on any identified gaps.<br />
The plan is signed by <strong>the</strong> employee and <strong>the</strong> responsible manager and administered by <strong>the</strong><br />
human resources unit.<br />
A three year activity plan <strong>of</strong> how each department <strong>of</strong> <strong>the</strong> TS unit will achieve <strong>the</strong> goals is<br />
issued annually.<br />
The average overtime <strong>of</strong> <strong>the</strong> TS unit is maintained at a low level (3% <strong>of</strong> annual working<br />
hours).<br />
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5.2 SURVEILLANCE PROGRAMME<br />
The surveillance programme verifies functional <strong>safety</strong> requirements and it is clearly<br />
compiled in<strong>to</strong> three programmes, e.g. <strong>the</strong> technical specifications (STF) (priority 1), <strong>the</strong><br />
ISI programme (priority 2) and <strong>the</strong> maintenance programme (priority 3).<br />
Operations department has clear responsibilities for ensuring that 1) tests, inspections<br />
and checks are performed, 2) <strong>the</strong> results are evaluated, and 3) any unacceptable results<br />
are remedied. The maintenance unit and TS unit take part in <strong>the</strong> assigned execution, such<br />
as <strong>the</strong> ISI activities.<br />
Tests, inspections and checks are clearly specified in <strong>the</strong> technical specifications (STF,<br />
Chapter 4) as measures <strong>to</strong> ensure that <strong>the</strong> production unit is <strong>operational</strong>. The information<br />
necessary for planning surveillance tests, including acceptance criteria and scheduling<br />
(time interval limit), are contained in <strong>the</strong> maintenance database (FENIX).<br />
Surveillance tests required in <strong>the</strong> technical specifications are properly conducted in<br />
accordance with F1-I-312 (Administrative procedures for technical specifications -<br />
related testing) and relevant procedures. Operational management approves <strong>the</strong> tests <strong>to</strong><br />
be performed during <strong>the</strong> daily operation <strong>review</strong> meeting held in <strong>the</strong> morning.<br />
Tests are documented in FENIX as well as in binders after <strong>review</strong> by <strong>the</strong> Shift<br />
Supervisor and are noted in <strong>the</strong> minutes <strong>of</strong> <strong>the</strong> daily operation <strong>review</strong> meeting. Trend<br />
analysis <strong>of</strong> test results is performed by shift members and <strong>the</strong> technical department <strong>of</strong><br />
maintenance unit. However, <strong>the</strong> comprehensive <strong>review</strong> <strong>of</strong> surveillance test results<br />
including trend analysis over a long term, is not conducted systematically. A suggestion<br />
by <strong>the</strong> <strong>team</strong> is made in this area.<br />
In cases where <strong>the</strong> test is not performed or is not successful, <strong>the</strong> operations management<br />
is informed by <strong>the</strong> Shift Supervisor. It is clearly stated in <strong>the</strong> technical specifications<br />
(Chapter 3) what correctives actions should be taken when a surveillance test result is<br />
found <strong>to</strong> be unacceptable.<br />
Changes <strong>to</strong> <strong>the</strong> technical specifications are <strong>review</strong>ed by <strong>the</strong> <strong>safety</strong> committee as an<br />
independent <strong>safety</strong> <strong>review</strong>. The President approves <strong>the</strong> change proposal based on <strong>the</strong><br />
committee’s recommendation. All changes <strong>of</strong> operating and maintenance procedures<br />
used for surveillance tests required in <strong>the</strong> technical specifications, should be <strong>review</strong>ed by<br />
<strong>the</strong> <strong>safety</strong> and environment unit as an independent <strong>safety</strong> <strong>review</strong> after <strong>the</strong> primary <strong>safety</strong><br />
<strong>review</strong> by <strong>the</strong> <strong>operational</strong> manager. The process is implemented in accordance with F1-I-<br />
302 (for unit 1).<br />
5.3 PLANT MODIFICATION SYSTEM<br />
Plant modifications are defined as all changes and new facilities that affect <strong>the</strong> technical<br />
documentation, including changes <strong>of</strong> operation, maintenance and <strong>safety</strong> analysis.<br />
Plant modifications are properly implemented such that:<br />
• Plant modifications are selected and prioritized in <strong>the</strong> best possible manner that<br />
supports <strong>the</strong> company’s business concept.<br />
• Each plant modification is performed with <strong>the</strong> least possible disruption <strong>to</strong><br />
production and while retaining nuclear <strong>safety</strong>.<br />
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The TS unit has an overall responsibility for <strong>the</strong> plant modification process. The roles<br />
and responsibilities for relevant departments are clearly documented. The process owner<br />
is <strong>the</strong> TS unit manager and <strong>the</strong> process manager is <strong>the</strong> project department manager <strong>of</strong> <strong>the</strong><br />
TS unit. The production unit is responsible for planning, prioritization and specification<br />
<strong>of</strong> plant modification, while <strong>the</strong> project management is responsible for ensuring that<br />
design, procurement, implementation and com<strong>mission</strong>ing are planned and executed as<br />
requested by <strong>the</strong> production unit.<br />
Plant modification programmes are performed according <strong>to</strong> systematically established<br />
instructions and procedures. F- I- 259 (Plant modification process) is <strong>the</strong> primary<br />
instruction for processing plant modifications. F-I- 274 (Inven<strong>to</strong>ry and Specification) and<br />
F-I-261 (Implementation) are sub process instructions and several instructions are<br />
provided for performing each specific modification activity. Procedures for each plant<br />
modification are prepared under <strong>the</strong> requirements specified in <strong>the</strong> above instructions. A<br />
good practice was identified by <strong>the</strong> <strong>team</strong> in <strong>the</strong> application <strong>of</strong> <strong>the</strong> Human-Machine-<br />
Interface design.<br />
A <strong>safety</strong> <strong>review</strong> for each plant modification is conducted in compliance with F-I- 824<br />
(Safety <strong>review</strong>). The instruction clearly describes how <strong>the</strong> plant modifications are<br />
classified according <strong>to</strong> <strong>the</strong> <strong>safety</strong> significance and how <strong>the</strong> <strong>safety</strong> <strong>review</strong> is performed<br />
depending on <strong>the</strong> <strong>safety</strong> significance. Plant modifications belonging <strong>to</strong> <strong>safety</strong> <strong>review</strong><br />
group 1 should be <strong>review</strong>ed in full and finally approved by <strong>the</strong> <strong>operational</strong> management<br />
level 1 following <strong>the</strong> <strong>safety</strong> committee.<br />
Installations, inspections and tests are properly implemented in accordance with F-I-299<br />
(Installation) and F-I-271 (Com<strong>mission</strong>ing) and <strong>the</strong> testing records are properly<br />
documented.<br />
Controlled documents which are required for operation and maintenance are clearly<br />
defined. They include an <strong>operational</strong> systematic diagram, an operations manual and a<br />
maintenance manual. The revised controlled documents, relating <strong>to</strong> a plant modification,<br />
are drafted by <strong>the</strong> TS unit and are well controlled and are submitted <strong>to</strong> <strong>the</strong> operations unit<br />
and maintenance unit (clients) in advance, i.e. several months before <strong>the</strong> hand-over stage.<br />
However, <strong>the</strong> finalization <strong>of</strong> controlled documents is not always completed at <strong>the</strong> handover<br />
stage <strong>of</strong> <strong>the</strong> modified system and equipment, from FT <strong>to</strong> <strong>the</strong> clients. A suggestion<br />
by <strong>the</strong> <strong>team</strong> is made in this area.<br />
5.4 REACTOR CORE MANAGEMENT (REACTOR ENGINEERING)<br />
The core and fuel department <strong>of</strong> <strong>the</strong> TS unit (FTB) has clear responsibilities for reac<strong>to</strong>r<br />
physics and fuel engineering. Reac<strong>to</strong>r physics group handles 1) In Core Fuel<br />
Management (ICFM) for <strong>operational</strong> <strong>safety</strong> moni<strong>to</strong>ring and 2) core design within <strong>the</strong><br />
project <strong>of</strong> “Ready Core”. The fuel engineering group (FTBR) mainly addresses <strong>the</strong><br />
project <strong>of</strong> “Ready Core”, relating <strong>to</strong> <strong>the</strong> reload <strong>of</strong> fuel and control rods, in addition <strong>to</strong><br />
o<strong>the</strong>r activities <strong>of</strong> fuel transport.<br />
FTB has one physicist and at least one “backup” physicist allocated for each unit <strong>to</strong><br />
ensure smooth and high quality work. Thorough recruiting, training and experience<br />
feedback are appropriately performed <strong>to</strong> maintain <strong>the</strong> expertise <strong>of</strong> reac<strong>to</strong>r physics and<br />
fuel engineering.<br />
The procedures <strong>of</strong> core management and fuel engineering are properly documented in F-<br />
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I-338 (comprehensive instruction on description <strong>of</strong> process <strong>of</strong> ready-core) and o<strong>the</strong>r<br />
instructions.<br />
Reac<strong>to</strong>r core and associated <strong>safety</strong> parameters are properly moni<strong>to</strong>red and trended in<br />
accordance with FT-I-206 (Instruction for TIP-analysis). In core calculation results serve<br />
as <strong>the</strong> basis for evaluation <strong>of</strong> core operation and <strong>the</strong>y are reported monthly <strong>to</strong> <strong>the</strong> relevant<br />
units including senior management. A good practice by <strong>the</strong> <strong>team</strong> is identified in <strong>the</strong><br />
application <strong>of</strong> <strong>the</strong> core stability prediction calculation code.<br />
The reac<strong>to</strong>r <strong>the</strong>rmal power change rate is clearly prescribed in D-I-1003 and D-I-1000<br />
(operation manuals) <strong>to</strong> mitigate PCI (pellet clad interaction).<br />
The plant has experienced ten fuel failures since 2004. The plant issued <strong>the</strong> Safety<br />
Directive (FKA-2004-193) including policy regarding fuel failure. Root cause<br />
investigations <strong>of</strong> failed fuel have been conducted intensively by FTBR in accordance<br />
with FT-I-224 (Instruction for project management <strong>of</strong> repair <strong>of</strong> failed fuel). Most <strong>of</strong> <strong>the</strong><br />
fuel failures were identified <strong>to</strong> have occurred due <strong>to</strong> debris fretting.<br />
After a fuel failure is detected, <strong>the</strong> actions <strong>to</strong> be taken are discussed at a special meeting<br />
consisting <strong>of</strong> operations unit, chemistry department and FTB and <strong>the</strong> actions are clearly<br />
noted in <strong>the</strong> meeting minutes. Based on <strong>the</strong> decision taken, <strong>the</strong> operations unit and<br />
chemistry department appropriately take necessary actions regarding implementation <strong>of</strong><br />
neutron flux-tilting operation, increased frequency <strong>of</strong> moni<strong>to</strong>ring <strong>of</strong> radionuclides in <strong>the</strong><br />
coolant water and o<strong>the</strong>r necessary activities in accordance with <strong>the</strong> prepared instructions.<br />
Various considerations are taken in<strong>to</strong> account in <strong>the</strong> application <strong>of</strong> computer<br />
programmes. A computerized <strong>of</strong>fline system can only receive data from <strong>the</strong> online<br />
system through a firewall, while <strong>the</strong> data from <strong>the</strong> <strong>of</strong>fline system only can be transferred<br />
<strong>to</strong> <strong>the</strong> online system through external media, e.g. CDs. The routines for transferring<br />
updated data such as burn-up <strong>to</strong> <strong>the</strong> online system are supervised by <strong>the</strong> <strong>operational</strong><br />
management. In addition, <strong>the</strong> change <strong>of</strong> <strong>the</strong> programme CASMO, with corresponding<br />
cross-section direc<strong>to</strong>ry, and POLCA used for online and <strong>of</strong>fline core calculation<br />
applications are always performed in accordance with <strong>the</strong> plant modifications procedure.<br />
Only <strong>the</strong> FTB manager can change <strong>the</strong> authorization level <strong>of</strong> <strong>the</strong> Core Master, part <strong>of</strong> <strong>the</strong><br />
<strong>of</strong>fline core calculation system.<br />
The inven<strong>to</strong>ry <strong>of</strong> fissile material for each production unit is regularly verified and<br />
checked with a computerized system.<br />
5.5 HANDLING OF FUEL AND CORE COMPONENTS<br />
The roles and responsibilities <strong>of</strong> relevant departments in handling fuel and core<br />
components are clearly documented in LOK.<br />
The inspection and transportation <strong>of</strong> new fuel assemblies is properly conducted in<br />
accordance with standards, e.g. UIM-3246-001 (unit 3). When new fuel assemblies<br />
arrive at <strong>the</strong> plant, <strong>the</strong>y are transported <strong>to</strong> <strong>the</strong> dry s<strong>to</strong>rage area for inspection. If no<br />
problems are detected on <strong>the</strong> fuel, <strong>the</strong>y are s<strong>to</strong>red in <strong>the</strong> designated dry area with<br />
adequate control. Dry, fresh fuel assemblies are handled with an overhead traversing<br />
crane in <strong>the</strong> reac<strong>to</strong>r hall. Likewise spent fuels, s<strong>to</strong>red in <strong>the</strong> fuel pool, are handled by <strong>the</strong><br />
fuel handling machine.<br />
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All administrative fuel handling steps are sufficiently performed by means <strong>of</strong> <strong>the</strong> plant’s<br />
computer-based system LADDA. The position <strong>of</strong> each fuel assembly is registered on<br />
paper and independently checked against data in <strong>the</strong> LADDA system. The approved<br />
s<strong>to</strong>rage <strong>of</strong> irradiated fuel and core components are ensured and <strong>the</strong> minimum cooling<br />
period <strong>of</strong> spent fuel, before transportation, is established as nine months.<br />
Transportation <strong>of</strong> spent fuel s<strong>to</strong>red in casks is managed in accordance with procedures<br />
for handling and loading <strong>of</strong> transport casks.<br />
The “STAR” system used during accounting and safeguards reporting <strong>of</strong> fissile materials<br />
fulfils every requirement in <strong>the</strong> EU regulation 302/2005.<br />
5.6 COMPUTER BASED SYSTEMS IMPORTANT TO SAFETY<br />
It is clearly documented in LOK that <strong>the</strong> TS unit is responsible for designing all systems<br />
and equipment relating <strong>to</strong> computer applications, while <strong>the</strong> maintenance unit is<br />
responsible for all maintenance activities for <strong>the</strong>se systems.<br />
The instruction (F-I-181) states that computer based application for s<strong>of</strong>tware in <strong>safety</strong><br />
and <strong>safety</strong>-related systems should be met with <strong>the</strong> TBE (nationwide technical<br />
requirements) and <strong>the</strong> KBE (nationwide quality assurance requirements) in accordance<br />
with <strong>the</strong> requirements <strong>of</strong> <strong>the</strong> SAR.<br />
Computer based applications, important <strong>to</strong> <strong>safety</strong>, are limited <strong>to</strong> two main groups, i.e. 1)<br />
programmable electronics with a simple fixed application used in some dedicated<br />
components and equipment such as UPS and switchgear equipment, and 2)<br />
programmable electronics with a more complex fixed application used for <strong>the</strong> neutron<br />
flux measurement systems.<br />
In addition, consideration is also given <strong>to</strong> ensure that digital controls in <strong>safety</strong><br />
applications is based on implementation <strong>of</strong> programmable electronics with a fixed<br />
application and <strong>the</strong> s<strong>of</strong>tware applications cannot be overwritten or changed without<br />
special equipment.<br />
The plant process computer (PPC) has no direct <strong>safety</strong> function and is categorized <strong>to</strong><br />
<strong>safety</strong> class 4 and is a non-class 1E function, however, PPC has an important role <strong>of</strong><br />
moni<strong>to</strong>ring and logging <strong>of</strong> plant operation. Handling and maintenance on non-<strong>safety</strong><br />
process computer applications are properly regulated in relevant procedures.<br />
The plant has established that PPC and o<strong>the</strong>r process computers send all events and<br />
almost all analogue signals once a minute <strong>to</strong> <strong>the</strong> long-term s<strong>to</strong>rage in <strong>the</strong> process data<br />
base (PDB) containing process information dating back <strong>to</strong> <strong>the</strong> beginning <strong>of</strong> 1980s, which<br />
is very useful for personnel outside <strong>the</strong> main control room.<br />
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TECHNICAL SUPPORT
DETAILED TECHNICAL SUPPORT FINDINGS<br />
5.2. SURVEILLANCE PROGRAMME<br />
5.2(1) Issue: The comprehensive trend analysis <strong>of</strong> results <strong>of</strong> surveillance tests required<br />
in <strong>the</strong> technical specifications is not conducted systematically.<br />
The <strong>team</strong> observed <strong>the</strong> following facts:<br />
• Test results are s<strong>to</strong>red in FENIX as well as in binders after <strong>the</strong> <strong>review</strong> by<br />
<strong>the</strong> shift supervisor.<br />
• Trend analysis <strong>of</strong> test results is performed by shift members and technical<br />
department <strong>of</strong> maintenance unit. However, this analysis is not always<br />
conducted in a systematic manner. Exceptions include <strong>the</strong> frequency <strong>of</strong><br />
analysis and evaluation method <strong>of</strong> analysis.<br />
• In addition, <strong>the</strong> trend analysis over a long term (several months <strong>to</strong> one<br />
year) is not performed in a systematic way.<br />
Without comprehensive and systematic trend analysis <strong>of</strong> surveillance test results,<br />
<strong>the</strong> plant could increase <strong>the</strong> potential <strong>of</strong> missing <strong>the</strong> opportunity for early detection<br />
<strong>of</strong> equipment vulnerability and unavailability.<br />
Suggestion: Consideration should be given <strong>to</strong> conducting a comprehensive and<br />
systematic analysis <strong>of</strong> surveillance test results.<br />
Basis: IAEA Safety Guide NS-G-2.6;<br />
Para 6.10<br />
“Additionally, <strong>the</strong> results should be examined, where appropriate, for trends that may<br />
indicate <strong>the</strong> deterioration <strong>of</strong> equipment.”<br />
5.3. PLANT MODIFICATION<br />
5.3(1) Issue: Some <strong>of</strong> <strong>the</strong> controlled documents are not finalized at <strong>the</strong> hand-over stage<br />
<strong>of</strong> a modified system and equipment <strong>to</strong> operation and maintenance unit.<br />
The <strong>team</strong> observed <strong>the</strong> following facts:<br />
• At plant modification, <strong>the</strong> engineering department (FT) submits <strong>the</strong> draft<br />
controlled documents <strong>to</strong> be revised <strong>to</strong> <strong>the</strong> operation unit and maintenance unit<br />
(clients) in advance, i.e. several months before hand-over stage.<br />
• The finalization <strong>of</strong> controlled documents is not always completed prior <strong>to</strong><br />
hand-over stage from engineering department <strong>to</strong> <strong>the</strong> clients.<br />
• Operational documents for <strong>the</strong> replaced air compressor system were<br />
handed over on 14 Oc<strong>to</strong>ber 2007 but was only finalised on 12 February<br />
2008.<br />
• Operational documents for <strong>the</strong> replaced power range neutron moni<strong>to</strong>r<br />
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system were handed over on 21 June 2007, but are only going <strong>to</strong> be<br />
finalised in March 2008.<br />
• Operational documents for <strong>the</strong> process signal system were handed over on<br />
26 June 2006, but was only finalised on 10 December 2007<br />
Without finalized controlled documents being provided at hand-over stage <strong>to</strong> operation<br />
and maintenance units, <strong>the</strong> plant could fail <strong>to</strong> prevent errors caused by use <strong>of</strong> preliminary<br />
approved controlled documents.<br />
Suggestion: Consideration should be given <strong>to</strong> finalizing all required controlled<br />
documents prior <strong>to</strong> com<strong>mission</strong>ing new modifications.<br />
Basis: IAEA Safety Guide NS-G-2-3<br />
Para 11.1<br />
“The following should be ensured by means <strong>of</strong> <strong>the</strong> document management system:<br />
- That all relevant documents affected by <strong>the</strong> modification are identified and updated,<br />
and remain consistent with <strong>the</strong> plant specific design requirements, and that <strong>the</strong>y<br />
accurately reflect <strong>the</strong> modified plant configuration;<br />
- That all changes <strong>to</strong> <strong>the</strong> design over <strong>the</strong> lifetime <strong>of</strong> <strong>the</strong> plant are based on <strong>the</strong> actual<br />
status <strong>of</strong> <strong>the</strong> plant, as reflected in <strong>the</strong> current plant documentation;<br />
- That <strong>the</strong> modified plant configuration conforms fully with <strong>the</strong> documentation and<br />
conditions <strong>of</strong> <strong>the</strong> operating license.”<br />
5.3(a) Good practice: The TIGER procedure ensures that HMI (Human-Machine-<br />
Interface) design can be incorporated in modernization projects in an appropriate<br />
manner. The TIGER procedure was developed in 1998. It has subsequently been well<br />
applied <strong>to</strong> about 30 modernization projects in this plant since <strong>the</strong> start <strong>of</strong> application.<br />
• The TIGER procedure is based upon a number <strong>of</strong> norms and guides from <strong>the</strong><br />
nuclear industry, e.g. NUREG, IEC and ISO.<br />
• The TIGER procedure consists <strong>of</strong> a five step procedure, e.g. TIGER extent<br />
description, present description, HMI design <strong>review</strong>, HMI verification and HMI<br />
validation.<br />
• At <strong>the</strong> stage <strong>of</strong> present description, all <strong>the</strong> opera<strong>to</strong>r work tasks that are affected by<br />
<strong>the</strong> modernization are identified and analyzed by <strong>the</strong> TIGER group. Each TIGER<br />
group consists <strong>of</strong> opera<strong>to</strong>rs and different type experts.<br />
• At <strong>the</strong> stage <strong>of</strong> HMI design <strong>review</strong>, a new HMI design developed by technical<br />
design department is <strong>review</strong>ed and approved by <strong>the</strong> TIGER group.<br />
• At <strong>the</strong> stage <strong>of</strong> HMI verification, <strong>the</strong> TIGER group can be complemented by an<br />
independent person that has not been involved in earlier steps in <strong>the</strong> TIGER<br />
process, in order <strong>to</strong> achieve a more independent verification.<br />
• At <strong>the</strong> stage <strong>of</strong> HMI validation, it is always performed by opera<strong>to</strong>rs that have not<br />
been earlier involved in <strong>the</strong> earlier steps <strong>of</strong> <strong>the</strong> TIGER process in order <strong>to</strong> show<br />
that <strong>the</strong> modernization is in accordance with <strong>the</strong> o<strong>the</strong>r systems and functions<br />
within <strong>the</strong> plant.<br />
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5.4 REACTOR CORE MANAGEMENT<br />
5.4(a) Good practice: MATSTAB (a full 3-dimensional neutron model in combination<br />
with <strong>the</strong>rmal hydraulic model) can provide information on core design for stability<br />
prediction and stability optimization. This model features fast calculation speed and high<br />
prediction accuracy. MATSTAB was developed by <strong>the</strong> plant in 2001 and subsequently<br />
applied <strong>to</strong> all BWR Swedish plants.<br />
• MATSTAB is developed in <strong>the</strong> context <strong>to</strong> prevent core instability incidents<br />
mainly due <strong>to</strong> <strong>the</strong>rmal hydraulic oscillation occurred in reac<strong>to</strong>r vessel.<br />
• MATSTAB takes full advantage <strong>of</strong> sparse matrix technology and frequency<br />
domain methods <strong>to</strong> meet with <strong>the</strong> CPU requirements for a full 3-dimensional<br />
reac<strong>to</strong>r representation.<br />
• MATSTAB can predict <strong>the</strong> behaviour <strong>of</strong> a global oscillation within 3 minutes,<br />
using <strong>the</strong> interface with <strong>the</strong> online steady state core simula<strong>to</strong>r (POLCA).<br />
• MATSTAB can display <strong>the</strong> influence <strong>to</strong> stability <strong>of</strong> an individual fuel assembly.<br />
This allows new insights in<strong>to</strong> <strong>the</strong> mechanisms behind instabilities and also <strong>to</strong><br />
optimize <strong>the</strong> core design or a control rod pattern with respect <strong>to</strong> stability.<br />
• The predictions <strong>of</strong> <strong>the</strong> code are validated against stability measurements obtained<br />
at <strong>the</strong> plant.<br />
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6. OPERATING EXPERIENCE<br />
6.1 MANAGEMENT, ORGANIZATION AND FUNCTIONS OF THE OE<br />
PROGRAMME<br />
The operating experience feedback (OEF) programme is in place and includes <strong>the</strong> basic<br />
functions <strong>of</strong> <strong>the</strong> OEF process. However, <strong>the</strong> criteria for reporting low level events and<br />
near misses are not clearly defined in <strong>the</strong> existing documents. The <strong>team</strong> has made a<br />
recommendation in this area.<br />
The plant management has declared and demonstrated its commitment <strong>to</strong> follow <strong>safety</strong><br />
culture principles including a blame free policy and a commitment <strong>to</strong> support and<br />
improve OEF as an effective <strong>to</strong>ol <strong>to</strong> enhance <strong>operational</strong> <strong>safety</strong>. The OEF process is<br />
considered as a production activity. All employees have a responsibility <strong>to</strong> contribute <strong>to</strong><br />
<strong>the</strong> OEF process. The plant policy, main goals, objectives and management expectations<br />
are defined and described in a set <strong>of</strong> documents (LOK 3 “Quality Management System”,<br />
F-I-845 “Operating Experience” (revised in Oc<strong>to</strong>ber 2007), FT-I-1379 “FTQ<br />
Organization and Responsibilities”).<br />
A set <strong>of</strong> procedures dedicated <strong>to</strong> handling reportable events have been developed,<br />
implemented and are used at <strong>the</strong> plant. However, under <strong>the</strong> process <strong>of</strong> <strong>the</strong> OEF<br />
programme improvement, <strong>the</strong> existing procedures should be thoroughly <strong>review</strong>ed and<br />
updated <strong>to</strong> ensure that all duties, responsibilities and lines <strong>of</strong> communication within <strong>the</strong><br />
plant are clearly defined and unders<strong>to</strong>od.<br />
In Oc<strong>to</strong>ber 2007 a new department for OEF and analysis support (FTQ) was established<br />
in <strong>the</strong> Technical Support Unit (FT) <strong>to</strong> manage all OE in a systematic and structured way.<br />
The new department for OEF is composed <strong>of</strong> six persons qualified in plant operation,<br />
personnel training and human performance. The allocated resources for <strong>the</strong> new<br />
department for OEF are currently considered as adequate.<br />
The plant has a plan <strong>to</strong> benchmark with British Energy on <strong>the</strong> organizational issues <strong>of</strong> <strong>the</strong><br />
OEF programme. A technical visit for OEF members <strong>of</strong> <strong>the</strong> new department is planned<br />
<strong>to</strong> Heysham NPP (UK).<br />
A group <strong>of</strong> coordina<strong>to</strong>rs for OEF was established at <strong>the</strong> plant in January 2008. The main<br />
plant units (including: F1 – <strong>Forsmark</strong> 1, F2 – <strong>Forsmark</strong> 2, F3 – <strong>Forsmark</strong> 3, FM –<br />
Maintenance Unit, FT – Technical Support Unit, FP – Human Resources, FQ – Safety<br />
and Environment Unit, FG – Services and Facilities Unit, FU – Business Development)<br />
have a nominated person responsible for ensuring that matters are handled as specified<br />
by <strong>the</strong> OEF process and for ensuring that actions are taken within <strong>the</strong>ir unit. The OEF<br />
coordina<strong>to</strong>r is a liaison <strong>of</strong>ficer between <strong>the</strong>ir unit and <strong>the</strong> new department for OEF which<br />
coordinates <strong>the</strong> group activity <strong>of</strong> OEF. A few <strong>of</strong> <strong>the</strong>m have been trained on analysis<br />
techniques for events that affect <strong>the</strong> interplay between Man, Technology and<br />
Organisation (MTO). However, most <strong>of</strong> <strong>the</strong> relevant department staff for OEF have not<br />
been specially trained in a root cause analysis methodology or <strong>the</strong> methodologies in <strong>the</strong><br />
OEF process. The <strong>team</strong> has made a recommendation in this area.<br />
The organization <strong>of</strong> <strong>the</strong> OEF process is assigned between two departments: FQ (Safety<br />
and Environmental Unit) and FT (Technical Support Unit). The first has a functional<br />
responsibility for <strong>the</strong> OEF process, <strong>the</strong> second is responsible for some activities<br />
(collecting, analysis, processing external and internal events, implementation <strong>of</strong><br />
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corrective actions programme (CAP), development <strong>of</strong> a new data base related <strong>to</strong> <strong>the</strong><br />
plant events, trend analyses). However, since <strong>the</strong> organizational changes started at <strong>the</strong><br />
end <strong>of</strong> 2007, it is <strong>to</strong>o early <strong>to</strong> evaluate <strong>the</strong> effectiveness <strong>of</strong> this responsibility subdivision.<br />
The plant uses <strong>the</strong> plant <strong>safety</strong> index (FSI) as a <strong>to</strong>ol for moni<strong>to</strong>ring <strong>the</strong> OEF process<br />
effectiveness. Annual reports submitted <strong>to</strong> <strong>the</strong> <strong>safety</strong> committee, evaluating causes <strong>of</strong><br />
events and some trends, are also used for this assessment. However, <strong>the</strong> existing<br />
moni<strong>to</strong>ring system only covers high level indica<strong>to</strong>rs <strong>of</strong> <strong>the</strong> OEF process at <strong>the</strong> moment.<br />
Reasonably low level indica<strong>to</strong>rs would make it possible <strong>to</strong> assess that <strong>the</strong> tasks carried<br />
out in <strong>the</strong> OEF process are effective. It is very important <strong>to</strong> provide measurable goals and<br />
objectives regarding <strong>the</strong> effectiveness <strong>of</strong> <strong>the</strong> OEF process. The <strong>team</strong> has made a<br />
suggestion in this area.<br />
6.2 REPORTING OF OPERATING EXPERIENCE<br />
Operating experience at <strong>the</strong> plant is identified and reported according <strong>to</strong> established<br />
criteria and procedures. The main types <strong>of</strong> events reported outside and inside <strong>the</strong> plant<br />
are:<br />
• events <strong>to</strong> be reported <strong>to</strong> <strong>the</strong> Swedish Nuclear Power Inspec<strong>to</strong>rate (SKI) in <strong>the</strong><br />
form <strong>of</strong> Licensee Event <strong>Report</strong>s (LERs);<br />
• events <strong>to</strong> be reported <strong>to</strong> <strong>the</strong> Swedish Radiation Protection Institute (SSI);<br />
• component failures;<br />
• low level events;<br />
• near misses;<br />
• observations <strong>of</strong> operating staff.<br />
<strong>Report</strong>ing <strong>of</strong> different types <strong>of</strong> events at <strong>the</strong> plant is regulated by numerous procedures<br />
(more than 12). Such fragmentation <strong>of</strong> reporting requirements in <strong>the</strong> plant documentation<br />
may lead <strong>to</strong> a situation when <strong>the</strong> relevant plant personnel are not fully aware <strong>of</strong> <strong>the</strong><br />
reporting process. As a result, <strong>the</strong> fragmentation in <strong>the</strong> reporting process may lead <strong>to</strong><br />
performance issues. The plant is encouraged <strong>to</strong> integrate reporting requirements for<br />
different types <strong>of</strong> events in<strong>to</strong> a single document.<br />
The reporting criteria for events <strong>to</strong> be reported <strong>to</strong> SKI and SSI and <strong>the</strong> timeliness <strong>of</strong> <strong>the</strong>ir<br />
reporting are well defined and strictly met.<br />
A formal procedure for organization <strong>of</strong> <strong>the</strong> investigation process exists at <strong>the</strong> plant (F-I-<br />
158 “Description <strong>of</strong> LER Documentation”). In addition, <strong>the</strong> procedures which have stepby-step<br />
instructions for managing <strong>the</strong> event inquiry are also provided for each unit (for<br />
example, for unit 3 it is <strong>the</strong> “Operational Disturbance Management and In-depth<br />
Technical Disturbance Analysis” (F3-I-1158).<br />
The following levels <strong>of</strong> in-house reporting are established at <strong>the</strong> plant:<br />
• Shift supervisor;<br />
• Operational management level 3 (operations manager);<br />
• Operational management level 2 (unit manager);<br />
• Operational management level 1 (President);<br />
• Safety and Environment Unit;<br />
• Engineering and Maintenance Units.<br />
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The reporting process at <strong>the</strong> plant also includes reports <strong>to</strong> <strong>the</strong> following authorities:<br />
• County Administrative Board;<br />
• Swedish Work Environment Authority;<br />
• Swedish National Electrical Safety Board;<br />
• Municipality Rescue Service Board;<br />
• National Board <strong>of</strong> Fisheries;<br />
• Swedish Environmental Protection Agency.<br />
Activities <strong>of</strong> <strong>the</strong> OEF programme, such as <strong>the</strong> handling and analysis <strong>of</strong> low level events<br />
and near misses are covered, but <strong>the</strong> criteria for reporting is not clearly defined in <strong>the</strong><br />
existing documents. Such uncertainties may lead <strong>to</strong> missed opportunities <strong>to</strong> evaluate<br />
events or potential problems such as precursors <strong>of</strong> significant events as well as additional<br />
data <strong>to</strong> draw realistic conclusions and take actions <strong>to</strong> improve <strong>the</strong> <strong>operational</strong> <strong>safety</strong> <strong>of</strong><br />
<strong>the</strong> plant. One <strong>of</strong> <strong>the</strong> reporting procedures, namely F-I-324 “<strong>Report</strong>ing <strong>of</strong> work injuries<br />
and near misses and reporting <strong>to</strong> <strong>the</strong> authorities”, gives more clear definitions for near<br />
misses in <strong>the</strong> area <strong>of</strong> industrial <strong>safety</strong> and radiation protection. However, this approach<br />
has not been applied by <strong>the</strong> plant <strong>to</strong> o<strong>the</strong>r areas <strong>of</strong> activities (operation, maintenance,<br />
etc.). The <strong>team</strong> has made a recommendation in this area.<br />
6.3 SOURCES OF OPERATING EXPERIENCE<br />
The possible sources <strong>of</strong> in-house operating experience are identified at <strong>the</strong> plant. These<br />
include areas such as: significant events, low level events and near misses, quality<br />
reports, reports and data from operation activities, maintenance testing and in-service<br />
inspection, surveillance reports, results from plant specific <strong>safety</strong> assessments, training<br />
feedback, non-blame reporting programme, performance indica<strong>to</strong>rs. Licensee Event<br />
<strong>Report</strong>s (LERs) are <strong>the</strong> main source <strong>of</strong> OE at <strong>the</strong> plant. According <strong>to</strong> <strong>the</strong> procedure, all<br />
events reported <strong>to</strong> SKI are used in <strong>the</strong> OEF process. Access <strong>of</strong> <strong>the</strong> plant personnel <strong>to</strong><br />
<strong>the</strong>se sources is formally established and reports are distributed in a printed version and<br />
electronic formats.<br />
The plant uses several different external sources <strong>of</strong> OE, including good practices, as a<br />
source <strong>of</strong> improvement. For <strong>the</strong> BWR operating experience feedback, Sweden is part <strong>of</strong> a<br />
Nordic system where a common organization ERFATOM <strong>review</strong>s experience feedback<br />
for reac<strong>to</strong>r <strong>safety</strong> and operation <strong>of</strong> nuclear facilities. O<strong>the</strong>r experience feedback, initiated<br />
by ERFATOM or internal organizations, is also <strong>review</strong>ed and placed in a common<br />
database. ERFATOM is formed by <strong>the</strong> Swedish and Finnish BWR-opera<strong>to</strong>rs and<br />
Westinghouse Electric Sweden AB. The analysis work is performed by representatives <strong>of</strong><br />
<strong>the</strong>se organizations and <strong>the</strong> result <strong>of</strong> <strong>the</strong> work is reported <strong>to</strong> <strong>the</strong> plants in weekly and<br />
monthly reports complemented with <strong>to</strong>pical and annual reports. The event reports are<br />
classified. Severe events also include recommendations directed <strong>to</strong>wards <strong>the</strong> Swedish<br />
and Finnish opera<strong>to</strong>rs.<br />
O<strong>the</strong>r external sources <strong>of</strong> OE include reports from IAEA/NEA IRS and reports from<br />
WANO (including SER, SOER). These sources <strong>of</strong> information are screened by KSU in<br />
cooperation with ERFATOM. KSU maintains <strong>the</strong> interface between <strong>the</strong> plant and<br />
WANO. In addition, external sources <strong>of</strong> OE include information on OE <strong>of</strong> similar<br />
systems and components (electrical, mechanical, etc.) from o<strong>the</strong>r power industry<br />
activities in <strong>the</strong> country and from o<strong>the</strong>r countries operating BWRs. There is intensive<br />
participation <strong>of</strong> plant personnel in exchange <strong>of</strong> OE related <strong>to</strong> maintenance matters in<br />
different programmes and forums such as Nordic Owners Group, BWR Owners Group,<br />
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INPO/EPRI, Vattenfall, Westinghouse, Als<strong>to</strong>m (not only nuclear enterprises), IAEA<br />
programs for training maintenance personnel and contrac<strong>to</strong>rs, I&C technical and<br />
managerial meeting, Outage maintenance experience and SKI meetings.<br />
6.4 SCREENING OF OPERATING EXPERIENCE INFORMATION<br />
Internal events are primarily screened at <strong>the</strong> plant during daily planning meetings, <strong>the</strong><br />
weekly <strong>operational</strong> <strong>review</strong> meetings and <strong>the</strong> <strong>safety</strong> committee meetings.<br />
The department for OEF initiated, in January 2008, a new screening process for internal<br />
events <strong>of</strong> any categories with a group <strong>of</strong> OEF coordina<strong>to</strong>rs. One <strong>of</strong> <strong>the</strong> items <strong>of</strong> this<br />
“weekly screening meeting” is <strong>the</strong> presentation <strong>of</strong> <strong>the</strong> main stages <strong>of</strong> RCA<br />
methodologies (as self-training) as well as <strong>the</strong> demonstration <strong>of</strong> access <strong>to</strong> <strong>the</strong> external<br />
sources <strong>of</strong> OE information (for example WANO Operating Experience Programme).<br />
However, <strong>the</strong> screening process for internal OE is not established in <strong>the</strong> plant procedures.<br />
Accordingly, <strong>the</strong>re are no criteria for systematic screening <strong>of</strong> in-house events. Screening<br />
<strong>of</strong> OE information should be undertaken <strong>to</strong> ensure that all significant matters relevant <strong>to</strong><br />
<strong>safety</strong> are considered and that all applicable lessons learned are taken in<strong>to</strong> account. The<br />
screening process should also be used <strong>to</strong> select events for detailed analysis and <strong>to</strong><br />
prioritize OE information use according <strong>to</strong> <strong>safety</strong> significance and <strong>the</strong> identification <strong>of</strong><br />
adverse trends. The <strong>team</strong> has made a recommendation in this area.<br />
External events are primarily screened and evaluated at ERFATOM teleconference<br />
meetings held every second week. The participants <strong>of</strong> <strong>the</strong> teleconference meeting are<br />
senior engineers from Westinghouse, Nordic utilities, FKA and KSU. The events are<br />
classified by participants on four categories: Class A (High impact on <strong>safety</strong>. Evaluated<br />
in details and followed by actions <strong>to</strong> be taken at <strong>the</strong> plant. In some cases <strong>the</strong> actions <strong>to</strong> be<br />
taken are upgraded <strong>to</strong> ERFATOM Recommendation), Class B (Medium impact on<br />
<strong>safety</strong>. Root cause analysis and relevance for o<strong>the</strong>r Nordic BWR is reported), Class C<br />
(Minor impact on <strong>safety</strong>. May be <strong>of</strong> interest for o<strong>the</strong>r plants and is reported), Class N<br />
(Not applicable or <strong>of</strong> no interest <strong>to</strong> Nordic BWRs). After consensus has been reached on<br />
<strong>the</strong> evaluated event, <strong>the</strong> project manager issues <strong>the</strong> ERFATOM evaluation report which<br />
is distributed electronically <strong>to</strong> <strong>the</strong> utilities. ERFATOM handles approximately 300<br />
reports per year.<br />
At <strong>the</strong> plant, ERFATOM evaluation reports are handling by <strong>the</strong> group <strong>of</strong> OEF<br />
coordina<strong>to</strong>rs and administered by <strong>the</strong> department for OEF.<br />
Significant reports, such as WANO SOERs are screened and <strong>review</strong>ed by <strong>the</strong> plant <strong>safety</strong><br />
committee. As a result <strong>of</strong> <strong>the</strong> <strong>review</strong>, analysis <strong>of</strong> <strong>the</strong> applicability for <strong>the</strong> plant is<br />
performed and reported back <strong>to</strong> <strong>the</strong> <strong>safety</strong> committee, where decisions on fur<strong>the</strong>r actions<br />
are taken.<br />
6.5 ANALYSIS<br />
Special analyses techniques are established for events that affect <strong>the</strong> interplay between<br />
Man, Technology and Organisation (MTO). Nuclear <strong>safety</strong> events and industrial <strong>safety</strong><br />
incidents and accidents are analysed. The events are categorised and trended by an MTO<br />
group comprising representatives <strong>of</strong> <strong>the</strong> Production Units, Maintenance Unit, Technical<br />
Support Unit and <strong>the</strong> Safety and Environment Unit. Behavioural scientific experts also<br />
participate in <strong>the</strong> analyses.<br />
Both <strong>the</strong> Maintenance and Technical Support Units have resources for technical analysis.<br />
The process <strong>of</strong> event analysis in <strong>the</strong> Maintenance Unit is controlled by FM-I-017<br />
“Maintenance Unit’s and Production Unit’s Operating Experience Feedback Activities”.<br />
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Full root cause analysis is required if an event has involved <strong>safety</strong> or <strong>safety</strong> related<br />
systems, i.e. for events <strong>to</strong> be reported <strong>to</strong> SKI. However, <strong>the</strong> existing RCA methodology<br />
(FT-I-1397) as well as <strong>the</strong> MTO-analysis (F-I-126) is used for a limited number <strong>of</strong> events<br />
(only significant events from <strong>the</strong> plant’s point <strong>of</strong> view or upon request <strong>of</strong> <strong>the</strong> regula<strong>to</strong>r).<br />
The <strong>team</strong> <strong>to</strong>ok in<strong>to</strong> account that <strong>the</strong> improvement <strong>of</strong> <strong>the</strong> OEF process at <strong>the</strong> plant started<br />
in autumn <strong>of</strong> 2007. Review showed that this is being progressed.<br />
As stated, root cause analysis process is described in two separate documents for<br />
different levels <strong>of</strong> investigation: FT-I-1397 “General Instructions for Analysis” and F-I-<br />
126 “MTO process”. Taking in<strong>to</strong> account similar elements <strong>of</strong> applied methodologies<br />
(ASSET, HPES and MTO) it would be more logic and practical <strong>to</strong> provide <strong>the</strong> root cause<br />
analysis process for different types <strong>of</strong> events in a single document. It is very important <strong>to</strong><br />
provide a document with clear definitions <strong>of</strong> abnormal events, recurrent events, apparent<br />
causes, direct causes, root causes, contributing fac<strong>to</strong>rs, etc. as well as a classification <strong>of</strong><br />
causes applicable <strong>to</strong> any event at <strong>the</strong> plant. Therefore, <strong>the</strong> plant is encouraged <strong>to</strong> enhance<br />
<strong>the</strong> procedure for <strong>the</strong> event root cause analysis process.<br />
In 2007, an independent <strong>review</strong> <strong>of</strong> all LERs and assessment <strong>of</strong> significant external events<br />
by <strong>the</strong> <strong>safety</strong> committee was initiated. The <strong>review</strong> involved an assessment <strong>of</strong> root causes,<br />
<strong>of</strong> <strong>the</strong> adequacy and <strong>the</strong> applicability <strong>of</strong> corrective actions and a <strong>safety</strong> assessment <strong>of</strong> <strong>the</strong><br />
event. The LERs are submitted <strong>to</strong> SKI after this <strong>review</strong>.<br />
A structured approach in presenting evaluations <strong>of</strong> high level OE reports <strong>to</strong> <strong>the</strong> <strong>to</strong>p<br />
management ensures that dissemination <strong>of</strong> OE is efficient and correctly addressed. Each<br />
WANO Significant Event <strong>Report</strong> (SER) and Significant Operating Experience <strong>Report</strong><br />
(SOER) at <strong>the</strong> plant is assessed in <strong>the</strong> highest and most important forum for <strong>safety</strong> issues:<br />
<strong>the</strong> plant Safety Committee. Upper management is involved in <strong>the</strong> processing and<br />
evaluation <strong>of</strong> <strong>the</strong>se documents. An assessment is first performed for applicability,<br />
relevance and importance <strong>to</strong> <strong>safety</strong> and <strong>the</strong>n <strong>the</strong> reports are forwarded <strong>to</strong> <strong>the</strong> responsible<br />
department for more thorough analysis. Time for presentation <strong>of</strong> <strong>the</strong> results in <strong>the</strong> FKA<br />
Safety Committee is scheduled in <strong>the</strong> meeting agenda. The WANO SER and SOER<br />
documents have been processed in this manner since March 2007. The <strong>team</strong> considers<br />
this as a good performance.<br />
6.6 CORRECTIVE ACTIONS<br />
The development <strong>of</strong> corrective actions is described in FT-I-1397 “General Instructions<br />
for Analysis”. The corrective actions are expected <strong>to</strong> be SMART (specific, measurable,<br />
achievable, realistic, within appropriate time). However, criteria for prioritization <strong>of</strong><br />
corrective actions and for conservative decision making are not clearly defined in<br />
procedures because <strong>the</strong> existing programme was developed a long time ago and has not<br />
been adapted <strong>to</strong> cater for <strong>the</strong> follow up <strong>of</strong> corrective actions.<br />
The work order system is used <strong>to</strong> track corrective actions. For LERs and component<br />
failures registered in <strong>the</strong> FENIX tracking system, <strong>the</strong> progress <strong>of</strong> corrective action<br />
implementation is provided. For minor events and near misses, tracking is provided in<br />
limited areas <strong>of</strong> activities at <strong>the</strong> plant.<br />
A <strong>review</strong> <strong>of</strong> corrective actions status and effectiveness is periodically performed by <strong>the</strong><br />
plant units responsible for implementation <strong>of</strong> corrective actions and by <strong>the</strong> plant <strong>safety</strong><br />
committee.<br />
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During <strong>the</strong> <strong>mission</strong>, <strong>the</strong> plant demonstrated <strong>to</strong> <strong>the</strong> <strong>team</strong> that positive steps were being<br />
taken <strong>to</strong> improve <strong>the</strong> OEF process including <strong>the</strong> development <strong>of</strong> a Corrective Actions<br />
Programme (CAP) which was started in autumn <strong>of</strong> 2007. The new CAP includes <strong>the</strong><br />
detection <strong>of</strong> deviations, documentation, decision on analyses, prioritizing, identification<br />
<strong>of</strong> corrective actions, control and approval <strong>of</strong> actions, tracking <strong>of</strong> actions, moni<strong>to</strong>ring and<br />
trending.<br />
6.7 USE OF OPERATING EXPERIENCE<br />
Information on event reports and analysis results is accessible <strong>to</strong> plant personnel through<br />
<strong>the</strong> intranet. However, <strong>the</strong> department for OEF (FTQ) has no access <strong>to</strong> <strong>the</strong> unit’s data<br />
bases on LERs. The plant is encouraged <strong>to</strong> enhance <strong>the</strong> existing process for access <strong>to</strong> inhouse<br />
sources <strong>of</strong> OE information.<br />
Operating experience data is extensively used in <strong>the</strong> main control room and for o<strong>the</strong>r<br />
plant personnel training at <strong>the</strong> training centre. Information on most significant events is<br />
analyzed and <strong>the</strong>n implemented in KSU simula<strong>to</strong>r training. The data that are considered<br />
<strong>to</strong> be applicable <strong>to</strong> <strong>the</strong> plant are analyzed and incorporated in<strong>to</strong> <strong>the</strong> training programmes<br />
<strong>of</strong> <strong>the</strong> relevant personnel. In <strong>the</strong> Maintenance Unit, <strong>the</strong> information on <strong>the</strong> applicable<br />
internal and external OE is introduced <strong>to</strong> <strong>the</strong> supervisors and workers (including<br />
contrac<strong>to</strong>r personnel) <strong>to</strong> focus <strong>the</strong>m on <strong>the</strong> important aspects: specifics, cautions, etc. <strong>of</strong><br />
<strong>the</strong> forthcoming activity. The plant practices <strong>the</strong> utilization <strong>of</strong> <strong>the</strong> relevant OE<br />
information before important operating activities via pre-job briefings.<br />
The plant also maintains <strong>the</strong> following systems for OE dissemination: <strong>the</strong> outage<br />
experience system on <strong>the</strong> results <strong>of</strong> <strong>the</strong> units’ maintenance, Digitala Logböcker<br />
(observations <strong>of</strong> operating staff), <strong>the</strong> system for all employees <strong>to</strong> report <strong>to</strong> <strong>the</strong><br />
management “Öppen Kanal”.<br />
Despite <strong>the</strong> fact that <strong>the</strong> plant has disseminated a large amount <strong>of</strong> valuable information<br />
regarding internal and external OE <strong>to</strong> <strong>the</strong> staff, feedback is not manda<strong>to</strong>ry. This is<br />
because <strong>of</strong> <strong>the</strong> feedback process regarding <strong>the</strong> OE information is not clearly formalized<br />
and documented at <strong>the</strong> plant. A considerable amount <strong>of</strong> external and internal OE<br />
information is placed on <strong>the</strong> plant intranet system. However, <strong>the</strong> existing system <strong>of</strong><br />
organization and logging <strong>the</strong> feedback from recipients <strong>of</strong> OE information does not allow<br />
tracking <strong>to</strong> assess adequately who was specifically informed and what fur<strong>the</strong>r actions<br />
follow, i.e. findings and remedial actions. The plant is encouraged <strong>to</strong> enhance <strong>the</strong><br />
established procedures for <strong>the</strong> control <strong>of</strong> in-house activities <strong>of</strong> <strong>the</strong> feedback <strong>of</strong> OE <strong>to</strong><br />
ensure that <strong>the</strong>y are consistent with <strong>the</strong> objectives <strong>of</strong> <strong>the</strong> management system.<br />
6.8 DATA BASE AND TRENDING OF OPERATING EXPERIENCE<br />
The plant maintains several data bases <strong>to</strong> facilitate <strong>the</strong> handling <strong>of</strong> OE throughout <strong>the</strong><br />
respective units.<br />
The data base on events reported <strong>to</strong> SKI (LERs) complies with <strong>the</strong> investigation reports<br />
with <strong>the</strong>ir <strong>safety</strong> assessment, identified causes and proposed corrective actions. This data<br />
base is generated and maintained by each responsible production unit. Results <strong>of</strong><br />
supporting in-depth event analysis are s<strong>to</strong>red separately in <strong>the</strong> form <strong>of</strong> analysis reports.<br />
Specific corrective actions developed after <strong>the</strong> event investigation are s<strong>to</strong>red and tracked<br />
in <strong>the</strong> work order system. The existing subsystem for tracking LERs, in particular, has a<br />
limited structure and coding <strong>of</strong> causes. The s<strong>of</strong>tware <strong>of</strong> <strong>the</strong> data base allows for <strong>the</strong><br />
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etrieval <strong>of</strong> events by a limited number <strong>of</strong> attributes (report number, category, causes,<br />
etc.).<br />
The plant maintains <strong>the</strong> FENIX system which provides <strong>the</strong> integrated information<br />
analysis support <strong>of</strong> plant operation problems related <strong>to</strong> component operation his<strong>to</strong>ry, <strong>to</strong><br />
maintenance, <strong>to</strong> spare parts, radiation <strong>safety</strong> and fire protection, etc. LER information<br />
related <strong>to</strong> component operation is also put in<strong>to</strong> <strong>the</strong> data base. The FENIX system has a<br />
procedure called “Data export in<strong>to</strong> “TUD system” for <strong>the</strong> au<strong>to</strong>matic preparation <strong>of</strong><br />
structured information package <strong>to</strong> be transmitted from <strong>the</strong> unit in<strong>to</strong> <strong>the</strong> TUD system (for<br />
Swedish and Finnish BWR plants). The TUD system collects data <strong>of</strong> component and<br />
equipment faults. The data is <strong>the</strong> basis for component and equipment failure rate<br />
calculations that, in turn, are used for probabilistic <strong>safety</strong> analysis (PSA).<br />
For minor events, including low level events and near misses, a data base has not been<br />
developed. Fragmented parts <strong>of</strong> minor events are s<strong>to</strong>red in different systems.<br />
The classification/coding <strong>of</strong> events <strong>of</strong> different types is not defined in <strong>the</strong> plant<br />
procedures. The existing trending system covers only events reported <strong>to</strong> SKI and<br />
component failures. Trending is performed by different plant units on <strong>the</strong> basis <strong>of</strong><br />
experts’ experience because <strong>of</strong> <strong>the</strong> absence <strong>of</strong> established criteria. Using data base<br />
information, <strong>the</strong> plant issues monthly, quarterly and annual unit operation reports. These<br />
reports contain information on component reliability, plant operation schedules,<br />
economic indica<strong>to</strong>rs, WANO performance indica<strong>to</strong>rs, etc. <strong>Report</strong>s are also forwarded <strong>to</strong><br />
interested organizations (Vattenfall, SKI). Results <strong>of</strong> trend analyses are compiled in<br />
annual reports presented <strong>to</strong> <strong>the</strong> <strong>safety</strong> committee.<br />
A new data base is under development <strong>to</strong> provide access <strong>to</strong> OE information <strong>to</strong> <strong>the</strong> plant<br />
employees. The <strong>team</strong> recommends enhancing <strong>the</strong> structure <strong>of</strong> <strong>the</strong> existing data base on<br />
events reported <strong>to</strong> SKI (LERs) by developing an integral data base with minor events,<br />
with application <strong>of</strong> a common coding system for all types <strong>of</strong> events. Coding systems<br />
developed by <strong>the</strong> IAEA/NEA (IRS) and WANO could be a basis for <strong>the</strong> plant system.<br />
6.9 ASSESSMENTS AND INDICATORS OF OPERATING EXPERIENCE<br />
A <strong>review</strong> <strong>of</strong> <strong>the</strong> OEF process has been performed by <strong>the</strong> plant Safety and Environmental<br />
Unit and Technical Support Unit. However, no performance indica<strong>to</strong>rs directly related <strong>to</strong><br />
<strong>the</strong> plant OEF process have been established, o<strong>the</strong>r that a monthly <strong>review</strong> (report) on<br />
reportable events and an annual report on plant operation, nei<strong>the</strong>r <strong>of</strong> which can be<br />
considered as a comprehensive self-assessment. The plant also has had no opportunity <strong>to</strong><br />
benchmark with o<strong>the</strong>r plants and utilities <strong>to</strong> identify fur<strong>the</strong>r improvements because it has<br />
no data on <strong>the</strong> particular trends <strong>of</strong> low level events and near misses.<br />
The plant uses <strong>the</strong> <strong>Forsmark</strong> Safety Index (FSI) as a <strong>to</strong>ol for moni<strong>to</strong>ring <strong>the</strong> OEF process<br />
effectiveness. Annual reports submitted <strong>to</strong> <strong>the</strong> <strong>safety</strong> committee evaluating causes <strong>of</strong><br />
events and some trends are also used for this assessment.<br />
In addition <strong>to</strong> <strong>the</strong> FSI, <strong>the</strong>re are twenty one Quality Indica<strong>to</strong>rs that were developed in<br />
2007 and are in trial operation. These indica<strong>to</strong>rs are <strong>the</strong>re <strong>to</strong> measure <strong>the</strong> effect <strong>of</strong> <strong>the</strong><br />
corrective action programme. However, some <strong>of</strong> <strong>the</strong> indica<strong>to</strong>rs are duplicated with <strong>the</strong><br />
indica<strong>to</strong>rs from FSI.<br />
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These indica<strong>to</strong>rs do not reflect <strong>the</strong> timeliness <strong>of</strong> OEF process, recurrent events and root<br />
causes, average time for initial screening <strong>of</strong> OE, number and age <strong>of</strong> reports awaiting<br />
evaluation, number and age <strong>of</strong> corrective actions awaiting implementation, etc. The <strong>team</strong><br />
has made a suggestion in this area.<br />
A special <strong>review</strong> <strong>of</strong> <strong>the</strong> event <strong>of</strong> 25 July 2006 was conducted and is included as an<br />
attachment <strong>to</strong> this section.<br />
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DETAILED OPERATION EXPERIENCE FINDINGS<br />
6.1 MANAGEMENT OF OPERATING EXPERIENCE FEEDBACK<br />
6.1(1) Issue: The plant procedures do not clearly define <strong>the</strong> criteria for reporting <strong>of</strong><br />
events less significant than events <strong>to</strong> be reported <strong>to</strong> <strong>the</strong> regula<strong>to</strong>ry authority.<br />
• The procedure FT-I-1397 “General Instructions for Analysis” sets only<br />
generic definitions <strong>of</strong> minor events, low level events, near misses, namely:<br />
“Minor events (<strong>of</strong> lesser importance <strong>to</strong> reac<strong>to</strong>r <strong>safety</strong>)”.<br />
• The procedure F-I-324 “<strong>Report</strong>ing <strong>of</strong> work injuries and near misses and<br />
reporting <strong>to</strong> <strong>the</strong> authorities” gives relatively clear definitions for near misses<br />
but in <strong>the</strong> area <strong>of</strong> industrial <strong>safety</strong> and radiation protection only.<br />
• The procedure FM-I-037 “Disturbance analysis instruction – Maintenance”<br />
has only a generic definition <strong>of</strong> minor events. For example:<br />
“Level 1<br />
Disturbance for which <strong>the</strong> cause is unknown and analysis is required. This indepth<br />
analysis is initiated for major disturbances where internal <strong>operational</strong><br />
disturbance analyses are deemed insufficient.<br />
Level 2<br />
Minor disturbance for which <strong>the</strong> underlying cause is unknown and a simple<br />
disturbance analysis is deemed sufficient. It is normally initiated by FMY<br />
when assessing a work order. A simple reporting template is used.”<br />
It may lead <strong>to</strong> missed opportunities <strong>to</strong> evaluate events or potential problems such as<br />
precursors <strong>of</strong> significant events as well as additional data <strong>to</strong> draw realistic conclusions<br />
and take actions <strong>to</strong> improve <strong>operational</strong> <strong>safety</strong> <strong>of</strong> <strong>the</strong> plant. By taking action in<br />
response <strong>to</strong> minor events and potential problems as part <strong>of</strong> <strong>the</strong> plant OE data can<br />
prevent more significant events from occurring.<br />
Recommendation: The plant should provide clearly defined criteria for reporting<br />
<strong>of</strong> events which are less significant than events <strong>to</strong> be reported <strong>to</strong> <strong>the</strong> regula<strong>to</strong>ry<br />
authority <strong>to</strong> enhance <strong>the</strong> plant operating experience feedback system. The criteria<br />
should be clearly communicated <strong>to</strong> all staff and contrac<strong>to</strong>rs <strong>to</strong> ensure adequate<br />
reporting levels.<br />
Note: IAEA-TECDOC-1477: Trending <strong>of</strong> low level events and near misses <strong>to</strong> enhance<br />
<strong>safety</strong> performance in nuclear power plants.<br />
“The objective <strong>of</strong> this publication is <strong>to</strong> provide guidance for <strong>the</strong> enhancement <strong>of</strong><br />
<strong>operational</strong> <strong>safety</strong> performance through <strong>the</strong> use <strong>of</strong> <strong>the</strong> low level events and near<br />
misses as an important input <strong>to</strong> <strong>the</strong> <strong>operational</strong> experience feedback (OEF) process”.<br />
Basis: NS-R-2; 2.24 All plant personnel shall be required <strong>to</strong> report all events and<br />
shall be encouraged <strong>to</strong> report on any ‘near misses’ relevant <strong>to</strong> <strong>the</strong> <strong>safety</strong> <strong>of</strong> <strong>the</strong> plant.<br />
INSAG-15; 3.4 (a) Failures and ‘near misses’ are considered by organizations with<br />
good <strong>safety</strong> cultures as lessons which can be used <strong>to</strong> avoid more serious events. There<br />
is thus a strong drive <strong>to</strong> ensure that all events which have <strong>the</strong> potential <strong>to</strong> be<br />
instructive are reported and investigated <strong>to</strong> discover <strong>the</strong> root causes, and that timely<br />
feedback is given on <strong>the</strong> findings and remedial actions, both <strong>to</strong> <strong>the</strong> work groups<br />
involved and <strong>to</strong> o<strong>the</strong>rs in <strong>the</strong> organization or industry who might experience <strong>the</strong> same<br />
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problem. This ‘horizontal’ communication is particularly important. Near misses are<br />
also very important because <strong>the</strong>y usually present a greater variety and volume <strong>of</strong><br />
information for learning. To achieve this, all employees need <strong>to</strong> be encouraged <strong>to</strong><br />
report even minor concerns.<br />
The following are pointers <strong>to</strong> consider in moving <strong>to</strong>wards a streng<strong>the</strong>ned <strong>safety</strong><br />
culture:<br />
(a) Are employees encouraged <strong>to</strong> report all events and near misses? Given that<br />
research has shown that <strong>the</strong> number <strong>of</strong> near misses usually exceeds <strong>the</strong> number <strong>of</strong><br />
actual events by at least an order <strong>of</strong> magnitude, is <strong>the</strong> ratio <strong>of</strong> reports <strong>of</strong> near misses <strong>to</strong><br />
events with real consequences sufficiently high?<br />
6.1(2) Issue: The plant has no initial training (for full scope <strong>of</strong> methodologies applied)<br />
or periodic requalification <strong>of</strong> personnel involved in <strong>the</strong> event root cause analysis<br />
process and use <strong>of</strong> operating experience.<br />
• A new department (FTQ) established at <strong>the</strong> plant for OEF and analysis<br />
support is composed <strong>of</strong> people qualified in plant operation, personnel training<br />
and human performance but not specially trained in a root cause analysis<br />
methodology as well as a methodology on OEF process.<br />
• Within <strong>the</strong> plant departments, <strong>the</strong>re are insufficient staff fully trained <strong>to</strong><br />
conduct full root cause analysis.<br />
Without having properly trained experts <strong>the</strong> analysis <strong>of</strong> events with respect <strong>to</strong> causes and<br />
contributing fac<strong>to</strong>rs as well as <strong>the</strong> operating experience process can be treated in an<br />
improper manner possibly resulting in recurrent <strong>safety</strong> significant events.<br />
Recommendation: The plant should organize and implement <strong>the</strong> system for regular<br />
training and retraining <strong>of</strong> personnel involved in<strong>to</strong> an event RCA process and OEF<br />
process.<br />
Basis: NS-G-2.4; 6.67 The responsibilities, qualification criteria and training<br />
requirements <strong>of</strong> personnel performing activities <strong>to</strong> <strong>review</strong> operating experience should be<br />
clearly defined. Personnel who conduct investigations <strong>of</strong> abnormal events should be<br />
provided with training in investigative root cause analysis techniques such as accident<br />
investigation, human fac<strong>to</strong>r analysis (including organizational fac<strong>to</strong>rs), management<br />
oversight and risk tree analysis, change analysis and barrier analysis. Event investiga<strong>to</strong>rs<br />
should be knowledgeable <strong>of</strong> plant design, procedures and operations.<br />
6.1(3) Issue: The plant does not provide a comprehensive and regular moni<strong>to</strong>ring <strong>of</strong> <strong>the</strong><br />
effectiveness <strong>of</strong> <strong>the</strong> OEF process.<br />
• The existing moni<strong>to</strong>ring system only covers high level <strong>of</strong> <strong>the</strong> OEF process and<br />
does not provide clear information on <strong>the</strong> effectiveness <strong>of</strong> <strong>the</strong> OE process at<br />
different levels <strong>of</strong> <strong>the</strong> organizational structure.<br />
• The organizational enhancements started in <strong>the</strong> end <strong>of</strong> 2007 as responsible<br />
subdivision for <strong>the</strong> OEF process.<br />
Ineffective assessment <strong>of</strong> <strong>the</strong> OEF process’ effectiveness may lead <strong>to</strong> <strong>the</strong> situation where<br />
a portion <strong>of</strong> employees are not involved in<strong>to</strong> <strong>the</strong> overall process for preventing <strong>the</strong><br />
reoccurrence <strong>of</strong> similar events and improving <strong>operational</strong> <strong>safety</strong> <strong>of</strong> <strong>the</strong> plant.<br />
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Suggestion: The plant should consider <strong>the</strong> enhancement <strong>of</strong> methods for <strong>review</strong> and<br />
moni<strong>to</strong>ring <strong>of</strong> <strong>the</strong> OEF process effectiveness.<br />
Basis: NS-G-2.4; 6.62 An effective programme for <strong>the</strong> <strong>review</strong> <strong>of</strong> operating experience<br />
should be established <strong>to</strong> provide methods <strong>to</strong> analyse both in-house events and events in<br />
<strong>the</strong> nuclear industry generally so as <strong>to</strong> identify plant specific actions needed <strong>to</strong> prevent<br />
<strong>the</strong> occurrence <strong>of</strong> similar events. In-house events <strong>of</strong> interest <strong>to</strong> o<strong>the</strong>r plants should be<br />
shared with <strong>the</strong> industry <strong>to</strong> prevent <strong>the</strong> occurrence <strong>of</strong> similar events. The effectiveness <strong>of</strong><br />
<strong>the</strong> operating experience <strong>review</strong> programme should be assessed periodically <strong>to</strong> identify<br />
areas <strong>of</strong> weakness that require improvement.<br />
6.4 SCREENING OF OPERATING EXPERIENCE INFORMATION<br />
6.4(1) Issue: The screening process for in-house operating experience information is not<br />
defined in <strong>the</strong> plant procedures.<br />
• Screening criteria for in-depth root cause analysis are not established.<br />
Responsibilities for this decision are unclear.<br />
• The thresholds for exclusion or inclusion <strong>of</strong> events as well as <strong>the</strong> prioritization<br />
<strong>of</strong> actions <strong>to</strong> be taken are not specified.<br />
• The amount <strong>of</strong> information introduced in<strong>to</strong> <strong>the</strong> plant OEF process is not<br />
evaluated.<br />
Recommendation: The plant should develop and implement a procedure for screening<br />
in-house OE information.<br />
Basis: NS-G-2.11; 3.1 Screening <strong>of</strong> event information is undertaken <strong>to</strong> ensure that all<br />
significant matters relevant <strong>to</strong> <strong>safety</strong> are considered and that all applicable lessons<br />
learned are taken in<strong>to</strong> account. The screening process should be used <strong>to</strong> select events for<br />
detailed investigation and analysis. This should include prioritization according <strong>to</strong> <strong>safety</strong><br />
significance and <strong>the</strong> identification <strong>of</strong> adverse trends.<br />
NS-G-2.11; 3.6 The screening <strong>of</strong> internal events should be carried out promptly <strong>to</strong><br />
assign priorities in <strong>the</strong> process for <strong>the</strong> feedback <strong>of</strong> experience from events and in <strong>the</strong><br />
follow-up actions. The screening <strong>of</strong> internal events should be performed first by<br />
appropriate personnel <strong>to</strong> determine whe<strong>the</strong>r <strong>the</strong>re is any immediate implication for <strong>the</strong><br />
plant. Events should <strong>the</strong>n be screened by a suitable multidisciplinary group <strong>of</strong> plant<br />
personnel on <strong>the</strong> basis <strong>of</strong> specified criteria <strong>to</strong> determine whe<strong>the</strong>r <strong>the</strong> regula<strong>to</strong>ry body or<br />
representatives <strong>of</strong> <strong>the</strong> utility need <strong>to</strong> be notified. This group should meet regularly <strong>to</strong><br />
<strong>review</strong> every event that occurs at <strong>the</strong> plant and <strong>to</strong> discuss whe<strong>the</strong>r <strong>the</strong> causes have been<br />
clearly identified, whe<strong>the</strong>r corrective actions have been taken or planned, and whe<strong>the</strong>r <strong>the</strong><br />
corrective actions are commensurate with <strong>the</strong> causes <strong>of</strong> <strong>the</strong> event. The events that were<br />
screened and initially found <strong>to</strong> be <strong>of</strong> less <strong>safety</strong> significance should be considered for<br />
trend analysis. The results <strong>of</strong> screening may be <strong>review</strong>ed in subsequent periodic plant<br />
self-assessments or in peer <strong>review</strong>s. The his<strong>to</strong>ry <strong>of</strong> <strong>the</strong> screening process should be made<br />
available <strong>to</strong> <strong>the</strong> regula<strong>to</strong>ry body.<br />
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6.7. USE OF OPERATING EXPERIENCE<br />
6.7(a) Good Practice: Structured cooperation with <strong>the</strong> original equipment manufacturer<br />
(OEM) for OE dissemination for improvement <strong>of</strong> <strong>safety</strong>.<br />
It is advisable <strong>to</strong> integrate <strong>the</strong> knowledge from <strong>the</strong> OEM in <strong>the</strong> OE process for two<br />
reasons. Firstly, <strong>the</strong> expertise <strong>of</strong> personnel at <strong>the</strong> OEM can be used for <strong>the</strong> evaluation <strong>of</strong><br />
<strong>the</strong> reports. Then <strong>the</strong> reports can be used as a basis for initiating bilateral technical<br />
projects.<br />
In cooperation with <strong>the</strong> original equipment manufacturer (OEM) Westinghouse Electric<br />
Sweden (former ASEA-ATOM) <strong>the</strong> plant has <strong>to</strong>ge<strong>the</strong>r with <strong>the</strong> o<strong>the</strong>r opera<strong>to</strong>rs<br />
established a programme for screening external events. This programme is called<br />
ERFATOM and has been <strong>operational</strong> since 1994.<br />
The input comes from sources commonly used in <strong>the</strong> industry, e.g. WANO, IRS, and<br />
NRC. In addition Finnish and Swedish reports (Licensee Event <strong>Report</strong>s) <strong>to</strong> <strong>the</strong> regula<strong>to</strong>ry<br />
bodies are used as input.<br />
Each utility has <strong>the</strong> opportunity <strong>to</strong> report events <strong>of</strong> interest even if <strong>the</strong> event is not<br />
reportable <strong>to</strong> <strong>the</strong> regula<strong>to</strong>ry body.<br />
Each event is screened for applicability for <strong>the</strong> BWR-plants in Sweden and Finland. The<br />
programme has a designated engineer at each site for <strong>the</strong> evaluation <strong>of</strong> <strong>the</strong> reported<br />
events. A common database is used for <strong>the</strong> processing <strong>of</strong> <strong>the</strong> reported events. At <strong>the</strong><br />
OEM <strong>the</strong> knowledge from <strong>safety</strong> experts and component/system engineers are used for<br />
<strong>the</strong> evaluation. The events that pass <strong>the</strong> first screening are classified according <strong>the</strong>ir<br />
relevance <strong>to</strong> <strong>safety</strong>.<br />
A telephone conference is held every fortnight with representatives from FKA, OKG,<br />
RAB, TVO and OEM Westinghouse in cooperation with ERFATOM. At <strong>the</strong> conference,<br />
<strong>the</strong> events are <strong>to</strong> be evaluated (international events and international and Swedish LERs)<br />
are selected. These events are <strong>the</strong>n evaluated and prioritized before <strong>the</strong>y are presented <strong>to</strong><br />
<strong>the</strong> opera<strong>to</strong>rs. This approach ensures that disciplined contact with <strong>the</strong> manufacturer<br />
(OEM) concerning events that have occurred in <strong>the</strong> nuclear-branch is maintained.<br />
The output is a report issued every second week where additional relevant comments are<br />
noted. The plants have this report and may use it for additional work in a separate<br />
database.<br />
In this way <strong>the</strong> utilities use <strong>the</strong> OEM expertise evaluations <strong>of</strong> events for improving<br />
<strong>safety</strong>.<br />
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ATTACHMENT<br />
EVENT OF 25 JULY 2006<br />
Summary <strong>of</strong> Event<br />
On 25 July 2006 <strong>Forsmark</strong> Unit 1 was in full power operation when a disturbance<br />
occurred in <strong>the</strong> <strong>of</strong>f-site 400kV sub-station that caused <strong>the</strong> reac<strong>to</strong>r <strong>to</strong> au<strong>to</strong>matically trip.<br />
The event generated two transients on <strong>the</strong> power supply <strong>to</strong> <strong>the</strong> unit. The first was an over<br />
voltage transient that caused <strong>the</strong> failure <strong>of</strong> two Un-interruptible Power Supply systems<br />
serving <strong>the</strong> 220 V AC grid in trains A and B. (C and D were unaffected by <strong>the</strong> transient)<br />
These 220V AC systems were necessary for <strong>the</strong> operation <strong>of</strong> <strong>the</strong> emergency diesel<br />
genera<strong>to</strong>rs (EDG) associated with trains A and B. The second transient was a low<br />
frequency transient that caused disconnection <strong>of</strong> <strong>the</strong> <strong>of</strong>f-site power <strong>to</strong> <strong>the</strong> <strong>safety</strong> related<br />
bus bars.<br />
The transients resulted in an au<strong>to</strong>matic reac<strong>to</strong>r power reduction and reduction <strong>of</strong> <strong>the</strong><br />
speed <strong>of</strong> <strong>the</strong> main recirculation pumps. The unit went on<strong>to</strong> house load operation for a<br />
short period before signals were received for reac<strong>to</strong>r au<strong>to</strong>matic trip, isolation <strong>of</strong> <strong>the</strong><br />
primary containment and <strong>the</strong> start <strong>of</strong> <strong>the</strong> reac<strong>to</strong>r <strong>safety</strong> systems.<br />
All four EDGs started au<strong>to</strong>matically, but A and B EDGs did not connect <strong>to</strong> <strong>the</strong>ir<br />
respective bus bars due <strong>to</strong> loss <strong>of</strong> <strong>the</strong>ir speed signal power supply.<br />
In this situation two out <strong>of</strong> four trains in each <strong>safety</strong> system were <strong>operational</strong>ly available<br />
(auxiliary feed water system, core spray system and containment spray system). Two out<br />
<strong>of</strong> four trains will provide 100% capability. The loss <strong>of</strong> two 220V AC bus bars however<br />
caused several isolation signals and also loss <strong>of</strong> several information systems in <strong>the</strong> Main<br />
Control Room (MCR). All <strong>of</strong> <strong>the</strong> above failures, au<strong>to</strong>matic changeovers, and transients<br />
occurred within <strong>the</strong> first minute <strong>of</strong> <strong>the</strong> event. The 70kV electrical system remained<br />
available throughout <strong>the</strong> event.<br />
The control room staff initiated <strong>the</strong> “first checks <strong>of</strong> disturbances” immediately. On<br />
completion <strong>of</strong> <strong>the</strong> initial checks, <strong>the</strong> “General Disturbance Instruction” was implemented<br />
and following a <strong>review</strong> <strong>of</strong> all available information, after approximately 22 minutes, <strong>the</strong><br />
6.6kV power supply <strong>to</strong> sub-divisions A and B was reconnected and thus all power was<br />
available <strong>to</strong> <strong>the</strong> unit. After 45 minutes <strong>the</strong> opera<strong>to</strong>rs confirmed that <strong>the</strong> unit was in a shutdown<br />
mode (Hot Standby). Following initial fault finding investigations and <strong>review</strong> <strong>of</strong><br />
<strong>the</strong> status <strong>of</strong> <strong>the</strong> reac<strong>to</strong>r <strong>the</strong> unit was placed in Cold Shutdown <strong>the</strong> following morning (26<br />
July 2006)<br />
Summary <strong>of</strong> Event Review Process<br />
Following stabilisation <strong>of</strong> <strong>the</strong> unit in Hot Standby <strong>the</strong> event <strong>review</strong> was commenced with<br />
a meeting chaired by <strong>the</strong> Unit 1 Manager and attended by representatives <strong>of</strong> <strong>the</strong><br />
departments <strong>of</strong> Operations, Maintenance, Electrical, Control and Instrumentation, Safety<br />
and Environment, Engineering and Technical Maintenance Analysis (<strong>the</strong> event occurred<br />
during <strong>the</strong> vacation period and many staff were on vacation and not all departments were<br />
represented by <strong>the</strong>ir Heads).<br />
The plant procedure F1-I-609 “Operational disturbance management and in-depth<br />
technical analysis <strong>of</strong> disturbances” was used as <strong>the</strong> basis for <strong>the</strong> subsequent event<br />
investigation. This procedure specifies <strong>the</strong> Objective, Scope, Initiation and Execution <strong>of</strong><br />
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an investigation and has appendices for convening personnel, trouble shooting, collection<br />
<strong>of</strong> suggested measures, underlying information for action plan, data collection after <strong>the</strong><br />
disturbance, and template for disturbance analysis and event description.<br />
An analysis leader with supporting deputy was appointed. At <strong>the</strong> initial Unit 1 meeting it<br />
was decided that each focus area <strong>of</strong> <strong>the</strong> event inquiry would be analysed by sub-<strong>team</strong>s<br />
and that <strong>the</strong> appointed analysis leader would bring <strong>the</strong>se separate inquiries <strong>to</strong>ge<strong>the</strong>r in<strong>to</strong><br />
an overall report. Their focus was <strong>to</strong> identify <strong>the</strong> cause <strong>of</strong> losing <strong>the</strong> <strong>safety</strong> trains,<br />
analysing how <strong>the</strong> plant had responded <strong>to</strong> <strong>the</strong> event in general and identifying <strong>the</strong><br />
consequences <strong>of</strong> <strong>the</strong> event on pressure vessels, fuel etc. It is apparent that at <strong>the</strong> time<br />
many people still thought <strong>the</strong>y would be returning <strong>the</strong> plant <strong>to</strong> power in <strong>the</strong> near future.<br />
At <strong>the</strong> first Unit 1 meeting it was decided that <strong>the</strong> initial areas requiring <strong>review</strong> were:<br />
Event Sequence, 400kV activities, UPS failure, EDG failure, and Control Room<br />
activities.<br />
As <strong>the</strong> event <strong>review</strong> progressed <strong>the</strong> importance <strong>of</strong> <strong>to</strong>pics for in-depth investigation were<br />
<strong>review</strong>ed and more focus areas were added including; reac<strong>to</strong>r and turbine functions, low<br />
frequency protection <strong>of</strong> <strong>the</strong> Genera<strong>to</strong>r circuit breakers, vessel integrity, reac<strong>to</strong>r coolant<br />
pump rundown, relay testing procedures, possible voltage transients, 70kV au<strong>to</strong>matic<br />
functions, and “What If” analysis. In <strong>to</strong>tal 22 focus areas were identified as requiring indepth<br />
analysis.<br />
The initial event report was developed within three days and <strong>review</strong>s conducted through<br />
<strong>the</strong> regular Unit 1 Primary Safety Review Meeting, <strong>the</strong> plant independent <strong>review</strong> process<br />
and <strong>the</strong> plant Safety Committee. The agreed initial report (version 3) was <strong>the</strong>n submitted<br />
<strong>to</strong> <strong>the</strong> Swedish regula<strong>to</strong>ry authority (SKI) on 3 August 2006.<br />
As <strong>the</strong> event inquiry progressed fur<strong>the</strong>r revisions were made and passed through <strong>the</strong><br />
<strong>review</strong> process culminating in <strong>the</strong> issue <strong>of</strong> <strong>the</strong> final event report on 27 September 2006<br />
(version 8).<br />
During <strong>the</strong> progress <strong>of</strong> <strong>the</strong> event investigation <strong>the</strong> frequent ad-hoc Unit 1 meetings were<br />
formalised in<strong>to</strong> a daily meeting held at 1300hrs with a formal agenda considering<br />
progress on on-going analysis, progress <strong>of</strong> corrective actions and completed analysis<br />
reports, etc.<br />
Following completion <strong>of</strong> <strong>the</strong> event <strong>review</strong>, and non-requirement for <strong>the</strong> continuation <strong>of</strong><br />
<strong>the</strong> special Unit 1 daily progress <strong>review</strong> meetings, an action plan was developed <strong>to</strong><br />
control and track corrective action progress. A list <strong>of</strong> actions (<strong>the</strong> 60 Point list) was<br />
prepared. The list contained actions already completed plus those in progress and <strong>the</strong>ir<br />
proposed completion date. The list is now overseen by <strong>the</strong> Business Development Group<br />
and regular progress reports given <strong>to</strong> plant Management Meetings and plant Safety<br />
Committee meetings.<br />
Off-site <strong>Report</strong>ing and Communication <strong>of</strong> Event Information<br />
Swedish Regula<strong>to</strong>ry Authority (SKI)<br />
SKI was immediately informed that <strong>the</strong> event had occurred and <strong>the</strong>y conducted <strong>the</strong>ir own<br />
investigation following <strong>the</strong> event <strong>to</strong> satisfy <strong>the</strong>m that <strong>the</strong> plant was in a safe condition.<br />
SKI representatives also attended <strong>the</strong> plant Safety Committee as observers. Throughout<br />
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<strong>the</strong> event investigation SKI was also provided with specific information <strong>to</strong> answer<br />
various international inquiries.<br />
KSU/ERFATOM<br />
KSU/ERFATOM was informed shortly after <strong>the</strong> event. ERFATOM received <strong>the</strong> LER <strong>of</strong><br />
<strong>the</strong> event on <strong>the</strong> 11 August 2006 and handled it according <strong>to</strong> normal procedures for<br />
evaluation and reporting <strong>to</strong> <strong>the</strong> o<strong>the</strong>r Swedish and Finnish BWRs.<br />
IAEA Nuclear Event Web-Based System –International Nuclear Event Scale<br />
notification<br />
The event was reported <strong>to</strong> IAEA NEWS - INES system on 27 July 2006 as an INES<br />
Level 2 event.<br />
IAEA/NEA Incident <strong>Report</strong>ing System (IRS)<br />
A preliminary report was received by <strong>the</strong> IAEA on 16 August 2006 and <strong>the</strong> final report<br />
was received on 4 September 2006. These were discussed at <strong>the</strong> IAEA General<br />
Conference in September 2006 and <strong>the</strong> IRS country co-ordina<strong>to</strong>rs meeting in Oc<strong>to</strong>ber<br />
2006.<br />
World Association <strong>of</strong> Nuclear Opera<strong>to</strong>rs (WANO)<br />
<strong>Report</strong>ing was via KSU/ERFATOM. An Early Notification <strong>Report</strong> (EAR) was prepared<br />
by <strong>the</strong> plant and posted by WANO on <strong>the</strong>ir proprietary web site (not available <strong>to</strong> nonmembers<br />
<strong>of</strong> WANO) on 10 August 2006.<br />
Following a plant visit by WANO a Significant Event <strong>Report</strong> (not available <strong>to</strong> nonmembers<br />
<strong>of</strong> WANO) was issued in June 2007.<br />
Nuclear Energy Agency (NEA)/Organisation for Economic Co-operation and<br />
Development (OECD)<br />
The event information was presented in detail <strong>to</strong> a NEA/OECD meeting in December<br />
2006 (note: this was not an IRS co-ordina<strong>to</strong>rs meeting).<br />
Local Community<br />
Key persons within <strong>the</strong> Local Safety Council and Local Community Government were<br />
informed (this was not actually required by <strong>the</strong> procedures but is usually done when<br />
events occur as a matter <strong>of</strong> courtesy and helps <strong>to</strong> build confidence between <strong>the</strong> plant and<br />
<strong>the</strong> local organisations) A special meeting was held with <strong>the</strong> Local Safety Council on 17<br />
August 2006 <strong>to</strong> detail <strong>the</strong> event. (The Local Safety Council is formed from locally<br />
nominated council representatives (however, it does not include <strong>the</strong> local emergency<br />
services)).<br />
Press <strong>Report</strong>s<br />
The plant made <strong>the</strong>ir first press release one hour after <strong>the</strong> event occurred on 25 July 2006<br />
and SKI issued a press release two days later.<br />
The national and local newspapers first published articles about <strong>the</strong> event on 28 July<br />
2006<br />
The plant ran through <strong>the</strong> event on <strong>the</strong> simula<strong>to</strong>r for media (approximately three weeks<br />
after <strong>the</strong> event). This exercise was considered a successful method <strong>to</strong> demonstrate and<br />
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explain <strong>the</strong> event in a concise and visual manner and was also performed for o<strong>the</strong>r groups<br />
including <strong>the</strong> SKI senior management, local government and council representatives, etc.<br />
COMMENTS ON SPECIFIC TECHNICAL AREAS AND OPERATIONAL<br />
ACTIVITIES<br />
The 400kv Electrical Sub-station<br />
Identified Causes<br />
The cause <strong>of</strong> <strong>the</strong> initiating event was determined <strong>to</strong> be an inadequate <strong>review</strong> <strong>of</strong> switching<br />
work orders by grid owner due <strong>to</strong> deficient administrative routines.<br />
Status <strong>of</strong> Corrective Actions<br />
The damaged isola<strong>to</strong>r was repaired and res<strong>to</strong>red <strong>to</strong> an <strong>operational</strong> state.<br />
The plant and <strong>the</strong> Grid Authority have established a working party <strong>to</strong> look at interfaces<br />
and a common control document was developed and agreed <strong>to</strong> specify communication,<br />
outage planning, handling <strong>of</strong> operating instructions/work orders, Interface Meeting<br />
schedule, education and competence.<br />
One point <strong>of</strong> contact for <strong>the</strong> plant has been identified (Control Room is still main point <strong>of</strong><br />
contact for routine operations) and Grid Authority contacts have been defined in <strong>the</strong><br />
control document.<br />
Operations involving Bus-bar protection (Collec<strong>to</strong>r Rail) can no longer be carried out if<br />
<strong>the</strong> reac<strong>to</strong>r is on load.<br />
The entire 400kV sub-station will be replaced in 2009 ( this decision was made prior <strong>the</strong><br />
event).<br />
OSART Comment<br />
The new instruction on Operations involving Bus-bar protection appears <strong>to</strong> be <strong>to</strong>o<br />
equipment specific; it maybe appropriate <strong>to</strong> include that a higher level <strong>of</strong> scrutiny should<br />
be applied <strong>to</strong> <strong>review</strong>ing tasks that are infrequently performed or are innovative. (The<br />
plant did receive <strong>the</strong> draft switching work order two weeks before <strong>the</strong> fault occurred and<br />
it was sent <strong>to</strong> all <strong>the</strong> relevant departments; however <strong>the</strong> o<strong>mission</strong> <strong>of</strong> <strong>the</strong> requirement <strong>to</strong><br />
block <strong>the</strong> protection was not recognised. The switching work order was complex and<br />
covered many operations and activities <strong>to</strong> be fulfilled). Breaking complex switching<br />
work orders in<strong>to</strong> more discrete orders may have assisted in identifying anomalies.<br />
Un-interruptible Power Supplies (UPS)<br />
Identified Causes<br />
The installed UPS had not been designed <strong>to</strong> handle a voltage transient as large and rapid<br />
as it was subjected <strong>to</strong> in this event. There was a lack <strong>of</strong> selectivity between <strong>the</strong> rectifier<br />
over voltage protection and <strong>the</strong> inverter over voltage protection.<br />
The root cause was identified as a lack <strong>of</strong> a requirement <strong>to</strong> cater for voltage transients<br />
outside <strong>the</strong> 85-110% range when <strong>the</strong> UPS was originally designed in <strong>the</strong> early 1990’s<br />
Status <strong>of</strong> Corrective Actions<br />
Voltage protection limits were changed based on extensive testing and verification<br />
performed by <strong>the</strong> equipment supplier in order <strong>to</strong> safeguard <strong>the</strong> function <strong>of</strong> <strong>the</strong> inverter in<br />
case <strong>of</strong> a voltage transient. Settings were changed <strong>to</strong> cope with transients within <strong>the</strong> 80 –<br />
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130% range and testing has been performed on <strong>the</strong> plant. The Safety Analysis <strong>Report</strong> has<br />
been updated with regard <strong>to</strong> <strong>the</strong> design requirements.<br />
OSART Comments<br />
There has been no explanation <strong>of</strong> why <strong>the</strong> o<strong>the</strong>r trains (C and D) remained available,<br />
(although a probable cause has been identified).They had been set up exactly <strong>the</strong> same as<br />
those that tripped and <strong>the</strong> likelihood <strong>of</strong> <strong>the</strong>m also tripping was not prevented by design<br />
requirements. The most likely reason was <strong>the</strong> different load and impedances between <strong>the</strong><br />
trains A, B, C and D.<br />
Low Frequency Protection trip <strong>of</strong> Genera<strong>to</strong>r Breakers<br />
Identified Causes<br />
The plant identified that root cause <strong>of</strong> <strong>the</strong> failure <strong>of</strong> <strong>the</strong> low frequency protection system<br />
was deficiencies in <strong>the</strong> modification design process.<br />
The plant also identified that inadequate testing procedures contributed <strong>to</strong> <strong>the</strong> failure <strong>to</strong><br />
recognise <strong>the</strong> deficiency.<br />
The plant modification process has been <strong>review</strong>ed and amended.<br />
Status <strong>of</strong> Corrective Actions<br />
The phase sequence has been connected in <strong>the</strong> correct way and inter-boundary testing<br />
conducted.<br />
A new modification testing administration procedure has been developed for Electrical<br />
and Instrumentation and Control. Extensive testing <strong>of</strong> o<strong>the</strong>r equipment has been<br />
performed<br />
OSART Comments<br />
The plant should also ensure that <strong>the</strong>y have <strong>review</strong>ed past modifications, especially <strong>to</strong><br />
ensure that boundaries <strong>of</strong> responsibility between contrac<strong>to</strong>r and plant are adequately<br />
considered. Lack <strong>of</strong> adequate testing (or inadvertent o<strong>mission</strong> <strong>of</strong> testing <strong>of</strong> some parts <strong>of</strong><br />
an installation) has resulted in significant international events in <strong>the</strong> recent past and <strong>the</strong><br />
plant should ensure that <strong>the</strong>y have adequately <strong>review</strong>ed recent generic industry advice in<br />
this area.<br />
Emergency Diesel Genera<strong>to</strong>rs<br />
Identified Causes<br />
The direct cause for <strong>the</strong> failure <strong>of</strong> <strong>the</strong> EDGs <strong>to</strong> connect <strong>to</strong> <strong>the</strong>ir associated 500V busbars<br />
has been identified in <strong>the</strong> report. There is no reference <strong>to</strong> it having been a known<br />
weakness in <strong>the</strong> design that was considered acceptable; <strong>the</strong> root cause <strong>of</strong> <strong>the</strong> weakness<br />
continuing <strong>to</strong> exist at <strong>the</strong> time <strong>of</strong> <strong>the</strong> event.<br />
Status <strong>of</strong> Corrective Actions<br />
The direct cause has been rectified by modifying <strong>the</strong> signal <strong>to</strong> DC supplied, and<br />
diversifying <strong>the</strong> supply (two EDGs on one DC voltage, two on ano<strong>the</strong>r).<br />
No root cause was identified and <strong>the</strong>refore no corrective action was proposed.<br />
OSART Comments<br />
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Because <strong>the</strong> direct cause <strong>of</strong> <strong>the</strong> EDG failures was obvious it seems that <strong>the</strong> plant did not<br />
consider <strong>the</strong> root cause <strong>to</strong> be significant enough <strong>to</strong> warrant fur<strong>the</strong>r analysis. The main<br />
event report does not discuss <strong>the</strong> root causes <strong>of</strong> <strong>the</strong> weaknesses in <strong>the</strong> design <strong>of</strong> <strong>the</strong><br />
supply for <strong>the</strong> start speed signal <strong>of</strong> <strong>the</strong> EDGs. If <strong>the</strong> EDGs had connected <strong>to</strong> <strong>the</strong>ir<br />
associated 500V bus-bars correctly <strong>the</strong> effects <strong>of</strong> <strong>the</strong> significance <strong>of</strong> <strong>the</strong> event would have<br />
been reduced. A possible root cause could have been a failure <strong>to</strong> adequately assess<br />
identified weaknesses in design. The corrective action would be a <strong>review</strong> <strong>of</strong> all known<br />
rejected modifications <strong>to</strong> ensure that <strong>the</strong>re are no o<strong>the</strong>r known weaknesses that have not<br />
been fully assessed. (To <strong>review</strong> records for known weaknesses in design is perceived <strong>to</strong><br />
be extremely difficult – maybe <strong>to</strong>o difficult when considering <strong>the</strong> possible returns in<br />
enhancing <strong>safety</strong>)<br />
70kV System<br />
Identified Causes<br />
The 70kV system remained available throughout <strong>the</strong> event, however, <strong>the</strong> back-up Gas<br />
Turbine did not start when requested as stand-by. The cause for this was lack <strong>of</strong> adequate<br />
maintenance.<br />
Status <strong>of</strong> Corrective Actions<br />
The maintenance processes and testing programme have been enhanced and put in place.<br />
OSART Comments<br />
It is important that each unit considers <strong>the</strong> impact <strong>of</strong> loss <strong>of</strong> 70kV on its operation when a<br />
loss event occurs even if <strong>the</strong> loss is not as a direct cause <strong>of</strong> that unit. In most<br />
circumstances it was noted that possibly affected units reported and considered <strong>the</strong><br />
implications (multiple LERs) however, <strong>the</strong>re was one event noted (25 January 2002)<br />
where this does not appear <strong>to</strong> have happened.<br />
Control Room Activities and Indications<br />
Identified Causes<br />
The Main Control Room (MCR) activities were assessed by <strong>the</strong> plant <strong>to</strong> have been<br />
conducted effectively in <strong>the</strong> circumstance <strong>of</strong> reduced available information and<br />
indication. The <strong>review</strong> <strong>of</strong> MCR activities, however, identified twenty six improvement<br />
measures (or areas for fur<strong>the</strong>r investigation). The MCR activities report identified <strong>the</strong>se<br />
issues as Procedures/Documentation, Training Issues, Control Room Design and<br />
Equipment. One <strong>of</strong> <strong>the</strong> concerns expressed by Operation Control Room staff was <strong>the</strong><br />
adequacy <strong>of</strong> shift staffing.<br />
Status <strong>of</strong> Corrective Actions<br />
An improvement in presentation <strong>of</strong> status <strong>of</strong> <strong>the</strong> 6kV bus-bar has been implemented. The<br />
electrical redundancy for <strong>the</strong> process computer network will be doubled during 2008.<br />
Replacement <strong>of</strong> bottleneck <strong>of</strong> information flow <strong>to</strong> <strong>the</strong> event recorder and increasing <strong>the</strong><br />
number <strong>of</strong> signals connected <strong>to</strong> it are some <strong>of</strong> <strong>the</strong> outstanding corrective actions awaiting<br />
resolution.<br />
A <strong>review</strong> <strong>of</strong> MCR staffing has been conducted and <strong>the</strong> long term goal for staffing is <strong>to</strong><br />
have an additional reac<strong>to</strong>r competent opera<strong>to</strong>r on each shift. The purpose is <strong>to</strong> relieve<br />
some <strong>of</strong> <strong>the</strong> workload on <strong>the</strong> shift supervisor and <strong>the</strong> o<strong>the</strong>r reac<strong>to</strong>r opera<strong>to</strong>r.<br />
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The electrical system control/indication computer supplies have been enhanced <strong>to</strong><br />
minimise possibility for loss during an event.<br />
OSART Comments<br />
The subsequent <strong>review</strong> <strong>of</strong> MCR was conducted by operations staff after <strong>the</strong> event. The<br />
<strong>review</strong> was conducted through a meeting <strong>of</strong> all participants present during <strong>the</strong> event. The<br />
assessment <strong>of</strong> improvement measures and deficiencies is basically done by “brains<strong>to</strong>rming”.<br />
The leader <strong>of</strong> investigation had some knowledge <strong>of</strong> Root Cause Analysis and<br />
Man-Technology-Organisation techniques but was not formally trained and had never<br />
conducted a formal Root Cause Analysis before. The simula<strong>to</strong>r was not used <strong>to</strong><br />
reconstruct <strong>the</strong> event, however, it was used later <strong>to</strong> demonstrate <strong>the</strong> event. The scope <strong>of</strong><br />
investigation was not adequately specified and was at <strong>the</strong> discretion <strong>of</strong> Operations<br />
Management.<br />
Many deficiencies were identified in <strong>the</strong> MCR, however, a full systematic root cause<br />
analysis was not conducted <strong>to</strong> determine why <strong>the</strong>y existed. The MTO process could have<br />
been used (or adapted) <strong>to</strong> identify all <strong>the</strong> challenges <strong>to</strong> <strong>the</strong> opera<strong>to</strong>rs during <strong>the</strong> event,<br />
<strong>to</strong>ge<strong>the</strong>r with <strong>the</strong> root causes <strong>of</strong> <strong>the</strong>se challenges and any contributing fac<strong>to</strong>rs. The actual<br />
<strong>review</strong> appears <strong>to</strong> have identified all <strong>the</strong> problems (direct causes) and corrective actions<br />
have been taken or are planned <strong>to</strong> correct <strong>the</strong>m.<br />
Safety Assessment<br />
Probabilistic Safety Assessment (PSA) on <strong>the</strong> Event <strong>of</strong> 25 July 2006<br />
The event was analyzed by <strong>the</strong> plant in order <strong>to</strong> calculate <strong>the</strong> risk as a year based risk if<br />
<strong>the</strong> error was present continuously. The probability for an un-acceptable release <strong>to</strong> <strong>the</strong><br />
environment during <strong>the</strong> event was 2.69·10 -5 . The probability for large release was<br />
2.21·10 -6 .<br />
The plant determined that four parallel actions were possible that would s<strong>to</strong>p <strong>the</strong> scenario<br />
developing fur<strong>the</strong>r. The failed components were not broken and manual action could<br />
have res<strong>to</strong>red supplies <strong>to</strong> <strong>the</strong> 500V bus-bars from <strong>the</strong> 6.6kV system, <strong>the</strong> Gas Turbine<br />
could have been started manually, <strong>the</strong> failed UPS could have been returned <strong>to</strong> service<br />
manually, and <strong>the</strong> EDGs could have been started by-passing <strong>the</strong> start delay blocking.<br />
Therefore, it was determined that, in <strong>the</strong> worst case scenario with no trains available and<br />
no manual actions taken, <strong>the</strong> risk <strong>of</strong> loss <strong>of</strong> core cooling was not guaranteed after one<br />
hour. However, it was observed that <strong>the</strong> decay heat, one hour after shutdown, would<br />
have been substantially lower than that postulated in <strong>the</strong> assessment. This would have<br />
resulted in a much greater time period <strong>to</strong> take mitiga<strong>to</strong>ry actions.<br />
Conclusions<br />
The plant has determined that failed components were not damaged and could have been<br />
reinstated by manual intervention. They also considered that <strong>the</strong>re were several<br />
possibilities <strong>to</strong> recover <strong>the</strong> situation and low decay heat would have allowed more time<br />
for manual intervention, a core damage scenario would have been extremely unlikely<br />
even if all four trains had been lost during <strong>the</strong> event.<br />
Evaluation <strong>of</strong> Root Cause Analysis<br />
Prior <strong>to</strong> <strong>the</strong> event, training in performing event investigations and <strong>the</strong> use <strong>of</strong> event<br />
analysis techniques appears <strong>to</strong> have been minimal. Approximately 15 people had been<br />
trained in <strong>the</strong> Man-Technology-Organisation (MTO) analysis methodology, however,<br />
only about three events a year are analysed using MTO so <strong>the</strong>y are not all very<br />
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experienced in its use. The establishment <strong>of</strong> <strong>the</strong> event inquiry and <strong>the</strong> conduct <strong>of</strong> <strong>the</strong><br />
analysis were not conducted <strong>to</strong> a comprehensive and systematic procedure. Terms <strong>of</strong><br />
Reference were not produced and <strong>the</strong> scope <strong>of</strong> <strong>the</strong> inquiry was not defined before <strong>the</strong><br />
various areas <strong>of</strong> concern were analysed. The methods used <strong>to</strong> conduct <strong>the</strong> investigation<br />
and analysis varied between <strong>the</strong> responsible sub-<strong>team</strong>s and <strong>the</strong>re is no evidence <strong>to</strong><br />
suggest that analysis <strong>to</strong>ols such as Causal Fac<strong>to</strong>r Charting, Task Analysis, Change<br />
Analysis, Barrier Analysis, and Equipment Failure Analysis were used systematically.<br />
The event <strong>review</strong> was <strong>the</strong>refore heavily focussed on technical issues that had <strong>to</strong> be<br />
corrected <strong>to</strong> return <strong>the</strong> unit <strong>to</strong> service. The original objectives (<strong>of</strong> <strong>the</strong> procedure used)<br />
were focused on “identifying underlying technical causes <strong>of</strong> <strong>the</strong> disturbance <strong>to</strong> prevent<br />
similar events, describing <strong>the</strong> measures <strong>to</strong> achieve operability and o<strong>the</strong>r technical<br />
recommendations” Little focus was applied <strong>to</strong> Organisational Issues that could have been<br />
at <strong>the</strong> root cause <strong>of</strong> <strong>the</strong> numerous failures. From <strong>the</strong> event report it is difficult <strong>to</strong><br />
determine whe<strong>the</strong>r all <strong>the</strong> identified causes resulted in corrective actions and vice versa.<br />
The lack <strong>of</strong> focus on Organisational issues was eventually highlighted <strong>to</strong> <strong>the</strong> plant by SKI<br />
in a decision (September 28, 2006) requiring <strong>the</strong> plant <strong>to</strong> implement measures <strong>to</strong> enhance<br />
problem identification, analysis, and resolution including conservative decision making,<br />
<strong>the</strong> Maintenance Process (including periodic testing), <strong>the</strong> routines and processes for<br />
altering <strong>the</strong> plant (design and modification), and Safety Culture at all levels in <strong>the</strong><br />
organisation. Subsequent <strong>to</strong> this <strong>the</strong> plant developed an overall Action Plan.<br />
Summary <strong>of</strong> Corrective Action Progress<br />
Sixty six corrective actions (activities) were identified following <strong>the</strong> issue <strong>of</strong> <strong>the</strong> final<br />
report by <strong>review</strong>ing <strong>the</strong> notes <strong>of</strong> all <strong>the</strong> meetings (some had already been completed)<br />
Of <strong>the</strong>se, twenty three were classified as Priority 1 (actions that will have <strong>the</strong> most<br />
(positive) impact <strong>of</strong> <strong>safety</strong>) addressing <strong>Forsmark</strong> Unit 1 or both Unit 1 and 2. All <strong>the</strong>se<br />
actions have been completed and assessed as effective. The last action <strong>to</strong> be completed<br />
was on 31 December 2007.<br />
Ten were classified as Priority 1 addressing <strong>Forsmark</strong> Unit 2 issues specifically. All <strong>the</strong>se<br />
actions have been completed and assessed as effective. The last action <strong>to</strong> be completed in<br />
this group was on 31 May 2007.<br />
Twenty one actions were classified as Priority 2 (Actions that give some (positive)<br />
impact on <strong>safety</strong>) addressing issues on <strong>Forsmark</strong> 1 and 2. Eleven <strong>of</strong> <strong>the</strong>se actions are<br />
outstanding (at <strong>the</strong> time <strong>of</strong> this <strong>review</strong>) and many include lengthy in-depth <strong>review</strong>s <strong>of</strong><br />
plant programmes. The most significant action remaining is deciding what information<br />
should be available (presented) <strong>to</strong> Operations and Analysts during and after an event<br />
(The need for segregated/prioritised alarm indications and a high speed event recorder,<br />
completion date for this activity is 31 December 2008, however, that is not <strong>the</strong> specified<br />
date for implementation).<br />
Twelve actions were classified as Priority 3 (Actions that can wait for action and receive<br />
priority later (<strong>review</strong>ed again in September 2007)) addressing issues on <strong>Forsmark</strong> 1 and<br />
2. Of <strong>the</strong>se, six are outstanding.<br />
Priority 4 were classified as actions that could be deleted (required a panel <strong>of</strong> Technical,<br />
Maintenance, Unit 1 Manager Engineering and Operations <strong>to</strong> approve <strong>the</strong>m).<br />
In addition, <strong>the</strong> plant has developed an action plan for <strong>safety</strong> and culture improvements<br />
resulting from regula<strong>to</strong>ry concerns raised following <strong>the</strong> event <strong>review</strong>.<br />
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Tracking <strong>of</strong> corrective actions from <strong>the</strong> “60 point programme” (as well as <strong>the</strong> programme<br />
<strong>to</strong> enhance programmes and processes identified as necessary by SKI and outstanding<br />
actions from international <strong>review</strong>s) is conducted by <strong>the</strong> Business Development Unit and<br />
reported <strong>to</strong> <strong>the</strong> regular Management Meeting. The Business Development Unit also<br />
conducts an effectiveness <strong>review</strong>. In addition, quality audits and <strong>the</strong> weekly F12 plant<br />
status <strong>review</strong> are performed. (However, <strong>to</strong> conduct this effectively will require a fully<br />
established Corrective Action Programme (CAP) that is in <strong>the</strong> early stages <strong>of</strong><br />
implementation). The current “effectiveness <strong>review</strong>” only ensures that <strong>the</strong> corrective<br />
action has actually been fully completed.<br />
Main conclusions<br />
At <strong>the</strong> time <strong>of</strong> <strong>the</strong> event <strong>the</strong> plant did not have adequate detailed procedural guidance <strong>to</strong><br />
conduct an in-depth event inquiry. The inquiry was almost exclusively conducted as a<br />
technical inquiry and <strong>the</strong>re is no reason <strong>to</strong> believe that any <strong>of</strong> <strong>the</strong> initiating faults or<br />
activities were not identified, analysed and corrective actions proposed. However, <strong>the</strong><br />
plant did not comprehensively and systematically identify <strong>the</strong> root causes <strong>of</strong> <strong>the</strong> event.<br />
This failure in <strong>the</strong> analysis process led <strong>to</strong> <strong>the</strong> imposition <strong>of</strong> corrective actions in this area<br />
by SKI. Overall sixty six actions were identified. Forty nine were completed by <strong>the</strong> end<br />
<strong>of</strong> 2007 and seventeen are outstanding. Some <strong>of</strong> lesser priority are scheduled <strong>to</strong> take until<br />
2010 <strong>to</strong> implement.<br />
Known problems from previous events and previously identified areas <strong>of</strong> concern (both<br />
by management and staff) had not been adequately eliminated or compensated for and<br />
contributed <strong>to</strong> <strong>the</strong> event. One fac<strong>to</strong>r not considered by <strong>the</strong> event inquiry was “why was<br />
this event not prevented (or its consequences minimised)” The lack <strong>of</strong> an effective<br />
operating experience programme at <strong>the</strong> time <strong>of</strong> <strong>the</strong> event was a contributing fac<strong>to</strong>r <strong>to</strong> this<br />
failure.<br />
Summary<br />
At <strong>the</strong> time <strong>of</strong> <strong>the</strong> event <strong>the</strong>re was a lack <strong>of</strong> an integrated <strong>operational</strong> experience (OE)<br />
feedback programme (Corrective Action Programme (CAP)) at <strong>Forsmark</strong>. This was<br />
coupled with <strong>the</strong> weak use <strong>of</strong> <strong>the</strong> systematic analysis methodology. While technical<br />
issues were investigated in depth utilising <strong>the</strong> expertise <strong>of</strong> experienced and<br />
knowledgeable staff, underlying organisational issues <strong>to</strong>ok longer <strong>to</strong> recognise. The<br />
deficiencies in <strong>the</strong> OE programme had been highlighted <strong>to</strong> <strong>the</strong> plant by an international<br />
<strong>review</strong> prior <strong>to</strong> <strong>the</strong> event. The subsequent international follow-up <strong>review</strong> conducted after<br />
<strong>the</strong> event highlighted that insufficient progress had been made <strong>to</strong> date in this area. The<br />
follow-up <strong>review</strong> resulted in <strong>the</strong> plant requesting an international technical assistance<br />
<strong>mission</strong>. One <strong>of</strong> <strong>the</strong> suggestions arising from <strong>the</strong> technical assistance <strong>mission</strong> was that a<br />
strategic plan should be developed that should include: Targets and timescales for project<br />
deployment, A staged approach <strong>to</strong> improvement <strong>of</strong> <strong>the</strong> various programme elements,<br />
Management sponsorship, Miles<strong>to</strong>nes <strong>to</strong> tune and refine, Performance Indica<strong>to</strong>rs <strong>to</strong><br />
moni<strong>to</strong>r effectiveness, Accountability measures. The technical assistance <strong>mission</strong> also<br />
highlighted that <strong>the</strong> MTO methodology is equally applicable <strong>to</strong> technical investigations<br />
and as a minimum should be used on all LER investigations.<br />
These recommendations, <strong>to</strong>ge<strong>the</strong>r with <strong>the</strong> relevant recommendations and suggestions in<br />
<strong>the</strong> main body <strong>of</strong> <strong>the</strong> OSART are supported by this <strong>review</strong>.<br />
However, with special regard <strong>to</strong> Significant Event Investigation it is recommended that<br />
<strong>the</strong> plant should ensure that <strong>the</strong> current initiatives <strong>to</strong> enhance <strong>the</strong>ir Operating Experience<br />
programme includes detailed procedures for managing and conducting complex<br />
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significant event inquiries. Adequate numbers <strong>of</strong> staff should be trained and practiced in<br />
<strong>the</strong> techniques <strong>of</strong> Root Cause Analysis. Technical staff should also be knowledgeable<br />
about <strong>the</strong> techniques so that <strong>the</strong>y can assist in investigations and analysis.<br />
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7. RADIATION PROTECTION<br />
7.1 ORGANIZATION AND FUNCTIONS<br />
The radiation protection policy is defined in <strong>the</strong> <strong>to</strong>p document, LOK Management and<br />
quality control, part 1.4: “RP issues should always be taken in<strong>to</strong> account”. On <strong>the</strong> basis<br />
<strong>of</strong> LOK, plant and unit instructions as well as <strong>the</strong> radiological year plans are developed.<br />
Radiation protection staff and radiation protection matters are divided between several<br />
departments within different units. The Safety and Environment unit is responsible for<br />
<strong>the</strong> plant programme for radiation protection as well <strong>the</strong> plant-wide procedures on<br />
radiation protection. The Radiation Protection Manager (RPM) within <strong>the</strong> Safety and<br />
Environment unit is a “Radiation protection <strong>of</strong>ficial” as required by national legislation<br />
and is responsible for liaising with <strong>the</strong> regula<strong>to</strong>ry authority, <strong>the</strong> ALARA programme and<br />
reporting <strong>to</strong> <strong>the</strong> plant management. The RPM is independent <strong>of</strong> <strong>operational</strong> and<br />
maintenance units. The chemistry department within <strong>the</strong> Technical Support unit is<br />
responsible for personal dosimetry, whole body counting, effluents and environment<br />
moni<strong>to</strong>ring. The industrial <strong>safety</strong> and radiation protection department (FMS) within <strong>the</strong><br />
maintenance unit is responsible for radiation protection <strong>of</strong> personnel, <strong>operational</strong><br />
dosimetry, maintenance <strong>of</strong> RP instruments, training in radiation protection and survey<br />
measurement. Moreover, <strong>the</strong>re are three external companies performing survey<br />
measurements and supervising radiation works. The system <strong>of</strong> responsibilities and<br />
authorities is clearly defined and working.<br />
The integration <strong>of</strong> <strong>the</strong> RP and industrial <strong>safety</strong> matters in one department has had a<br />
positive effect on improving personal <strong>safety</strong> and work preparation. The <strong>team</strong> recognised<br />
this as a good performance in <strong>the</strong> field <strong>of</strong> <strong>operational</strong> radiation protection.<br />
The ALARA programme is very good and functioning well, <strong>the</strong> ALARA principles are<br />
well unders<strong>to</strong>od. Moreover, <strong>the</strong> best available technique principle is applied. The<br />
ALARA programme is evaluated and revised every year – results are compared with<br />
goals and new targets are determined. The results are reported <strong>to</strong> <strong>the</strong> plant management.<br />
The ALARA group is appointed by <strong>the</strong> President and has ten members from all units; its<br />
meetings are held four times per year. The ALARA group makes recommendations,<br />
which are developed in<strong>to</strong> modification plans and implemented.<br />
To measure <strong>the</strong> effectiveness <strong>of</strong> <strong>the</strong> RP programme, several indica<strong>to</strong>rs are used. The<br />
collective and individual doses from <strong>operational</strong> dosimetry and <strong>the</strong> number <strong>of</strong><br />
contaminated people are checked daily. These data is reported every second week <strong>to</strong> <strong>the</strong><br />
RP manager in an RP meeting. Doses, contamination, and effluent indica<strong>to</strong>rs are reported<br />
<strong>to</strong> <strong>the</strong> production unit managers every month.<br />
There is no instruction on radiological events with respect <strong>to</strong> root cause analysis and<br />
reporting. The <strong>team</strong> encourages <strong>the</strong> plant <strong>to</strong> include this in<strong>to</strong> a general root cause analysis<br />
procedure. On <strong>the</strong> o<strong>the</strong>r hand, anybody may write a report on “near-miss” situations in<br />
industrial <strong>safety</strong> and RP; <strong>the</strong> reports are regularly processed. The <strong>team</strong> recognised this as<br />
a good performance. The relevant instructions define near-miss situations and describe<br />
routines for its reporting and evaluation. The radiological near-miss situations are<br />
defined as “any situations which could lead <strong>to</strong> an external or internal dose greater than 20<br />
mSv”.<br />
Radiation protection staff has adequate authority and independence. Budgets and<br />
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esources correspond <strong>to</strong> requirements. The radiation protection managers perform<br />
periodic observations <strong>of</strong> radiation work performance or supervision, take notes from<br />
<strong>the</strong>ir observations and evaluate <strong>the</strong>m. Results are regularly reported <strong>to</strong> <strong>the</strong> RPM. A<br />
radiation protection meeting is held every second week – this includes <strong>the</strong> exchange <strong>of</strong><br />
<strong>operational</strong> experience, feedback and coordination.<br />
Radiation protection staff also <strong>review</strong>s <strong>operational</strong> procedures addressing radiological<br />
issues. Radiation protection staff (including radiation protection contrac<strong>to</strong>r staff) write<br />
down measured results or observations in an electronic logbook. Important facts can be<br />
easily checked, sorted and evaluated in this way. The <strong>team</strong> recognised this as a good<br />
performance.<br />
The FMS department cooperates with o<strong>the</strong>r maintenance departments, <strong>the</strong> production<br />
units, <strong>the</strong> radiation protection <strong>of</strong>ficial and <strong>the</strong> <strong>safety</strong> and environment unit in order <strong>to</strong><br />
create long-term, constructive work on radiation protection, industrial <strong>safety</strong> and<br />
environmental issues.<br />
RP staff qualifications and experience are adequate. Plant instructions include basic<br />
qualification requirements for personnel with RP tasks and prescribe <strong>the</strong>ir follow-up.<br />
Once a year, each employee is interviewed by a manager concerning qualification.<br />
Prescribed training and retraining is checked and new training requirements are set. On<br />
<strong>the</strong> basis <strong>of</strong> <strong>the</strong> interview record, an education plan is developed which is sent <strong>to</strong> <strong>the</strong><br />
Human Resources unit <strong>to</strong> ensure its implementation. Inside <strong>the</strong> industrial <strong>safety</strong> and<br />
radiation protection section, an internal training programme is followed up.<br />
The medical surveillance <strong>of</strong> radiation workers is satisfac<strong>to</strong>ry. A medical report is<br />
necessary once a year with a medical examination at least once every 3 years (by national<br />
legislation). Data are s<strong>to</strong>red in a database; <strong>the</strong> system notifies workers au<strong>to</strong>matically 60,<br />
30 and 10 days before expiration <strong>of</strong> <strong>the</strong> term.<br />
Medical support is available if necessary for decontamination; instructions for<br />
summoning help are prepared. RP staff is supposed <strong>to</strong> perform personal decontamination<br />
with chemicals; a written instruction is in place but <strong>the</strong> staff is not regularly trained. The<br />
<strong>team</strong> encourages <strong>the</strong> plant <strong>to</strong> apply prepared training schedules as soon as possible.<br />
The documentation system for RP seems <strong>to</strong> be well developed, however not always<br />
accessible <strong>to</strong> <strong>the</strong> personnel involved. The <strong>team</strong> encourages <strong>the</strong> plant <strong>to</strong> ensure that <strong>the</strong><br />
personnel have all <strong>the</strong> necessary instructions at <strong>the</strong>ir disposal.<br />
7.2 RADIATION WORK CONTROL<br />
All work in <strong>the</strong> plant is planned in advance. Routinely performed work follows prepared<br />
instructions. During <strong>the</strong> work planning, any activity is analyzed with respect <strong>to</strong> possible<br />
associated health hazards – both industrial and radiation. The integration <strong>of</strong> <strong>the</strong> RP<br />
department in<strong>to</strong> <strong>the</strong> Maintenance unit makes it easier <strong>to</strong> assess. The FMS personnel<br />
support answering questions on radiation. In case <strong>of</strong> any hazards including radiological,<br />
<strong>the</strong> request for a Safety Work Directive (SWD – radiation work permit) is made. The<br />
FMS personnel prepare <strong>the</strong> SWD in co-operation with <strong>the</strong> Operational and Performance<br />
units. The work permit (WP) is <strong>the</strong>n approved only with a valid SWD. All <strong>the</strong> WP and<br />
SWD are prepared via <strong>the</strong> FENIX database, which enables effective work planning. The<br />
SWD procedures are suitable for <strong>the</strong> working conditions and are strictly complied with.<br />
When work with an enhanced radiological hazard is planned, special provisions are<br />
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made, including pre-job briefings or suitable mock-up training, if necessary. The<br />
individual, as well as collective doses, are minimised in this way.<br />
The work order instructions are summarized in relevant documentation. Moreover, <strong>the</strong><br />
plant must send a report on planned activities with assumed collective doses <strong>to</strong> <strong>the</strong> SSI.<br />
Au<strong>to</strong>matic personnel contamination moni<strong>to</strong>rs are located at <strong>the</strong> entrance <strong>to</strong> <strong>the</strong> reac<strong>to</strong>r<br />
hall, at <strong>the</strong> exit from <strong>the</strong> controlled area (pre-measurement) and in <strong>the</strong> locker rooms (final<br />
measurement), which is adequate for <strong>the</strong> plant design. A sufficient amount <strong>of</strong> manual<br />
contamination moni<strong>to</strong>rs are prepared in <strong>the</strong> RP <strong>of</strong>fice, near <strong>to</strong> <strong>the</strong> controlled area<br />
entrance. If any contamination is detected during pre-moni<strong>to</strong>ring, <strong>the</strong> RP staff performs a<br />
follow-up <strong>of</strong> <strong>the</strong> performed work, contamination occurrence etc. The events are recorded<br />
in <strong>the</strong> logbook and fur<strong>the</strong>r analyzed. The number <strong>of</strong> contaminations is reported <strong>to</strong><br />
management. This way, <strong>the</strong> number <strong>of</strong> contaminated persons has been decreased by a<br />
fac<strong>to</strong>r <strong>of</strong> three in <strong>the</strong> last two years. The <strong>team</strong> recognised this follow-up as a good<br />
performance.<br />
All controlled area rooms are clearly marked with information tables in a simple threecoloured<br />
(blue, yellow, red) system. Surveillance measurements are performed regularly<br />
by a prescribed moni<strong>to</strong>ring plan. All measurement results are inserted in<strong>to</strong> a database,<br />
which simplifies <strong>the</strong> SWD preparation and helps <strong>to</strong> keep <strong>the</strong> dose ALARA.<br />
Contaminated <strong>to</strong>ols are adequately handled. Every contaminated <strong>to</strong>ol is put in<strong>to</strong> a bag<br />
and carried <strong>to</strong> <strong>the</strong> decontamination workshop. No contaminated <strong>to</strong>ol is s<strong>to</strong>red elsewhere.<br />
A comprehensive survey programme in <strong>the</strong> controlled area is established. During<br />
operation, rooms and areas are moni<strong>to</strong>red at regular intervals once, twice or four times a<br />
year, or weekly, as prescribed in a moni<strong>to</strong>ring plan. During outages, <strong>the</strong> moni<strong>to</strong>ring is<br />
adapted <strong>to</strong> <strong>the</strong> work performed. However, a satisfac<strong>to</strong>ry RP survey programme for <strong>the</strong><br />
chemistry labs is not established. The <strong>team</strong> has made a recommendation in this area.<br />
As <strong>the</strong> <strong>operational</strong> RP staffing is limited, contrac<strong>to</strong>rs are recruited for certain specific<br />
activities. Contrac<strong>to</strong>rs perform periodical survey measurements during regular unit<br />
operation as well as during outages. Contrac<strong>to</strong>rs also supervise activities performed by<br />
<strong>the</strong> radiation work permit during outages. Such contrac<strong>to</strong>r workers are trained in<br />
accordance with plant requirements.<br />
All controlled area access points have proper and logical layouts. However, some<br />
imperfections were found and <strong>the</strong> <strong>team</strong> has made a recommendation about <strong>the</strong><br />
organization and work practices.<br />
7.3 CONTROL OF OCCUPATIONAL EXPOSURE<br />
Optimization <strong>of</strong> radiation protection is performed by implementation <strong>of</strong> <strong>the</strong> ALARA<br />
programme. Occupational exposure is carefully planned; target values are estimated and<br />
<strong>the</strong>n evaluated. The ALARA principles are applied already at <strong>the</strong> planning stage. For<br />
each activity, <strong>the</strong> individual as well as collective doses are estimated; any o<strong>the</strong>r hazard is<br />
taken in<strong>to</strong> account. Special measures are taken when <strong>the</strong>re is a risk <strong>of</strong> airborne activity<br />
which could lead <strong>to</strong> internal contamination, including providing adequate respira<strong>to</strong>ry<br />
equipment.<br />
Supervisors are appointed in order <strong>to</strong> ensure radiation protection for activities on a<br />
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adiation work permit. The supervision is done by <strong>the</strong> FMS staff or by contrac<strong>to</strong>rs.<br />
Appropriate dose rate moni<strong>to</strong>ring and survey measurement is provided that way.<br />
An internal contamination assessment programme is well installed. The internal<br />
contamination moni<strong>to</strong>ring programme is widely developed and based on <strong>the</strong> periodical<br />
moni<strong>to</strong>ring <strong>of</strong> a reference group <strong>of</strong> workers who work in particularly hazardous<br />
situations (e.g. control rod servicemen) or are suspected <strong>of</strong> internal contamination. The<br />
programme also includes workers performing special activities (measured before and<br />
after <strong>the</strong>ir work) and everyone who requests <strong>to</strong> be measured.<br />
Whole body counting procedures are well implemented. The measuring time is adequate<br />
<strong>to</strong> measured nuclide activities. Last year, <strong>the</strong>re was no internal contamination cases<br />
reported indicating that <strong>the</strong>re were no cases <strong>of</strong> a committed effective dose above <strong>the</strong><br />
investigation value <strong>of</strong> 0.25 mSv.<br />
The plant has implemented air sampling moni<strong>to</strong>ring whenever a risk <strong>of</strong> airborne activity<br />
is recognized. Mobile measurement devices are used and appropriate alarm levels are set.<br />
Effective protective equipment is prescribed and used by all workers.<br />
The routine exposure moni<strong>to</strong>ring programme is well established, “legal” (TL) and<br />
<strong>operational</strong> (electronic) dosimetry are used. The TL dosimeter badge also includes a<br />
neutron dosimeter. Every radiation worker is equipped with TL and electronic dosimeter<br />
as well as with supplementary dosimeters if necessary (e.g. extremity dosimeters).<br />
Visi<strong>to</strong>rs are adequately moni<strong>to</strong>red by means <strong>of</strong> electronic dosimeters.<br />
The number <strong>of</strong> both electronic and TL dosimeters available is fully sufficient, as is <strong>the</strong><br />
number <strong>of</strong> readers. The electronic dosimeter readers are located at <strong>the</strong> controlled area<br />
entry points and <strong>the</strong> evaluating routine is fully au<strong>to</strong>matic so <strong>the</strong> reader does not permit<br />
<strong>the</strong> use <strong>of</strong> a dosimeter with an expired calibration.<br />
Individual doses are s<strong>to</strong>red in a database and periodically evaluated. Each month, <strong>the</strong><br />
doses are reported <strong>to</strong> <strong>the</strong> Central Dose Register in Sweden (CDIS) shared by <strong>the</strong> Swedish<br />
plants and some o<strong>the</strong>r companies in <strong>the</strong> nuclear industry. The CDIS is open <strong>to</strong> <strong>the</strong><br />
regula<strong>to</strong>ry authority and forms part <strong>of</strong> a national dose register. Contrac<strong>to</strong>r exposures are<br />
tracked in <strong>the</strong> same way; contrac<strong>to</strong>rs receive <strong>the</strong>ir workers’ doses via <strong>the</strong> national dose<br />
register.<br />
7.4 RADIATION PROTECTION INSTRUMENTATION, PROTECTIVE<br />
CLOTHING, AND FACILITIES<br />
The inven<strong>to</strong>ry <strong>of</strong> fixed and portable dose rate and contamination measuring devices is<br />
adequate. Fixed personnel contamination measuring devices are properly located at <strong>the</strong><br />
controlled area entry points, in <strong>the</strong> locker rooms and in appropriate locations inside <strong>the</strong><br />
controlled area. The portable instrumentation is located in dosimetry rooms near <strong>the</strong><br />
controlled area entry points for easy access. The portable device inven<strong>to</strong>ry includes<br />
instruments for measuring alpha, beta, gamma, and neutron radiation.<br />
RP instruments, procedures and routines are documented in <strong>the</strong> relevant guidelines.<br />
Instrument handling, operative maintenance and calibration are described in individual<br />
documents. All <strong>the</strong> documents are easy available for both <strong>the</strong> RP section and <strong>the</strong><br />
contrac<strong>to</strong>rs’ personnel in <strong>the</strong> FMS homepage which was recognised by <strong>the</strong> <strong>team</strong> as a<br />
good performance.<br />
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Calibration <strong>of</strong> dose rate and contamination measurement instrumentation is performed in<br />
<strong>the</strong> site calibration labora<strong>to</strong>ry. Although not up-<strong>to</strong>-date, <strong>the</strong> calibration facility is<br />
adequate and ensures safe operation with <strong>the</strong> large radiation sources used. Calibration<br />
procedures are comprehensively described in documents for individual devices. Co-60<br />
and Tc-99 sources are regularly used for calibration. Personnel responsible for<br />
calibration keep calibration records in a written form as well as in <strong>the</strong> FENIX database.<br />
The database is also used for maintenance and calibration planning in accordance with<br />
<strong>the</strong> prescribed terms. The calibration facility is periodically traced (every 2 years) <strong>to</strong><br />
national standard sources and confirmed by <strong>the</strong> SSI labora<strong>to</strong>ry, <strong>the</strong> pro<strong>to</strong>cols are<br />
archived.<br />
The schedule for routine device checks is well established and carefully respected. The<br />
portable devices are checked before each use applying <strong>the</strong> Cs-137 and/or Tc-99 sources;<br />
written records are kept. The check response information is available at <strong>the</strong> place <strong>of</strong><br />
issue.<br />
The plant adequately controls all effluent release paths. All components <strong>of</strong> gaseous<br />
effluents are measured at appropriate intervals. To ensure requested redundancy in<br />
nuclide-specific gaseous effluents moni<strong>to</strong>ring in <strong>the</strong> main stack, <strong>the</strong> plant is going <strong>to</strong><br />
replace <strong>the</strong> low-volume chambers with larger ones.<br />
In addition, <strong>the</strong> liquid effluents moni<strong>to</strong>ring is suitably organized. Samples are analyzed<br />
before each waste water tank release for <strong>the</strong> release permit. A proportional sample is<br />
taken during release and <strong>the</strong> collected sample is analyzed monthly for <strong>the</strong> balance. Sr-90<br />
and alpha-radionuclides are analyzed and balanced twice a year.<br />
The environmental moni<strong>to</strong>ring instrumentation and equipment is adequate. It enables<br />
sampling <strong>of</strong> all components <strong>of</strong> <strong>the</strong> environment prescribed in <strong>the</strong> relevant instructions.<br />
Sample analyses are performed via HPGe spectrometry in <strong>the</strong> chemistry department. The<br />
spectrometers are regularly calibrated, QA routines are implemented.<br />
Protective clothing and respira<strong>to</strong>ry equipment inven<strong>to</strong>ry is adequate, covering all types <strong>of</strong><br />
hazards anticipated at <strong>the</strong> plant. There are several types <strong>of</strong> respira<strong>to</strong>ry equipment<br />
ensuring protection in various situations. All <strong>the</strong> protective equipment is carefully<br />
maintained, checked and/or periodically tested; written records are kept. The<br />
maintenance schedule is well established. Protective clothing routines and procedures are<br />
well documented in <strong>the</strong> relevant instructions. Ano<strong>the</strong>r instruction regulates<br />
decontamination activity limits. All necessary routines and information are accessible at<br />
<strong>the</strong> FMS homepage. Miscellaneous supplies such as shielding, signs, ropes, stands, etc.<br />
are adequate and periodically res<strong>to</strong>cked.<br />
Laundry, s<strong>to</strong>rage and shower facilities are well maintained and housekeeping is well<br />
performed. The laundry and housekeeping are performed by contrac<strong>to</strong>rs; sorting <strong>of</strong><br />
laundry by contamination is under <strong>the</strong> responsibility <strong>of</strong> RP staff.<br />
No radioactive waste is temporarily s<strong>to</strong>red in <strong>the</strong> workplace or at <strong>the</strong> sorting station. All<br />
waste with a dose rate <strong>of</strong> above 0.3 mSv/h is transported directly <strong>to</strong> <strong>the</strong> radioactive waste<br />
treatment facility. The decontamination workshop is adequately equipped <strong>to</strong> perform <strong>the</strong><br />
activities and appropriately moni<strong>to</strong>rs <strong>the</strong> area with respect <strong>to</strong> possible contamination and<br />
airborne activity.<br />
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7.5 RADIOACTIVE WASTE MANAGEMENT AND DISCHARGES<br />
The plant has declared a policy that all waste streams shall be minimized and what can<br />
be shall be recycled. The policy was implemented in a radioactive waste management<br />
programme – <strong>the</strong> instruction on waste sorting according <strong>to</strong> source. In <strong>the</strong> instructions, <strong>the</strong><br />
goals and objectives <strong>of</strong> minimizing solid waste are clearly expressed. The instruction<br />
classifies <strong>the</strong> radioactive waste according <strong>to</strong> its nature and activity, its chemical and<br />
physical form, and <strong>the</strong> intended methods <strong>of</strong> processing. The instructions prescribe waste<br />
sorting; <strong>the</strong> waste sorting scheme at <strong>the</strong> sorting stations is displayed <strong>the</strong>re and in several<br />
places inside <strong>the</strong> controlled area, e.g. in lifts. The collecting, s<strong>to</strong>ring and packaging <strong>of</strong><br />
radioactive waste during normal unit operation as well as during an outage are developed<br />
in order <strong>to</strong> minimize exposures. However, <strong>the</strong> <strong>team</strong> found some deficiencies and made a<br />
suggestion on waste sorting at <strong>the</strong> source. The plant recently recognized that <strong>the</strong>re is no<br />
solid-waste related performance indica<strong>to</strong>r and has already started a discussion on its<br />
implementation.<br />
The gaseous and liquid releases are kept far below <strong>the</strong> authorized limits. Every year <strong>the</strong><br />
goals are set in <strong>the</strong> ALARA programme; it is reported <strong>to</strong> <strong>the</strong> management and <strong>the</strong><br />
regula<strong>to</strong>ry authority how <strong>the</strong> goals were met. The plant set an ambitious long-term goal<br />
<strong>to</strong> decrease water effluents <strong>to</strong> <strong>the</strong> value <strong>of</strong> 1E-7mSv per year per unit before 2013.<br />
The plant has developed effective procedures for controlling effluent releases. The best<br />
available technology approach is applied <strong>to</strong> reduce effluents. Nearly all liquid radioactive<br />
waste is reprocessed, so its impact on <strong>the</strong> environment has been minimized in recent<br />
years. The <strong>team</strong> consider this as a good performance.<br />
Both <strong>the</strong> liquid and gaseous releases are adequately moni<strong>to</strong>red and balanced. The results<br />
are evaluated monthly and reported <strong>to</strong> management and <strong>to</strong> <strong>the</strong> regula<strong>to</strong>ry authority.<br />
Effluent release moni<strong>to</strong>ring records are carefully maintained and archived. Alarm levels<br />
are specified and <strong>the</strong> alarm signals are transmitted <strong>to</strong> <strong>the</strong> MCR.<br />
The environmental moni<strong>to</strong>ring programme is established in accordance with <strong>the</strong><br />
authority’s requirements. Calculation <strong>of</strong> doses for critical groups <strong>of</strong> <strong>the</strong> population is<br />
performed using approved methods. The programme is well structured and covers all<br />
important parts <strong>of</strong> <strong>the</strong> environment. Moreover, <strong>the</strong> plant has “Biotest zones” at several<br />
small islands in <strong>the</strong> plant’s neighbourhood for investigation <strong>of</strong> <strong>the</strong> influence <strong>of</strong> <strong>the</strong><br />
plant’s releases on <strong>the</strong> sea life.<br />
7.6 RADIATION PROTECTION SUPPORT DURING EMERGENCIES<br />
Plant emergency documentation defines detailed responsibilities <strong>of</strong> radiation protection<br />
staff in emergencies. RP staff understands <strong>the</strong>ir duties and responsibilities with respect <strong>to</strong><br />
emergency situations which might arise. Procedures regarding maximum doses in<br />
emergencies are appropriate.<br />
The standard set <strong>of</strong> dose-rate and survey measurement instruments is also used for<br />
emergencies. RP personnel will use <strong>the</strong>ir standard survey and dose-rate measuring<br />
devices <strong>to</strong> moni<strong>to</strong>r <strong>the</strong> assembly points for radiation. For this purpose, <strong>the</strong> range <strong>of</strong><br />
survey meters seems <strong>to</strong> be insufficient and <strong>the</strong> <strong>team</strong> encourages <strong>the</strong> plant <strong>to</strong> take<br />
corresponding corrective measures.<br />
Two special sets <strong>of</strong> ten individual electronic dosimeters for moni<strong>to</strong>ring <strong>of</strong> rescue<br />
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personnel are available at <strong>the</strong> main entrance and at <strong>the</strong> fire brigade, which is adequate.<br />
The dosimeters are periodically checked and maintained at full charge.<br />
RP personnel regularly train on emergency procedures with o<strong>the</strong>r emergency staff.<br />
Training is recorded and evaluated.<br />
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DETAILED RADIATION PROTECTION FINDINGS<br />
7.2 RADIATION WORK CONTROL<br />
7.2(1) Issue: The organization and work practices do not cover all aspects <strong>of</strong> minimizing<br />
exposure <strong>of</strong> workers and <strong>the</strong> risk <strong>of</strong> spreading contamination.<br />
• Radiation survey programme for <strong>the</strong> labora<strong>to</strong>ries is not satisfac<strong>to</strong>ry.<br />
• Chemistry labora<strong>to</strong>ries are not equipped with measuring devices for routine daily<br />
workplace moni<strong>to</strong>ring (after finishing <strong>the</strong> work).<br />
• In <strong>the</strong> chemistry labora<strong>to</strong>ries, active samples were standing on a desk without<br />
shielding. Dose rate measured – 0.4 mSv/h. Labora<strong>to</strong>ries are not satisfac<strong>to</strong>rily<br />
equipped with shielding.<br />
• In <strong>the</strong> chemistry labora<strong>to</strong>ry 1.P2.19 inside <strong>the</strong> controlled area, <strong>the</strong>re is an<br />
emergency exit (a window). There was no seal on <strong>the</strong> window handle <strong>to</strong> prevent<br />
non-controlled openings <strong>of</strong> <strong>the</strong> window. A person could leave and return <strong>to</strong> <strong>the</strong><br />
controlled area without being noticed.<br />
• A similar handle on a window (not an emergency exit) was found in maintenance<br />
room 1.P2.02 within <strong>the</strong> chemistry labora<strong>to</strong>ries.<br />
• In <strong>the</strong> chemistry labora<strong>to</strong>ry 1.P2.21 <strong>the</strong> wheels <strong>of</strong> a carriage were covered with<br />
yellow tape. The purpose is not clear, but it can cause more problems – e.g.<br />
spreading <strong>the</strong> contamination ra<strong>the</strong>r than keeping <strong>the</strong> wheels uncontaminated.<br />
• A stainless steel floor <strong>of</strong> a draught cupboard in a chemistry labora<strong>to</strong>ry was covered<br />
with a plastic film which was probably not removed when <strong>the</strong> floor was installed.<br />
The film was <strong>to</strong>rn in several places. This could cause problem during<br />
decontamination. The same thing was seen in ano<strong>the</strong>r room on a labora<strong>to</strong>ry sink.<br />
• “Clean” and possibly contaminated paths cross in <strong>the</strong> area next <strong>the</strong> RP <strong>of</strong>fice,<br />
which could cause unwanted spread <strong>of</strong> contamination e.g. <strong>to</strong> <strong>the</strong> RP <strong>of</strong>fice.<br />
Without organization and work practices covering all aspects, <strong>the</strong> exposure <strong>of</strong> workers<br />
and <strong>the</strong> risk <strong>of</strong> spreading contamination cannot be minimized.<br />
Without a satisfac<strong>to</strong>ry RP survey programme for <strong>the</strong> chemistry labora<strong>to</strong>ries, surfaces may<br />
accidentally become contaminated or personnel could be irradiated.<br />
Recommendation: The plant should improve <strong>the</strong> organization and work practices <strong>to</strong><br />
cover all aspects in order <strong>to</strong> limit <strong>the</strong> exposure <strong>of</strong> workers and <strong>the</strong> spread <strong>of</strong> any<br />
contamination.<br />
IAEA Basis: NS-R-2, para 8.5.<br />
“The operating organization shall verify, by means <strong>of</strong> surveillance, inspections and<br />
audits, that <strong>the</strong> radiation protection programme is being correctly implemented and that<br />
its objectives are being met, and shall undertake corrective actions if necessary. The<br />
programme shall be <strong>review</strong>ed and updated in <strong>the</strong> light <strong>of</strong> experience.”<br />
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IAEA Basis: NS-G-2.7, para 3.24.<br />
“The main objectives <strong>of</strong> radiological moni<strong>to</strong>ring and surveying are: <strong>to</strong> provide<br />
information about <strong>the</strong> radiological conditions at <strong>the</strong> plant and in specific areas before and<br />
during a task; <strong>to</strong> ensure that <strong>the</strong> zone designation remains valid; and <strong>to</strong> determine<br />
whe<strong>the</strong>r <strong>the</strong> levels <strong>of</strong> radiation and contamination are suitable for continued work in <strong>the</strong><br />
zone.”<br />
IAEA Basis: NS-G-2.7, para 3.26.<br />
“The frequency <strong>of</strong> moni<strong>to</strong>ring and surveys as well as <strong>the</strong> types and locations <strong>of</strong> <strong>the</strong><br />
measurements <strong>to</strong> be performed should be designated on radiological surveillance forms<br />
as part <strong>of</strong> <strong>the</strong> RPP and updated as necessary in accordance with <strong>the</strong> prevailing<br />
conditions.”<br />
IAEA Basis: NS-G-2.7, para 3.28.<br />
“The operating organization should ensure that equipment necessary for <strong>the</strong> RPP is<br />
provided, including various instruments for measuring radiation and for sampling and<br />
analysis. The quantities and types <strong>of</strong> equipment provided should be adequate for<br />
anticipated needs in normal operations and emergencies, and account should be taken <strong>of</strong><br />
radiological conditions prevailing and suspected or expected <strong>to</strong> prevail in <strong>the</strong> local area.”<br />
IAEA Basis: NS-G-2.7, para 3.57.<br />
“The plant should be equipped with radiation shielding materials <strong>of</strong> different types for<br />
temporary use in special jobs. Examples <strong>of</strong> such shielding materials are lead blankets<br />
(lead wool in flexible covers), sheets and bricks <strong>of</strong> lead, sheets <strong>of</strong> transparent perspex<br />
and blocks <strong>of</strong> concrete.”<br />
IAEA Basis: NS-G-2.7, para 3.9.<br />
“Access <strong>to</strong> a controlled area is required <strong>to</strong> be restricted and should be restricted by way<br />
<strong>of</strong> a limited number <strong>of</strong> checkpoints in order <strong>to</strong> limit <strong>the</strong> spread <strong>of</strong> any contamination and<br />
<strong>to</strong> facilitate control at any time <strong>of</strong> exposure and occupancy. Procedures should be<br />
established for control <strong>of</strong> access <strong>to</strong> a controlled area or <strong>to</strong> a particular zone. These should<br />
include an authorization <strong>to</strong> enter, <strong>to</strong>ge<strong>the</strong>r with instructions on <strong>the</strong> use <strong>of</strong> moni<strong>to</strong>ring<br />
devices, <strong>the</strong> wearing <strong>of</strong> specified protective clothing and equipment, and time limits for<br />
remaining on <strong>the</strong> premises.”<br />
7.5 RADIOACTIVE WASTE MANAGEMENT AND DISCHARGES<br />
7.5(1) Issue: Instructions on waste sorting at <strong>the</strong> source are not satisfac<strong>to</strong>rily developed<br />
and implemented.<br />
• Instruction F-I-353 on “Waste sorting according <strong>to</strong> source” (radioactive waste<br />
management programme) defines in parts 3.2.1 – 3.2.3 “s<strong>of</strong>t (compressible)” and<br />
“hard (incompressible)” waste and requires waste sorting.<br />
o<br />
o<br />
In accordance with <strong>the</strong> instruction (part 3.2.2 or 3.3.2), <strong>the</strong> s<strong>of</strong>t waste is<br />
collected in 125 litre bags in a bag frame located at <strong>the</strong> unit and at <strong>the</strong> sorting<br />
stations.<br />
In accordance with instruction (part 3.2.3), <strong>the</strong> hard waste is collected in<br />
Berglöfs boxes at <strong>the</strong> point <strong>of</strong> generation or delivered <strong>to</strong> <strong>the</strong> sorting stations <strong>of</strong><br />
each respective unit.<br />
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• In accordance with instruction, boxes for hard waste (e.g. metal) are located at two<br />
“sorting stations” located on <strong>the</strong> ground floor.<br />
• Most rooms contain labelled bags for waste (s<strong>of</strong>t waste according <strong>to</strong> <strong>the</strong><br />
instructions) but <strong>the</strong>re are no corresponding boxes for hard waste. Personnel must<br />
take <strong>the</strong> hard waste <strong>to</strong> one <strong>of</strong> <strong>the</strong> two sorting stations on <strong>the</strong> ground floor.<br />
• The lack <strong>of</strong> hard waste bins in rooms forces personnel <strong>to</strong> mix wastes:<br />
o<br />
o<br />
o<br />
Metal strips were found in a plastic bag in a container for (s<strong>of</strong>t) waste in <strong>the</strong><br />
room 1.J01.03. They could tear <strong>the</strong> bag when it is taken from <strong>the</strong> container.<br />
A piece <strong>of</strong> a metal grid was found in a plastic bag in a container for (s<strong>of</strong>t) waste<br />
in <strong>the</strong> room 1.D4.50.<br />
A metal coil spring was put in plastic bag for (s<strong>of</strong>t) waste in <strong>the</strong> room 1.F1.21.<br />
Additional sorting is necessary before moulding.<br />
Without satisfac<strong>to</strong>rily developed and implemented instruction on waste sorting at <strong>the</strong><br />
source, opportunities <strong>to</strong> reduce <strong>the</strong> amount <strong>of</strong> radioactive waste (e.g. decontamination <strong>of</strong><br />
hard waste) may be lost.<br />
Suggestion: The plant should consider that instructions on waste sorting at <strong>the</strong> source<br />
are satisfac<strong>to</strong>rily developed and implemented in order <strong>to</strong> ensure an efficient waste<br />
management programme.<br />
IAEA Basis: NS-G-2.7, para 4.16.<br />
“The segregation <strong>of</strong> radioactive waste in<strong>to</strong> appropriate categories should be carried out as<br />
near <strong>to</strong> <strong>the</strong> point <strong>of</strong> generation as practicable. The waste should be segregated in<br />
accordance with written procedures.”<br />
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8. CHEMISTRY<br />
8.1 ORGANIZATION AND FUNCTIONS<br />
The responsibilities and functions <strong>of</strong> <strong>the</strong> Chemistry Department at <strong>the</strong> plant are described<br />
in <strong>the</strong> Management and Quality Handbook (LOK). Plant management is committed <strong>to</strong><br />
this document. The Chemistry Department at <strong>the</strong> plant is responsible for preserving <strong>the</strong><br />
integrity <strong>of</strong> systems and components, controlling and moni<strong>to</strong>ring activity build-up,<br />
controlling <strong>the</strong> release <strong>of</strong> activity and moni<strong>to</strong>ring activity in <strong>the</strong> environment.<br />
The Chemistry Department at <strong>the</strong> plant is part <strong>of</strong> <strong>the</strong> Technical Support unit. The<br />
Department is clearly structured as it is subdivided in<strong>to</strong> four groups, <strong>the</strong> process<br />
chemistry group for unit 1&2, <strong>the</strong> process chemistry group for unit 3, a chemistry<br />
specialist group and <strong>the</strong> radio physics group. The members <strong>of</strong> <strong>the</strong> specialist group reports<br />
directly <strong>to</strong> <strong>the</strong> department manager while <strong>the</strong> o<strong>the</strong>r groups are headed by group<br />
managers. The chemistry specialist group forms a strong and important <strong>of</strong>fice for <strong>the</strong><br />
whole department.<br />
With <strong>the</strong> support <strong>of</strong> upper management, <strong>the</strong> department recently increased <strong>the</strong> number <strong>of</strong><br />
employees and is now sufficiently staffed.<br />
Additional goals <strong>to</strong> those already mentioned in <strong>the</strong> LOK are established.<br />
In 2004, a WANO peer <strong>review</strong> with subsequent follow-up in 2007 was conducted. Self<br />
assessment was identified as not being undertaken. However, in preparation for <strong>the</strong><br />
OSART <strong>mission</strong> <strong>the</strong> department performed a non formalized internal audit that proved <strong>to</strong><br />
be beneficial. Indica<strong>to</strong>rs for human performance are available. The <strong>team</strong> recommends<br />
formalizing fur<strong>the</strong>r internal audits and self assessments.<br />
Interfaces with o<strong>the</strong>r plant groups are well described. Cooperation with o<strong>the</strong>r groups,<br />
especially <strong>the</strong> material group, is intensive and will be promoted by <strong>the</strong> modern analytical<br />
instruments, like <strong>the</strong> scanning electron microscope (SEM) that will be installed. Health<br />
physics and chemistry work closely <strong>to</strong>ge<strong>the</strong>r, e.g. when new chemical substances are<br />
approved.<br />
Operations are informed about <strong>the</strong> measures that need <strong>to</strong> be taken if chemical parameters<br />
exceed certain limits. The operations instructions give clear guidance. If operations are<br />
not able <strong>to</strong> fix <strong>the</strong> problems, <strong>the</strong> chemistry department is asked for help. The overall<br />
cooperation is good as operations appreciate <strong>the</strong> pr<strong>of</strong>essional work <strong>of</strong> <strong>the</strong> chemistry staff.<br />
However, operations staff wants <strong>to</strong> have even more information on chemistry<br />
specifications, procedures and organization.<br />
During normal working hours, chemistry responds in a timely manner <strong>to</strong> requests from<br />
operations and o<strong>the</strong>r departments. Corrective actions <strong>to</strong> chemical parameter variations<br />
are properly taken, as o<strong>the</strong>r departments, especially operations, are sensitive <strong>to</strong> <strong>the</strong><br />
chemistry department’s concern. However, <strong>the</strong>re is no chemist on call during nights or at<br />
weekends. The <strong>team</strong> recommended implementing such a service and in <strong>the</strong> course <strong>of</strong> <strong>the</strong><br />
<strong>mission</strong> <strong>the</strong> plant decided <strong>to</strong> reinstall <strong>the</strong> service <strong>of</strong> chemists on duty.<br />
The chemistry department gives strong support in all plant-related chemical issues, e.g.<br />
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fuel cladding related questions or material optimization. Chemistry competence is also<br />
effectively brought in e.g. <strong>to</strong> minimize risk <strong>of</strong> flow assisted corrosion <strong>of</strong> feed water in <strong>the</strong><br />
preheater drain system when power is upgraded, or reducing waste by oxidization <strong>of</strong><br />
evapora<strong>to</strong>r concentrate in a plasma flame. For bigger projects, like <strong>the</strong> renewal <strong>of</strong> <strong>the</strong><br />
water treatment plant, appropriate project groups with specialists from different<br />
departments are assembled.<br />
Chemistry department management is responsible for moni<strong>to</strong>ring national and<br />
international developments inside and outside <strong>the</strong> nuclear community by attending<br />
scientific conferences and workshops. Chemistry management promotes nuclear<br />
competence with research and development projects on site. Communication with<br />
external organizations is adequate.<br />
Regular reports are distributed <strong>to</strong> <strong>the</strong> o<strong>the</strong>r units, <strong>the</strong> upper management and <strong>the</strong><br />
regula<strong>to</strong>ry authority, containing relevant <strong>operational</strong> and chemical parameters.<br />
Department management is responsible for providing qualified staff. The basic education<br />
<strong>of</strong> <strong>the</strong> chemistry staff is very good and most have a university background. Department<br />
management has realized that only motivated staff can be retained and only well trained<br />
staff is able <strong>to</strong> perform <strong>the</strong> high level tasks at <strong>the</strong> plant.<br />
Responsibilities and functions for all levels <strong>of</strong> management and staff are clearly<br />
described and more personally specified in job descriptions that have been recently<br />
updated.<br />
The department has very experienced senior staff and young employees that are eager <strong>to</strong><br />
learn from <strong>the</strong> older colleagues. For a new employee, a designated senior staff member<br />
acts as <strong>the</strong>ir men<strong>to</strong>r and introduces <strong>the</strong> trainee <strong>to</strong> labora<strong>to</strong>ry work and culture. Line<br />
management records and follows <strong>the</strong> progress <strong>of</strong> <strong>the</strong> training by a checklist, <strong>the</strong> so called<br />
“driver’s licence”, that contains all relevant techniques required for pr<strong>of</strong>essional work in<br />
<strong>the</strong> labora<strong>to</strong>ry. The initial training is facilitated as <strong>the</strong> work in each labora<strong>to</strong>ry is well<br />
organized. Any additional need for individual development, e.g. external training, is<br />
agreed on during <strong>the</strong> annual goal talks between line management and staff.<br />
Each labora<strong>to</strong>ry group is organized in such a manner that <strong>the</strong> work can be done by<br />
several group members, so <strong>the</strong> groups are independent. Never<strong>the</strong>less, each labora<strong>to</strong>ry can<br />
backup <strong>the</strong> o<strong>the</strong>r.<br />
The information flow within <strong>the</strong> department is well organized. In a series <strong>of</strong> formal and<br />
informal meetings, information is transferred from <strong>the</strong> <strong>to</strong>p management and operations <strong>to</strong><br />
<strong>the</strong> staff and vice versa. The daily meetings <strong>of</strong> chemistry staff are also used for <strong>team</strong>building.<br />
By a combination <strong>of</strong> manager meetings and specialist meetings, different<br />
subjects can be discussed and decisions taken in a timely manner.<br />
Staff has an open attitude <strong>to</strong> discussions with experts and seek advice on improving <strong>the</strong>ir<br />
performance. Staff appreciate <strong>the</strong> open atmosphere within <strong>the</strong> department.<br />
8.2 CHEMISTRY CONTROL IN PLANT SYSTEMS<br />
The Management and Quality Handbook (LOK), <strong>the</strong> Operational Technical<br />
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Specifications (STF) and <strong>the</strong> Safety Directive are <strong>the</strong> basic instructions that contain <strong>the</strong><br />
expectations <strong>of</strong> <strong>the</strong> plant designer, <strong>the</strong> regula<strong>to</strong>ry authority and <strong>the</strong> management and set<br />
limits <strong>to</strong> operations. The Process Chemical Specification procedure and <strong>the</strong> Samplingand<br />
Analysis Frequency procedure are <strong>the</strong> basis for <strong>the</strong> daily work <strong>of</strong> <strong>the</strong> chemistry<br />
department. They have been recently changed due <strong>to</strong> <strong>the</strong> organizational merging <strong>of</strong> units<br />
1 and 2.<br />
However, <strong>the</strong> above-mentioned procedures are not comprehensive as regards <strong>the</strong><br />
surveillance <strong>of</strong> reac<strong>to</strong>r coolant and o<strong>the</strong>r systems as specified in international guidelines.<br />
Parameters with action levels, e.g. conductivity <strong>of</strong> reac<strong>to</strong>r water, time limits are not all<br />
defined. Therefore, not all necessary actions might be taken in a timely manner. The<br />
plant has already recognized this issue but has not yet made <strong>the</strong> necessary changes. The<br />
<strong>team</strong> made a recommendation in this regard.<br />
Responsibilities for quality control <strong>of</strong> diesel fuel and lubricant oils rest not only with<br />
chemistry but also with o<strong>the</strong>r departments like <strong>the</strong> maintenance department and<br />
procurement. However <strong>the</strong> process is not clearly organized. The <strong>team</strong> provided a<br />
suggestion in this area.<br />
The water s<strong>team</strong> circuits <strong>of</strong> <strong>the</strong> three reac<strong>to</strong>rs are operated under normal water chemistry<br />
conditions (NWC) without any additives. The concentration <strong>of</strong> impurities like chloride,<br />
sulphate, fluoride and corrosion products in <strong>the</strong> feed water is very low. The corrosion<br />
product transport in<strong>to</strong> <strong>the</strong> reac<strong>to</strong>r pressure vessel is properly moni<strong>to</strong>red; <strong>the</strong> values are<br />
also low.<br />
A combination <strong>of</strong> online moni<strong>to</strong>ring and sampling <strong>of</strong> <strong>the</strong> reac<strong>to</strong>r water, in <strong>the</strong> <strong>of</strong>f gas<br />
system and in <strong>the</strong> condenser evacuation system, are used <strong>to</strong> detect fuel failures early.<br />
During power operation, <strong>the</strong> defective fuel is roughly localized by flux tilting. After <strong>the</strong><br />
results are evaluated <strong>to</strong>ge<strong>the</strong>r with o<strong>the</strong>r departments, mast sipping is performed<br />
according <strong>to</strong> procedure. The plant is developing a technique <strong>to</strong> measure helium in <strong>the</strong> <strong>of</strong>f<br />
gas <strong>to</strong> get additional information on defects. Records <strong>of</strong> <strong>the</strong> results are available.<br />
According <strong>to</strong> <strong>the</strong> material composition, <strong>the</strong> closed cooling water systems should be<br />
oxygen free with hydrazine used as <strong>the</strong> reducing agent. Due <strong>to</strong> a management decision,<br />
hydrazine is banned from <strong>the</strong> site and oxygen is removed with a de-gasifier. However,<br />
this system does not always work adequately. Since <strong>the</strong> outage in 2005, <strong>the</strong> systems are<br />
operated without hydrazine. Also, an increased tritium level in <strong>the</strong> closed cooling water<br />
system indicates an in-leakage from <strong>the</strong> reac<strong>to</strong>r coolant system and <strong>the</strong> reason for that<br />
leakage is not clear. Therefore, changes in <strong>the</strong> chemistry <strong>of</strong> this system should be done<br />
only after thorough evaluation.<br />
De-mineralized water is prepared from water from a nearby lake. A new water treatment<br />
plant is being installed with several technical benefits, e.g. reduced chemical<br />
consumption. Optimization processes in <strong>the</strong> water management has significantly reduced<br />
<strong>the</strong> water requirements <strong>of</strong> <strong>the</strong> plant. The new and <strong>the</strong> old plant were properly moni<strong>to</strong>red,<br />
including online silica meters. The online moni<strong>to</strong>rs are properly checked by <strong>the</strong> operation<br />
units with support from chemistry.<br />
The plant has scrubber tanks for washing gases from <strong>the</strong> containment during pressure<br />
release. The released gases can be analyzed online and by grab samples. The contents <strong>of</strong><br />
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<strong>the</strong> tank are regularly analyzed.<br />
The post accident sampling system (PASS) has been recently modified. The system can<br />
sample <strong>the</strong> reac<strong>to</strong>r water, <strong>the</strong> condensation pool and <strong>the</strong> atmosphere <strong>of</strong> <strong>the</strong> containment.<br />
It is set up <strong>to</strong> test <strong>the</strong> system regularly.<br />
The mechanism <strong>of</strong> erosion/corrosion in <strong>the</strong> condensate and feed water system is well<br />
unders<strong>to</strong>od and <strong>the</strong> plant is operated accordingly. By adjusting <strong>the</strong> oxygen level in <strong>the</strong><br />
pre-heater drain, <strong>the</strong> formation <strong>of</strong> protective layers is favoured. The <strong>team</strong> identified this<br />
<strong>to</strong> be a good practice.<br />
8.3 CHEMICAL SURVEILLANCE PROGRAMME<br />
Chemistry staff is technically qualified <strong>to</strong> do <strong>the</strong>ir work and <strong>the</strong>ir performance is<br />
annually assessed. Procedures for analysis are available and are clearly unders<strong>to</strong>od and<br />
followed by <strong>the</strong> staff. The sample preparation and <strong>the</strong> calibration <strong>of</strong> most instruments are<br />
done very thoroughly. The sampling plans are properly followed; exceptions are only<br />
possible under certain conditions.<br />
The <strong>the</strong>ory <strong>of</strong> proper instrument calibration and <strong>the</strong> quality control <strong>of</strong> analytical<br />
measurements are well unders<strong>to</strong>od. Online instruments are regularly controlled by<br />
comparison with grab samples or with <strong>the</strong> results <strong>of</strong> labora<strong>to</strong>ry instruments that are<br />
transported in <strong>the</strong> field. However, <strong>the</strong> <strong>team</strong> observed some online conductivity meters<br />
that showed values that were below <strong>the</strong> <strong>the</strong>oretically possible value. It turned out that<br />
online conductivity meters have been controlled with labora<strong>to</strong>ry instruments that were<br />
not included in <strong>the</strong> quality control programme. The <strong>team</strong> provided a suggestion in this<br />
area. Appropriate chemical standards that are traceable <strong>to</strong> certified reference standards<br />
are used for calibration and quality control.<br />
The plant understands <strong>the</strong> influence <strong>of</strong> <strong>the</strong> different analytical steps like sample<br />
preparation and instrument calibration on <strong>the</strong> overall accuracy <strong>of</strong> chemical<br />
measurements. Measurement uncertainties are taken in<strong>to</strong> account when results are<br />
evaluated, especially when only a few values are available. However, <strong>the</strong> experimental<br />
measurement results that are used for <strong>the</strong> validation <strong>of</strong> analytical methods and <strong>the</strong><br />
determination <strong>of</strong> <strong>the</strong> analytical characteristics like detection limits, should be archived<br />
<strong>to</strong>ge<strong>the</strong>r with <strong>the</strong> results <strong>of</strong> <strong>the</strong>oretical approaches <strong>to</strong> <strong>the</strong> subject.<br />
Comparisons between different labora<strong>to</strong>ries, so called ‘round robin tests’, are regularly<br />
carried out for <strong>the</strong> chemical and radiochemical examination techniques. Some samples,<br />
especially from liquids released <strong>to</strong> <strong>the</strong> environment, are independently analyzed by <strong>the</strong><br />
Swedish regula<strong>to</strong>ry authorities.<br />
8.4 CHEMISTRY OPERATIONAL HISTORY<br />
The water chemistry in <strong>the</strong> three reac<strong>to</strong>rs is normal water chemistry (NWC). <strong>Forsmark</strong> 1<br />
& 2 were <strong>the</strong> first BWR units in <strong>the</strong> world with internal recirculation pumps <strong>to</strong> inject<br />
hydrogen (HWC, Hydrogen Water Chemistry). However, <strong>the</strong>rmo hydraulic calculations<br />
indicated that mixing in <strong>the</strong> down comer was not sufficient, so <strong>the</strong> units were <strong>the</strong> first<br />
and only <strong>to</strong> return <strong>to</strong> NWC in 1991.<br />
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In 1997, all three plants replaced several pipes and nozzles in <strong>the</strong> residual heat removal<br />
system and <strong>the</strong> feed water system due <strong>to</strong> cracks. However, <strong>the</strong> material handbook has not<br />
been changed since 1990.<br />
It happens frequently that residual boron solution from <strong>the</strong> annual testing <strong>of</strong> <strong>the</strong> boron<br />
injection system is injected in<strong>to</strong> <strong>the</strong> reac<strong>to</strong>r. Therefore <strong>the</strong> reac<strong>to</strong>r coolant is<br />
contaminated by boron, with a maximum concentration, in unit 2 in 2001, <strong>of</strong> 250 ppb<br />
boron. In unit 1 since 2004 <strong>the</strong> boron concentration has increased slowly and is now<br />
some 70 ppb. Experience from o<strong>the</strong>r plants show that concentrations over some 100 ppb<br />
increase <strong>the</strong> conductivity and <strong>the</strong>refore o<strong>the</strong>r impurities, e.g. corrosion inducing can be<br />
hidden. Although <strong>the</strong> plant started <strong>to</strong> improve <strong>the</strong> technical situation it should go on <strong>to</strong><br />
fur<strong>the</strong>r improve it. It is foreseen, that with <strong>the</strong> change <strong>to</strong> 10-boron-enriched boron <strong>the</strong><br />
problem will be finally fixed.<br />
Increases in conductivity in <strong>the</strong> reac<strong>to</strong>r water could be attributed <strong>to</strong> nitrate in<br />
concentrations <strong>of</strong> up <strong>to</strong> 25 ppb that develops from organic amines when new resins are<br />
leached. Again, o<strong>the</strong>r impurities could be hidden under <strong>the</strong>se conditions. To know that<br />
<strong>the</strong> conductivity increase is always “under control” <strong>the</strong> plant should consider improving<br />
<strong>the</strong> surveillance <strong>of</strong> plant systems e.g. with online ion chroma<strong>to</strong>graphy.<br />
The <strong>review</strong> <strong>of</strong> <strong>the</strong> activity concentrations in <strong>the</strong> reac<strong>to</strong>r water and <strong>the</strong> <strong>of</strong>f gas system<br />
since 2000, revealed several fuel defects in unit 1 and 2, presumably due <strong>to</strong> debris. The<br />
defects have been indicated early by <strong>the</strong> ratio <strong>of</strong> Xe-133 <strong>to</strong> Xe-138 in <strong>the</strong> <strong>of</strong>f gas system.<br />
The nuclide specific online moni<strong>to</strong>rs in <strong>the</strong> <strong>of</strong>f gas helped <strong>the</strong> plant <strong>to</strong> identify fuel<br />
defects early. The plant has installed cyclone filters <strong>to</strong> remove debris from feed water.<br />
The oxygen level in <strong>the</strong> closed cooling water system came up <strong>to</strong> 25 ppb, since hydrazine<br />
is abandoned by <strong>the</strong> plant, which is not in compliance with <strong>the</strong> specifications. However<br />
as <strong>the</strong> material concept is still <strong>the</strong> same, i.e. <strong>the</strong>re are forty three identified stainless steel<br />
components in conjunction with carbon steel components according <strong>to</strong> <strong>the</strong> plant,<br />
electrochemical reactions that cause corrosion will start. The applied chemistry is not in<br />
accordance with <strong>the</strong> original designed materials concept. A surveillance programme has<br />
been updated during <strong>the</strong> period <strong>of</strong> <strong>the</strong> <strong>review</strong>.<br />
Responsibilities for trend analysis are clearly assigned <strong>to</strong> a chemistry staff, who report <strong>to</strong><br />
line- and upper management. However, in February 2008 tritium values in <strong>the</strong> closed<br />
cooling water system were published and turned out <strong>to</strong> be false.<br />
The labora<strong>to</strong>ry information and management system (LIMS), <strong>the</strong> data base for all<br />
chemical results, does not meet <strong>the</strong> expectations. It is very difficult <strong>to</strong> display several<br />
parameters, like concentrations, conductivities and <strong>the</strong>rmal power in one diagram.<br />
However, this type <strong>of</strong> diagram is important for discovering interactions between <strong>the</strong>se<br />
parameters. Never<strong>the</strong>less, analytical data are s<strong>to</strong>red properly and are easy retrievable.<br />
The chemistry department has access <strong>to</strong> <strong>operational</strong> process data via <strong>the</strong> Plant Vision<br />
data application. The plant digital logbook is used for recording chemistry-relevant<br />
issues in operations and in <strong>the</strong> lab as well for retrieving documents. The project<br />
management register (KUR) is used <strong>to</strong> track open tasks.<br />
The chemistry department has put much effort in<strong>to</strong> improving its performance and <strong>the</strong><br />
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control <strong>of</strong> plant systems. During <strong>the</strong> last years radioactive liquid discharges have been<br />
significantly reduced by optimizing <strong>the</strong> treatment process and by minimizing <strong>the</strong> volume<br />
<strong>of</strong> unwanted water in-leakage. Thus <strong>the</strong> impact on <strong>the</strong> environment is being reduced <strong>to</strong> as<br />
low as reasonably achievable (ALARA).<br />
When <strong>the</strong> destruction <strong>of</strong> yarn <strong>of</strong> <strong>the</strong> filter candles <strong>of</strong> <strong>the</strong> condensate polishing plant was<br />
discovered <strong>the</strong> chemistry staff was strongly involved in developing and implementing<br />
new stabilized yarn for <strong>the</strong> candles. At <strong>the</strong> same time, new sulphur free ion exchange<br />
powder resins have been introduced <strong>to</strong> reduce <strong>the</strong> risk <strong>of</strong> sulphate induced stress<br />
corrosion cracking in <strong>the</strong> systems, which is a major problem in boiling water reac<strong>to</strong>rs. In<br />
addition, <strong>the</strong> chemistry department is operating a test rig for coating filter candles with<br />
powder resins. Therefore <strong>the</strong> department is able <strong>to</strong> continuously seeking improvements<br />
in this area. The <strong>team</strong> identifies this as a good practice.<br />
8.5 LABORATORIES, EQUIPMENT AND INSTRUMENTS<br />
The hot labora<strong>to</strong>ry <strong>of</strong> unit 1 and 2 is very spacious with several rooms. The different<br />
analytical chemical and radiochemical techniques can be spatially separated and special<br />
environments created, e.g. with reduced radioactive contamination. The labora<strong>to</strong>ry is<br />
equipped with exhaust hoods and laminar flow devices, both surveyed with electronic<br />
flow meters. This equipment is regularly tested. A circle line with demineralized water<br />
provides high quality water in <strong>the</strong> whole lab, <strong>the</strong> quality is continuously surveyed.<br />
The labora<strong>to</strong>ry is equipped with all necessary instruments, like high purity Germanium<br />
detec<strong>to</strong>rs, inductively coupled plasma optical e<strong>mission</strong> spectrometer (ICP-OES), ion<br />
chroma<strong>to</strong>graph, gas chroma<strong>to</strong>graphs etc. However some <strong>of</strong> <strong>the</strong>se instruments are old and<br />
<strong>the</strong> <strong>team</strong> suggests replacing <strong>the</strong>m.<br />
Analytical equipment is regularly calibrated with appropriate calibration ranges. The<br />
calibration is checked with an independent quality control standard. Although each<br />
standard is labelled with preparation date and name <strong>of</strong> opera<strong>to</strong>r, <strong>the</strong>re is not yet a<br />
procedure that required such a consistent labelling.<br />
Logbooks for <strong>the</strong> instruments are available and clearly structured. However, <strong>the</strong>re is no<br />
entry on who is responsible for <strong>the</strong> instrument. The instruments are not labelled <strong>to</strong><br />
indicate that <strong>the</strong>y are quality controlled. Handbooks are s<strong>to</strong>red close <strong>to</strong> <strong>the</strong> instruments<br />
and frequently used by staff. Control charts are available for some instruments, however<br />
when quality control limits are violated no comments are entered and countermeasures<br />
applied are not always retraceable.<br />
The labora<strong>to</strong>ry <strong>of</strong> unit 3 is equipped with <strong>the</strong> same instruments, so analytical redundancy<br />
is available.<br />
The labora<strong>to</strong>ries are regularly assessed by health physics under <strong>the</strong> aspects <strong>of</strong> industrial<br />
<strong>safety</strong>, however, <strong>the</strong> <strong>team</strong> made a suggestion in <strong>the</strong> RP area. A comprehensive list <strong>of</strong><br />
chemicals used in <strong>the</strong> plant labora<strong>to</strong>ries is available; however, this list should be<br />
extended <strong>to</strong> indicate in which labora<strong>to</strong>ry (F12 or F3) <strong>the</strong>se chemicals are s<strong>to</strong>red. Material<br />
<strong>safety</strong> data sheets are s<strong>to</strong>red in <strong>the</strong> labs.<br />
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8.6 QUALITY CONTROL OF OPERATIONAL CHEMICALS AND OTHER<br />
SUBSTANCES<br />
Operational chemicals and auxiliary substances like gases, detergents, tapes etc. are well<br />
controlled in <strong>the</strong> plant. A sticker on each part indicates <strong>the</strong> application area for <strong>the</strong><br />
substance. If new substances are needed, a formalized and clearly structured process is<br />
initiated including an assessment from health physics and <strong>the</strong> environmental department<br />
and a chemical analysis by a contrac<strong>to</strong>r. Approved substances are registered in a data<br />
base that is common for all Swedish nuclear power plants. However <strong>the</strong> <strong>team</strong> found<br />
several deviations from <strong>the</strong>se rules and provided a suggestion in this area.<br />
Most substances are only analyzed once, <strong>the</strong>re is no periodical sampling. The <strong>team</strong><br />
suggests improving <strong>the</strong> process. Diesel fuel is sampled periodically; however, <strong>the</strong><br />
procedures are not clear, several departments are involved in organizing chemical<br />
analysis.<br />
The handling <strong>of</strong> material <strong>safety</strong> data sheets (MSDS) is not yet clearly defined.<br />
International practice is <strong>to</strong> s<strong>to</strong>re MSDS centrally on a single place or in a data base.<br />
Also, a plant procedure describes <strong>the</strong> labelling <strong>of</strong> filled bottles but <strong>the</strong> <strong>team</strong> found several<br />
poorly labelled bottles and containers in <strong>the</strong> field resulting in inadequate age<br />
management <strong>of</strong> <strong>the</strong>se substances.<br />
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DETAILED CHEMISTRY FINDINGS<br />
8.1 ORGANIZATION AND FUNCTIONS<br />
8.1(1) Issue: The chemistry department has not yet implemented clear chemistry<br />
management expectations for a high level <strong>of</strong> pr<strong>of</strong>essional work in <strong>the</strong> department.<br />
The <strong>team</strong> observed <strong>the</strong> following facts:<br />
• The department has started <strong>to</strong> conduct internal audits, however that process is<br />
not formalized.<br />
• The <strong>safety</strong> expectations in <strong>the</strong> labora<strong>to</strong>ry are not issued in a procedure.<br />
• In <strong>the</strong> sampling rooms 1.C.4.16 and 2.C.4.16 hand written procedures<br />
(“Utbildningsmeddelande” 060209 Nr. 06/003) were found, that were not<br />
approved.<br />
• In one sampling lab <strong>the</strong> <strong>team</strong> found a non labelled spray bottle.<br />
• Some radioactive samples, which had been prepared for measurement, were<br />
s<strong>to</strong>red without proper shielding.<br />
Without clear rules and chemistry management expectations implemented, staff may take<br />
incorrect decisions which can result in damage <strong>to</strong> health or endanger <strong>the</strong> integrity <strong>of</strong><br />
systems and components.<br />
Recommendation: The plant should implement clear chemistry management<br />
expectations for <strong>the</strong> chemistry department.<br />
Basis:<br />
Draft SG DS388<br />
2.9. By <strong>to</strong>uring <strong>the</strong> chemistry areas <strong>the</strong> managers that are responsible for chemistry<br />
should observe that indica<strong>to</strong>rs <strong>of</strong> staff behaviour and attitude that are likely <strong>to</strong> be<br />
helpful <strong>to</strong> <strong>the</strong> development <strong>of</strong> strong <strong>safety</strong> culture are evident (proper attention <strong>to</strong><br />
alarms, timely reporting <strong>of</strong> malfunctions, minimization <strong>of</strong> backlog <strong>of</strong> overdue<br />
maintenance, adequate labelling, accurate recording system etc.).<br />
2.10. Managers and supervisors should routinely observe chemistry activities <strong>to</strong> ensure<br />
adherence <strong>to</strong> plant policies and procedures. …<br />
2.11. QA audits and o<strong>the</strong>r self assessment and independent <strong>review</strong>s should be regularly<br />
conducted, <strong>review</strong> <strong>of</strong> non conformances should be reported and status <strong>of</strong><br />
corrective actions should be evaluated.<br />
2.12. The plant self assessment programme should include chemistry area.<br />
2.13. There must be a clear distribution <strong>of</strong> responsibilities at <strong>the</strong> plant for particular<br />
chemistry activities like control <strong>of</strong> resources, chemistry control, conducting <strong>of</strong><br />
water chemistry regimes, analysis <strong>of</strong> <strong>the</strong> results, staff training etc.<br />
5.29. The labora<strong>to</strong>ries should have a good general housekeeping, orderliness,<br />
cleanliness at working areas and sampling points, including contamination levels<br />
as well, according <strong>to</strong> <strong>the</strong> plant procedure.<br />
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5.30. Industrial <strong>safety</strong> (s<strong>to</strong>rage <strong>of</strong> flammable solvents and hazardous materials, <strong>safety</strong><br />
showers, personnel protective equipment, as well as first aid kits etc.) and<br />
radiological <strong>safety</strong> (proper radiation shielding)should be ensured, applied and<br />
well maintained in labora<strong>to</strong>ries, according <strong>to</strong> <strong>the</strong> foreseen risk. The whole<br />
labora<strong>to</strong>ry installation and work practice should be in accordance with good<br />
industrial <strong>safety</strong> and <strong>the</strong> ALARA principle.<br />
8.2 CHEMISTRY CONTROL IN PLANT SYSTEMS<br />
8.2(a) Good Practice: The Plant has optimized <strong>the</strong> oxygen content in <strong>the</strong> drain <strong>of</strong> <strong>the</strong><br />
pre-heaters by changing <strong>the</strong> ventilation from <strong>the</strong> pre-heaters <strong>to</strong> <strong>the</strong> condenser <strong>to</strong>ge<strong>the</strong>r<br />
with installation <strong>of</strong> a bypass flow through some pre-heaters. Thus <strong>the</strong> formation <strong>of</strong><br />
protective Haematite layers was favoured. The mass <strong>of</strong> transported iron was significantly<br />
reduced, as was <strong>the</strong> power loss due <strong>to</strong> pressure drop. This modification is even more<br />
important as power up rates will change <strong>the</strong> oxygen content in <strong>the</strong> systems.<br />
8.2(1) Issue: The chemistry specifications and <strong>the</strong> chemistry control programme are not<br />
in accordance with international guidelines and chemistry experience.<br />
The <strong>team</strong> observed <strong>the</strong> following facts:<br />
• For most action levels no time limits are defined before which action must be taken<br />
or <strong>the</strong> plant has <strong>to</strong> be shut down.<br />
• For <strong>the</strong> closed cooling water system (711) normal values for oxygen and hydrazine<br />
are defined in <strong>the</strong> procedure that cannot be met at <strong>the</strong> same time.<br />
• The chemistry specifications (F12-I-0017) do not yet contain references <strong>to</strong> <strong>the</strong><br />
material handbook, EPRI guidelines and o<strong>the</strong>r documents.<br />
• For <strong>the</strong> wet well and some o<strong>the</strong>r systems <strong>the</strong>re exist non-defined concentration gaps<br />
between normal values and action levels. Staff might be confused, if parameters are<br />
in this concentration range.<br />
• The valid LOK document does not refer properly <strong>to</strong> <strong>the</strong> applicable procedures for<br />
<strong>the</strong> chemistry program.<br />
• The material manual was not updated since 1990 although in 1997 an extensive<br />
exchange <strong>of</strong> material has taken place.<br />
• In <strong>the</strong> closed cooling water system, <strong>the</strong>re are forty three (according <strong>to</strong> <strong>the</strong> plant)<br />
identified stainless steel components which are combined with carbon steel<br />
components. The system is designed <strong>to</strong> be operated with hydrazine as reducing<br />
agent. However, due <strong>to</strong> a management decision, <strong>the</strong> use <strong>of</strong> hydrazine has been<br />
abandoned. Since 2005, <strong>the</strong> hydrazine concentration in Unit 1 has been close <strong>to</strong><br />
zero and in action level 1, although <strong>the</strong> material composition has not been changed.<br />
A surveillance programme has been updated during <strong>the</strong> <strong>mission</strong>.<br />
• The important parameter “lubricity” is not included in <strong>the</strong> analysis programme for<br />
Diesel fuel.<br />
• Oxygen concentrations in <strong>the</strong> condensate <strong>of</strong> unit 1 are below normal values<br />
according document F12-I-0017.<br />
Without chemistry specifications and chemistry control that are in accordance with<br />
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international guidelines and chemistry experience <strong>the</strong> integrity <strong>of</strong> systems and components can<br />
be endangered.<br />
Recommendation: The plant should implement chemistry specifications and chemistry control<br />
that are in accordance with international guidelines and chemistry experience.<br />
Basis:<br />
Draft SG DS388<br />
2.5. The operating organization should ensure that <strong>the</strong> chemistry applied <strong>to</strong> <strong>the</strong> SSCs<br />
important <strong>to</strong> <strong>safety</strong> are <strong>of</strong> such a standard as <strong>to</strong> ensure that <strong>the</strong> level <strong>of</strong> reliability<br />
and functionality <strong>of</strong> <strong>the</strong> SSCs remains in accordance with <strong>the</strong> design assumptions<br />
and intent throughout <strong>the</strong> plant ’s operating lifetime. Chemistry is one <strong>of</strong> <strong>the</strong> main<br />
contribu<strong>to</strong>rs <strong>to</strong> long term operation <strong>of</strong> <strong>the</strong> plant.<br />
3.5 Chemistry programme should ensure <strong>the</strong> following:<br />
• suitable chemistry regime in accordance with original design and material<br />
concept, following any structural modification or due <strong>to</strong> operating experience;<br />
• evaluation <strong>of</strong> adequacy <strong>of</strong> chemistry regimes and chemistry parameters from <strong>the</strong><br />
point <strong>of</strong> view <strong>of</strong> short and long term operation;<br />
4.40. Dissolved hydrogen and oxygen levels should be within specifications, and<br />
impurity levels (e.g. corrosion products, chloride and fluoride) should be<br />
maintained well below <strong>the</strong> limits.<br />
8.3 CHEMICAL SURVEILLANCE PROGRAMME<br />
8.3(1) Issue: The quality control programme for chemical analysis and <strong>the</strong> analytical<br />
equipment is not adequate.<br />
The <strong>team</strong> observed <strong>the</strong> following facts:<br />
• In February 2008 tritium concentrations in <strong>the</strong> closed cooling water system<br />
were released that turned out <strong>to</strong> be wrong. A closer inspection during <strong>the</strong><br />
<strong>mission</strong> revealed, that incorrect, extremely high blank values (100 counts per<br />
minutes) instead <strong>of</strong> some 5 - 10 counts per minute were subtracted from <strong>the</strong><br />
measurement, resulting in a <strong>to</strong>o low final result. Although <strong>the</strong> LIMS data base<br />
for chemical results performs a first plausibility check on entered data,<br />
incorrect data have been found in <strong>the</strong> data base but staff did not add any<br />
comment or inform <strong>the</strong> labora<strong>to</strong>ry leader.<br />
• On <strong>the</strong> 4 th <strong>of</strong> December 2007 <strong>the</strong> quality control standard for sulfate was lying<br />
outside <strong>the</strong> control limits. However, at <strong>the</strong> same day values for sulfate were<br />
entered in <strong>the</strong> data base. The wrong values were entered in <strong>the</strong> control chart.<br />
• The QC-data base did not always contain comments when warning or control<br />
limits had been violated, e.g. <strong>the</strong> warning limit for calcium was violated<br />
several times in January 2007 without any comments or countermeasures<br />
recorded.<br />
• When discussing some control charts with staff it was not clear, what <strong>the</strong><br />
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different markings (different colors <strong>of</strong> crosses) mean.<br />
• The <strong>team</strong> observed that online conductivity meters had been controlled with<br />
labora<strong>to</strong>ry instruments that were not included in <strong>the</strong> quality control<br />
programme. The failure was obvious, as <strong>the</strong> measured conductivity is<br />
<strong>the</strong>oretically not achievable!<br />
• Some analytical instruments like <strong>the</strong> inductively coupled plasma optical<br />
e<strong>mission</strong> spectrometer and <strong>the</strong> UV-vis spectrometer are old.<br />
Without a comprehensive quality control for chemical analysis and reliable analytical<br />
equipment incorrect analytical results can cause decisions which endanger <strong>the</strong> integrity <strong>of</strong><br />
systems and components and may endanger <strong>the</strong> health <strong>of</strong> staff.<br />
Suggestion: The plant should consider improving its quality control programme for<br />
chemical analysis and <strong>the</strong> analytical equipment.<br />
Basis:<br />
Draft SG DS388<br />
5.18 & 5.21 For online/ labora<strong>to</strong>ry instruments, <strong>the</strong>re should be developed a procedure<br />
with: a summary <strong>of</strong> analytical methods indicating possible interferences, accuracy,<br />
linearity and range capability…<br />
5.39 If instrument performance shows significant scatter from <strong>the</strong> expected value, an<br />
investigation should be performed <strong>to</strong> determine <strong>the</strong> cause <strong>of</strong> <strong>the</strong> deviations…<br />
6.3 Analytical data should be <strong>review</strong>ed <strong>to</strong> verify completeness, accuracy and<br />
inconsistency. Chemistry data assessment for identifying <strong>of</strong> actual and potential<br />
problems should start as soon as data is generated or first recorded. Without timely and<br />
effective <strong>review</strong> <strong>of</strong> <strong>the</strong> data, a chemistry problem may not be identified until it affects <strong>the</strong><br />
system or plant performance.<br />
6.15 Plant should have implemented management system, which ensures that data<br />
collected by online moni<strong>to</strong>rs and data acquisition system are trustful and reliable. There<br />
are more methods usable for this, such as: …timely comparison <strong>of</strong> online moni<strong>to</strong>ring and<br />
labora<strong>to</strong>ry results or o<strong>the</strong>r well calibrated portable online moni<strong>to</strong>rs…<br />
8.4 CHEMISTRY OPERATIONAL HISTORY<br />
8.4(a) Good Practice: The sulphate content in <strong>the</strong> coolant increased after <strong>the</strong> power<br />
upgrade (100% <strong>to</strong> 108%). The new <strong>the</strong>rmo hydraulic conditions caused a more oxidizing<br />
environment at <strong>the</strong> condensate clean up filters, and <strong>the</strong> strong cation exchange resins<br />
containing sulphuric functional groups were decomposed. Weak cation exchanger with<br />
carboxyl groups were tested and fulfilled all requirements for coating, waste handling,<br />
clean up function etc. This Low Sulphur Resin (LSR) was tested in a test rig and later on<br />
a real filter during <strong>operational</strong> conditions. It was concluded that <strong>the</strong> differential pressure<br />
increase was slower compared <strong>to</strong> normal resins and <strong>the</strong> particle separation was excellent.<br />
A draw-back <strong>of</strong> this type <strong>of</strong> resin is leakage <strong>of</strong> trimethyl amine from <strong>the</strong> anion resin,<br />
which is not captured in <strong>the</strong> weak cation resin bed, but leaks <strong>to</strong> <strong>the</strong> reac<strong>to</strong>r coolant<br />
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esulting in increased nitrate content.<br />
However, nitrate ions are less harmful with respect <strong>to</strong> stress corrosion cracking as<br />
compared <strong>to</strong> sulphate ions.<br />
In addition, <strong>the</strong> chemistry department has developed a test rig for simulating <strong>the</strong> coating<br />
<strong>of</strong> candle filters from <strong>the</strong> condensate clean up system. The test rig consists <strong>of</strong> sampling<br />
holder <strong>of</strong> Plexiglas, mixture vessel for resin, stirrer, coating pump, pump for sufficient<br />
flow for adhesion <strong>of</strong> <strong>the</strong> resins, flow meter, differential pressure meter, regulation valves<br />
and tubes for connection <strong>of</strong> air and water. The sampling holder has sufficient space for<br />
mounting filters <strong>of</strong> different sizes from <strong>the</strong> condensate cleanup system (CCS). The<br />
construction is built <strong>to</strong> simulate <strong>the</strong> real CCS. Mixture time, coating flow, amount <strong>of</strong><br />
resins, flocking size and temperature are parameters that can be varied. The result <strong>of</strong> <strong>the</strong><br />
coating is visually determined as <strong>the</strong> filter inside is seen through <strong>the</strong> Plexiglas.<br />
Observation <strong>of</strong> <strong>the</strong> size <strong>of</strong> <strong>the</strong> flock, sedimentation rate, adhesion <strong>of</strong> <strong>the</strong> resin and <strong>the</strong><br />
distribution over <strong>the</strong> surface can be carefully evaluated. The coating <strong>of</strong> <strong>the</strong> filter can be<br />
optimized by pressure variations. Even small variations <strong>of</strong> <strong>the</strong> parameters strongly affect<br />
<strong>the</strong> result <strong>of</strong> <strong>the</strong> coating.<br />
8.6 QUALITY CONTROL OF OPERATIONAL CHEMICALS AND OTHER<br />
SUBSTANCES<br />
8.6(1) Issue: The quality control programme for <strong>operational</strong> chemicals and o<strong>the</strong>r<br />
auxiliary chemical substances is not adequate.<br />
• All chemical auxiliary substances are at least analyzed once. In some cases,<br />
repetitive analyses are performed but <strong>the</strong>re is no periodical sampling.<br />
Suppliers may change <strong>the</strong>ir recipes without notifying <strong>the</strong> plant or violate <strong>the</strong>ir<br />
own specifications. The plant itself experienced this several times, e.g. during<br />
<strong>the</strong> change <strong>of</strong> turbine oil in F3 in 2004 (<strong>the</strong> new oil did not meet <strong>the</strong> promised<br />
water separation capability), Loctite 415 (first analysis in 1991 okay, category<br />
1, second analysis in 1995 increased chlorine values, category 2).<br />
• Diesel fuel is sampled periodically; however, <strong>the</strong> procedures are not clear,<br />
several departments are involved in organizing chemical analysis.<br />
• Only turbine oil, transformer oil and <strong>the</strong> oil from <strong>the</strong> feed water pump gear<br />
box are periodically analysed.<br />
• Specifications for auxiliary substances and bulk chemicals are not included in<br />
a procedure.<br />
• In an unlocked cabinet in <strong>the</strong> main cooling water room <strong>the</strong> <strong>team</strong> found four,<br />
poorly labelled bottles (Rando HD 68, each 1 l, different colour) <strong>of</strong> lube oil,<br />
obviously <strong>to</strong> refill some leaking pumps. However, issues like this are not in<br />
accordance with nuclear practice, as <strong>the</strong> risk <strong>of</strong> mixing up and pollution <strong>of</strong> <strong>the</strong><br />
content exist. In addition <strong>the</strong> age management (control <strong>of</strong> shelf lives) is no<br />
longer under control.<br />
• In 1.K1.08 a tank with glycol with no category, handwritten label “glycol”<br />
was found.<br />
• In <strong>the</strong> service water building a jug with handwritten sign “Aminosyra” on <strong>to</strong>p<br />
<strong>of</strong> sulphuric acid pallet was found. Old drum, not labelled on <strong>to</strong>p <strong>of</strong> spare<br />
natron pallet (pallet looked very temporary- not clean and not easy accessible.<br />
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• Handling <strong>of</strong> <strong>the</strong> material <strong>safety</strong> data sheets (MSDS) is not clearly described,<br />
<strong>the</strong>y will be available online and <strong>the</strong>y are already available in <strong>the</strong> warehouse.<br />
Workers receive a copy <strong>of</strong> <strong>the</strong> MSDS, some <strong>of</strong> <strong>the</strong> working groups have <strong>the</strong>ir<br />
own collection sometimes single worker collect <strong>the</strong>m, sometimes <strong>the</strong>y are<br />
fixed <strong>to</strong> <strong>the</strong> barrels in <strong>the</strong> field, however <strong>the</strong> <strong>team</strong> found also container<br />
without MSDS being attached.<br />
• The online data base, which should have been already in full operation, is still<br />
under construction and does not contain all substances and necessary<br />
information, e.g. <strong>the</strong> MSDS for Borax 10 Hydrat, which was found in <strong>the</strong><br />
field, was not found in <strong>the</strong> data base.<br />
Without a comprehensive quality control programme for delivered and s<strong>to</strong>red chemicals<br />
serious damage <strong>to</strong> systems and components can result that endanger humans and<br />
environment.<br />
Suggestion: The plant should consider implementing a comprehensive quality control<br />
programme for delivered and s<strong>to</strong>red chemical.<br />
Basis:<br />
Draft SG DS388<br />
8.6 Chemicals and substances should be labelled (under <strong>the</strong> responsibility <strong>of</strong> <strong>the</strong> plant)<br />
according <strong>to</strong> <strong>the</strong> area where <strong>the</strong>y can be used, so that <strong>the</strong>y can be clearly identified. The<br />
label should indicate <strong>the</strong> shelf life <strong>of</strong> <strong>the</strong> material and he application area <strong>of</strong> <strong>the</strong> material<br />
(system contact/no system contact).<br />
8.7 If it is necessary <strong>to</strong> fill a certain amount from a s<strong>to</strong>ck container <strong>to</strong> a smaller flask, this<br />
flask must be properly labelled with name <strong>of</strong> <strong>the</strong> chemicals, date and pic<strong>to</strong>grams <strong>to</strong><br />
indicate <strong>the</strong> risk and <strong>the</strong> application area. This amount must be small enough <strong>to</strong> be used<br />
within a certain time under work permit… Rests <strong>of</strong> non needed chemicals and substances<br />
should be disposed accordingly plant procedures.<br />
8.12. Safety Data Sheets for all approved chemicals and substances must be available and<br />
easily accessible<br />
8.15 Shelf life should be clearly defined by manufacturer or a plant organization.<br />
8.16 The s<strong>to</strong>rage <strong>of</strong> chemicals should take in<strong>to</strong> account <strong>the</strong> reduced shelf life <strong>of</strong> opened<br />
containers. Unsealed and partly emptied containers should be controlled in such a<br />
manner, that <strong>the</strong> quality <strong>of</strong> <strong>the</strong> remaining product is in satisfac<strong>to</strong>ry condition.<br />
8.18 Use <strong>of</strong> proper chemicals and right quality is responsibility <strong>of</strong> <strong>the</strong> plant. Before being<br />
used <strong>the</strong> specified quality should be verified by chemical analysis and/or by a certificate<br />
and a chemical identity check. The quality <strong>of</strong> <strong>the</strong>se materials should be rechecked if<br />
appropriate (e.g. Diesel fuel).<br />
8.20 Plant procedure should define <strong>the</strong> proper quality <strong>of</strong> lubricant oil for each component<br />
that is essential for <strong>safety</strong> and availability.<br />
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8.21 Lubricant oils from systems, that are important for <strong>safety</strong> and/or availability should<br />
be regularly analysed for control parameters that characterize <strong>the</strong> condition <strong>of</strong> <strong>the</strong><br />
lubricant (e.g. viscosity, neutralization number etc.).<br />
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9. EMERGENCY PLANNING AND PREPAREDNESS<br />
9.1 EMERGENCY PROGRAMME<br />
Sweden assigned clear responsibilities for nuclear emergency planning and response in<br />
two legislations. The Nuclear Operations Act assigns <strong>to</strong> <strong>the</strong> plant <strong>the</strong> responsibility for<br />
<strong>safety</strong>, planning and response on site. It also specifies that <strong>the</strong> plant must notify <strong>the</strong><br />
authorities in case <strong>of</strong> an emergency. The Rescue Service Act assigns responsibility <strong>to</strong> <strong>the</strong><br />
Local County Government (Lsty) for preparedness and protective measures outside <strong>the</strong><br />
plant. Responsibility is assigned <strong>to</strong> <strong>the</strong> Swedish Radiation Protection Authority (SSI) for<br />
providing recommendations <strong>to</strong> Lsty on radiation protection issues and <strong>to</strong> organize<br />
nationwide protective measures. Responsibility is assigned <strong>to</strong> <strong>the</strong> Swedish Nuclear<br />
Power Inspec<strong>to</strong>rate (SKI) for providing advice <strong>to</strong> Lsty on reac<strong>to</strong>r <strong>safety</strong> issues.<br />
Alerting <strong>the</strong> public <strong>of</strong> an emergency during working hours is rapid and effective. The<br />
Unit Operation Manager (Level 2) or Duty Engineer (VHI) takes over immediate actions<br />
for emergency response. This includes declaring emergency level and initial notification<br />
<strong>to</strong> SOS-Alarm in Uppsala.<br />
As soon as SOS-Alarm receives <strong>the</strong> fax notification <strong>of</strong> an emergency at <strong>Forsmark</strong>, its<br />
duty <strong>of</strong>ficer phones back <strong>the</strong> Duty Engineer and requests confirmation. He <strong>the</strong>n asks if<br />
<strong>the</strong> release has started or is anticipated. This information is entered on a form and used <strong>to</strong><br />
select one <strong>of</strong> <strong>the</strong> pre-arranged media messages. This message is immediately sent <strong>to</strong><br />
media outlets. As was observed during a drill, this means that notification <strong>of</strong> <strong>the</strong> public<br />
through <strong>the</strong> media could start within thirty minutes <strong>of</strong> <strong>the</strong> declaration <strong>of</strong> an emergency.<br />
This is an exemplary arrangement during working hours but <strong>the</strong> <strong>team</strong> identified that,<br />
outside <strong>of</strong> normal working hours, <strong>the</strong> process for declaring an emergency and notifying<br />
<strong>of</strong>f-site authorities may result in unnecessary delays in <strong>the</strong> implementation <strong>of</strong> protective<br />
actions. The <strong>team</strong> has made a recommendation in this regard in <strong>the</strong> MOA area.<br />
It should be noted that <strong>the</strong> Lsty did not receive <strong>the</strong> usual “courtesy notification” by <strong>the</strong><br />
normal channel during <strong>the</strong> event <strong>of</strong> July 2006. The Duty Engineer – VHI could not reach<br />
<strong>the</strong> duty <strong>of</strong>ficer through SOS-Alarm. This breakdown in communication is unusual and<br />
is being investigated by <strong>the</strong> plant and <strong>the</strong> Lsty.<br />
While SSI is responsible <strong>of</strong> advising <strong>the</strong> Lsty on <strong>the</strong> radiological aspects <strong>of</strong> protective<br />
measures for <strong>the</strong> public, this does not delay <strong>the</strong> decision process. Lsty demonstrates a<br />
good understanding <strong>of</strong> its responsibilities, and is pro-active in making decisions for <strong>the</strong><br />
protection <strong>of</strong> <strong>the</strong> population. It maintains a direct link with <strong>the</strong> plant and exchanges<br />
gamma survey measurements and information that could be useful in <strong>the</strong> decision<br />
making process. Lsty uses Operational Intervention Levels <strong>to</strong> promptly decide if<br />
protective actions are required. The use <strong>of</strong> Operational Intervention Levels is encouraged<br />
by <strong>the</strong> <strong>team</strong>.<br />
The Human Resources unit has created a Crisis Group that handles post-traumatic stress<br />
disorders and problems associated with fitness for duty. This arrangement was<br />
established <strong>to</strong> conform <strong>to</strong> Swedish Work Environment Authority regulation AFS 1999:7.<br />
The Crisis Group is integrated in<strong>to</strong> <strong>the</strong> emergency plan and this demonstrates good<br />
foresight and a pro-active attitude on <strong>the</strong> part <strong>of</strong> <strong>the</strong> plant.<br />
The plant recommends that each employee contacts his or her family when an Alert or<br />
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General Emergency is declared. Most use <strong>the</strong>ir mobile, but <strong>the</strong>re is a phone near <strong>the</strong><br />
assembly point for that purpose. Provided that <strong>the</strong> employees are well informed, this<br />
arrangement may prove very effective at informing <strong>the</strong> local population.<br />
During an Emergency, <strong>the</strong> Lsty, SSI and SKI arrange press briefings and press<br />
conferences at <strong>the</strong> Joint Media Information Centre in Uppsala. The plant plans <strong>to</strong> use a<br />
separate Media Centre, located on site at <strong>the</strong> Information Centre during <strong>the</strong> first day <strong>of</strong><br />
<strong>the</strong> emergency. On subsequent days, <strong>the</strong> plant would relocate its Media Team <strong>to</strong> <strong>the</strong> Joint<br />
Media Information Centre in Uppsala. Relocation <strong>to</strong> Joint Media Centre is important for<br />
joint operations with Lsty, SSI and SKI and this should happen as soon as possible. The<br />
plant is encouraged <strong>to</strong> document this arrangement clearly in <strong>the</strong> procedures <strong>of</strong> <strong>the</strong> Media<br />
Information Team.<br />
9.2 EMERGENCY PLAN<br />
The on-site and <strong>of</strong>f-site emergency plans for Lsty are well coordinated. For example, <strong>the</strong><br />
local police, fire-fighters, reception centres, emergency operation centres in Östhammar<br />
and Uppsala use <strong>the</strong> same maps as <strong>the</strong> plant. This is evidence <strong>of</strong> good coordination at<br />
<strong>the</strong> local level and it is <strong>to</strong> be commended. It is noted that <strong>the</strong> plant and <strong>the</strong> SSI<br />
emergency centre do not use <strong>the</strong> same maps, although this has no impact on <strong>the</strong> local<br />
response.<br />
The plant declares an Alert or General Emergency on <strong>the</strong> basis <strong>of</strong><br />
• plant conditions compared <strong>to</strong> Emergency Action Levels; or<br />
• gamma dose rate measurements from fixed detec<strong>to</strong>rs or mobile surveys compared <strong>to</strong><br />
Operational Intervention Levels.<br />
At <strong>the</strong> Alert level, <strong>the</strong> plant immediately shelters personnel at <strong>the</strong> assembly points. At<br />
<strong>the</strong> General Emergency Level, <strong>the</strong> plant immediately evacuates non essential personnel<br />
from <strong>the</strong> site. This is a good arrangement that minimizes delays in <strong>the</strong> implementation <strong>of</strong><br />
<strong>the</strong> on-site protective actions.<br />
The Site Emergency Direc<strong>to</strong>r receives a high level view <strong>of</strong> <strong>the</strong> management <strong>of</strong> technical<br />
issues during a nuclear emergency that is unique in <strong>the</strong> Team’s opinion. This has been<br />
identified as good practice.<br />
The Inner Emergency Zone, 10-15 km in radius, represents <strong>the</strong> area where evacuation is<br />
pre-planned. Reception centres outside <strong>the</strong> zone are identified and prepared. Every<br />
permanent resident <strong>of</strong> <strong>the</strong> Inner Emergency Zone receives a package containing 10<br />
tablets <strong>of</strong> potassium iodide, and two pamphlets issued by SSI, Lsty and Rescue Services<br />
describing <strong>the</strong> <strong>of</strong>f-site emergency plan and <strong>the</strong> protective actions during a nuclear<br />
emergency. The information package for <strong>the</strong> public is good and effective.<br />
Lsty has recovery plans for <strong>the</strong> area. This is impressive, since very few countries go that<br />
far in <strong>the</strong> planning process.<br />
9.3 EMERGENCY PROCEDURES<br />
Source term assessment is carried out at <strong>the</strong> Emergency Management Centre (EMC) by<br />
<strong>the</strong> Radiation Protection Manager and <strong>the</strong> Specialist Group. The procedures for source<br />
term assessment are very good, and great efforts are expended on this task, even if it<br />
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gives results with great uncertainties 1 . The plant is encouraged <strong>to</strong> emphasize this when<br />
communicating <strong>the</strong> results <strong>of</strong> <strong>the</strong> assessment <strong>to</strong> SSI.<br />
The procedures for emergency workers are designed for those wearing respira<strong>to</strong>ry<br />
protection and taking potassium iodide tablets. If <strong>the</strong> emergency workers are not wearing<br />
respira<strong>to</strong>ry protection and not taking potassium iodide tablets, <strong>the</strong>y can be exposed<br />
through inhalation in addition <strong>to</strong> external exposure. To account for this, <strong>the</strong> dose alarms<br />
on <strong>the</strong>ir electronic dosimeters should be lowered 2 by a fac<strong>to</strong>r 10. The plant is encouraged<br />
<strong>to</strong> include this instruction in <strong>the</strong> procedures for setting <strong>the</strong> alarm thresholds <strong>of</strong> emergency<br />
workers.<br />
Events below <strong>the</strong> threshold for Alert or General Emergency are handled like normal<br />
<strong>operational</strong> issues by <strong>the</strong> plant, even if <strong>the</strong>y have an impact on <strong>the</strong> <strong>safety</strong> <strong>of</strong> <strong>the</strong> personnel<br />
or <strong>the</strong> relations with <strong>the</strong> community. The <strong>team</strong> has made a recommendation in this<br />
regard.<br />
9.4 EMERGENCY RESPONSE FACILITIES<br />
The Emergency Operations Management Centre (DLC) and <strong>the</strong> Technical Support<br />
Centre (TSC) are tidy, well equipped with faxes and telephones. The Emergency<br />
Management Centre is in a well protected bunker, has good communication facilities and<br />
a good layout. An air filtration system and a diesel genera<strong>to</strong>r are installed. The protection<br />
<strong>of</strong> this facility is very good and <strong>the</strong> alternative arrangements are credible since <strong>the</strong> Fire<br />
Station in Östhammar is <strong>the</strong> alternate Emergency Management Centre (EMC) for <strong>the</strong><br />
plant.<br />
There are nine assembly points on site, near each group <strong>of</strong> buildings. <strong>Forsmark</strong> Units 1-<br />
2-3 have an assembly point in <strong>the</strong> lunch room <strong>of</strong> <strong>the</strong> non-controlled area. The nine<br />
assembly points provide minimum protection from radiation in <strong>the</strong> event <strong>of</strong> a release. For<br />
this reason, <strong>the</strong>y should be moni<strong>to</strong>red continuously during an emergency. This function<br />
is carried out by <strong>the</strong> Duty Engineer or <strong>the</strong> Radiation Protection Manager at <strong>the</strong><br />
Emergency Management Centre (EMC). They access <strong>the</strong> online system <strong>of</strong> outdoors fixed<br />
moni<strong>to</strong>rs, check those that are closest <strong>to</strong> each assembly point and ask <strong>the</strong> Communication<br />
Manager <strong>to</strong> telephone and send a fax <strong>to</strong> <strong>the</strong> assembly point if it is not safe. The<br />
Information Centre is not in <strong>the</strong> vicinity <strong>of</strong> any <strong>of</strong> <strong>the</strong> outdoors fixed moni<strong>to</strong>rs. The plant<br />
agreed that local moni<strong>to</strong>ring using portable ambient gamma survey meters would<br />
improve <strong>the</strong> ability <strong>of</strong> each assembly point <strong>to</strong> moni<strong>to</strong>r its habitability. The portable<br />
ambient gamma survey meters will be distributed <strong>to</strong> <strong>the</strong> assembly points upon<br />
declaration <strong>of</strong> an Alert.<br />
The Reception Centres in Norrskedika and Skärplinge were in part provided and<br />
equipped by <strong>the</strong> plant. This is evidence <strong>of</strong> <strong>the</strong> good collaboration between <strong>the</strong> plant and<br />
<strong>the</strong> <strong>of</strong>f-site authorities. These locations are also <strong>the</strong> assembly point for police,<br />
ambulance, fire fighters who will enter and exit <strong>the</strong> inner emergency zone. These<br />
arrangements are noteworthy for <strong>the</strong>ir thoroughness.<br />
The plant does not have a dedicated medical centre on site. Casualties receive first-aid<br />
1 The great uncertainty is not <strong>the</strong> result <strong>of</strong> a poor methodology on <strong>the</strong> part <strong>of</strong> <strong>the</strong> plant. It<br />
is inherent in this type <strong>of</strong> assessment, as discussed in EPR-Method 2003; A7.<br />
2 The recommended fac<strong>to</strong>r is explained in TECDOC 955, procedures C1, F1.<br />
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from Rescue Services and are transported by ambulance or helicopter <strong>to</strong> <strong>the</strong> hospital in<br />
Östhammar or Uppsala. The Östhammar hospital in <strong>the</strong> inner emergency zone accepts<br />
contaminated victims and <strong>the</strong> hospital in Uppsala is specialized in <strong>the</strong> treatment <strong>of</strong><br />
overexposed patients. These arrangements are good however <strong>the</strong>re are currently no<br />
written agreements between <strong>the</strong> hospitals and <strong>the</strong> plant. The plant is encouraged <strong>to</strong> put<br />
more formal agreements in place.<br />
9.5 EMERGENCY EQUIPMENT AND RESOURCES<br />
Unlike <strong>the</strong> control room at <strong>Forsmark</strong> Unit 3, <strong>the</strong> control rooms at Units 1 and 2 are not<br />
equipped with fixed ambient gamma moni<strong>to</strong>r <strong>to</strong> check <strong>the</strong> habitability <strong>of</strong> <strong>the</strong> control<br />
room during an accident. Procedures at <strong>the</strong> Emergency Operations Management Centre<br />
(DLC) require RP <strong>to</strong> bring a portable ambient gamma survey meter <strong>to</strong> <strong>the</strong> control room.<br />
The plant plans <strong>to</strong> equip <strong>the</strong> control rooms at F1/F2 with fixed ambient gamma moni<strong>to</strong>rs<br />
within <strong>the</strong> next few months.<br />
The Alert system for <strong>the</strong> population includes Radio Broadcast Warning devices (RDS) in<br />
homes <strong>of</strong> about 1000 permanent residents, sirens that alert transient populations, and <strong>the</strong><br />
use <strong>of</strong> local television and radio <strong>to</strong> broadcast alert messages. These arrangements are<br />
good and are tested quarterly.<br />
The plant and Lsty perform and share <strong>the</strong> results <strong>of</strong> gamma surveys in <strong>the</strong> inner<br />
emergency zone. Every fire station in <strong>the</strong> inner emergency zone is equipped with<br />
portable gamma survey instruments and <strong>team</strong>s <strong>of</strong> fire-fighters have been trained <strong>to</strong> use<br />
<strong>the</strong>m. These <strong>team</strong>s are deployed <strong>to</strong> measure dose rates in <strong>the</strong> communities surrounding<br />
<strong>the</strong> plant. The fire-fighter moni<strong>to</strong>ring <strong>team</strong>s use <strong>the</strong> RADOS SRV-2000 gamma survey<br />
meters with a high range <strong>of</strong> 10 Sv/h. The plant moni<strong>to</strong>ring <strong>team</strong>s use <strong>the</strong> Au<strong>to</strong>mess<br />
survey meters that has an inadequate high range (10 mSv/h) and this is not sufficient for<br />
emergency surveys near <strong>the</strong> release point. The plant is encouraged <strong>to</strong> include an<br />
additional probe that has a range <strong>of</strong> at least 1 Sv/h in <strong>the</strong>ir equipment bags.<br />
The rest <strong>of</strong> <strong>the</strong> equipment used by <strong>the</strong> plant has an adequate high range (gamma dose rate<br />
moni<strong>to</strong>r in containment up <strong>to</strong> 10 kGy/h and radiation detection equipment used by RP<br />
inside <strong>the</strong> plant up <strong>to</strong> 1 Sv/h). The ring <strong>of</strong> fixed detec<strong>to</strong>rs around <strong>the</strong> plant is well<br />
implemented and <strong>the</strong> detec<strong>to</strong>rs have a high range (1 Sv/h), ten year battery life and use a<br />
web-based interface that can be accessed from any location on site (but currently not <strong>of</strong>fsite).<br />
A visual alarm is displayed when <strong>the</strong> user accesses <strong>the</strong> webpage <strong>of</strong> <strong>the</strong> detec<strong>to</strong>rs,<br />
but <strong>the</strong>re are no continuously moni<strong>to</strong>red alarms associated with this system. There should<br />
be one, moni<strong>to</strong>red from a location manned 24/7 (such as <strong>the</strong> Security Centre or <strong>the</strong><br />
Control Room). SSI has 32 fixed detec<strong>to</strong>rs across Sweden that are used <strong>to</strong> moni<strong>to</strong>r<br />
gamma dose rates. SSI does not currently have direct access (internet) <strong>to</strong> <strong>the</strong> ring <strong>of</strong><br />
detec<strong>to</strong>rs on <strong>the</strong> site. These arrangements are good, although <strong>the</strong> plant and SSI are<br />
encouraged <strong>to</strong> investigate <strong>the</strong> feasibility <strong>of</strong> au<strong>to</strong>matically exchanging <strong>the</strong> data from <strong>the</strong><br />
on site ring <strong>of</strong> detec<strong>to</strong>rs.<br />
The plant has a one hundred meter meteorological <strong>to</strong>wer and uses a very effective web<br />
interface for presenting <strong>the</strong> wea<strong>the</strong>r data. This web site is accessible <strong>to</strong> <strong>the</strong> public or any<br />
organization, inside or outside <strong>the</strong> plant.<br />
Four functionalities are included in <strong>the</strong> web interface.<br />
1. A simple page shows <strong>the</strong> temperature, <strong>the</strong> wind speed and <strong>the</strong> wind direction using<br />
pic<strong>to</strong>grams that are easily understandable by <strong>the</strong> public.<br />
2. A map <strong>of</strong> <strong>the</strong> area shows <strong>the</strong> direction <strong>of</strong> <strong>the</strong> wind with a large arrow.<br />
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3. Graphical records <strong>of</strong> <strong>the</strong> data collected at <strong>the</strong> meteorological <strong>to</strong>wer are available for<br />
temperature, windspeed, wind direction and standard deviation at three levels.<br />
4. Capability <strong>to</strong> export data in text or Excel format.<br />
This has been identified as good performance by <strong>the</strong> Team.<br />
9.6 TRAINING, DRILL AND EXERCISES<br />
The web-based training is very effective and covers emergency signals and emergency<br />
levels well. The basic training would be more complete if it included a description <strong>of</strong><br />
signs on <strong>the</strong> floor that are routinely used in <strong>the</strong> plant. One set (<strong>the</strong> “Ut” sign) directs <strong>the</strong><br />
person <strong>to</strong> <strong>the</strong> nearest exit and <strong>the</strong> o<strong>the</strong>r (<strong>the</strong> “Running man”) is showing <strong>the</strong> safest route<br />
<strong>to</strong> evacuate, but this is not currently taught.<br />
The preparation and conduct <strong>of</strong> <strong>the</strong> drills is generally adequate, although <strong>the</strong> drill<br />
preparation process could be optimized if <strong>the</strong> objectives <strong>of</strong> <strong>the</strong> drill were always selected<br />
before preparing <strong>the</strong> scenario. As an example, a drill prepared for <strong>the</strong> Crisis Group did<br />
not achieve <strong>the</strong> objective <strong>of</strong> testing <strong>the</strong> notification and activation process because <strong>the</strong><br />
call from <strong>the</strong> Site Emergency Direc<strong>to</strong>r (OL) <strong>to</strong> <strong>the</strong> Crisis Group was not simulated.<br />
The process for preparing, co-ordinating and conducting exercises is more formal and<br />
this is appropriate since many groups are involved. The large scale emergency exercises<br />
are well organized, involving a group <strong>of</strong> emergency preparedness personnel from <strong>the</strong><br />
Unit that will exercise. The Crisis Group (handling post-traumatic stress syndrome) is<br />
invited <strong>to</strong> participate in exercise preparation <strong>to</strong> give visibility <strong>to</strong> this service <strong>to</strong> personnel.<br />
This is an effective method <strong>to</strong> improve awareness since individuals suffering from posttraumatic<br />
stress syndrome may not be aware that this type <strong>of</strong> support is available after an<br />
emergency.<br />
The exercise evaluation material for generic issues is very good, covering logistics,<br />
procedures, communications, facilities, training, etc… This material was prepared under<br />
<strong>the</strong> sponsorship <strong>of</strong> SKI for use by <strong>the</strong> power plants. The evaluation criteria for <strong>the</strong><br />
specific issues that are being tested have <strong>to</strong> be adapted <strong>to</strong> match <strong>the</strong> objectives <strong>of</strong> each<br />
exercise, and this done well by <strong>the</strong> plant. In order <strong>to</strong> facilitate this process, <strong>the</strong> plant is<br />
encouraged <strong>to</strong> use <strong>the</strong> evaluation criteria contained in Appendix III <strong>of</strong> EPR-Method<br />
2003.<br />
The plant is also encouraged <strong>to</strong> adopt a list <strong>of</strong> response functions (such as those in EPR-<br />
Method 2003 section 4.2 or EPR-Exercise 2005 Appendix II) that would be tested in<br />
drills and exercises over a five year cycle.<br />
9.7 QUALITY PROGRAMME<br />
The plant has set forth <strong>the</strong> requirements for Emergency Preparedness in <strong>the</strong> Management<br />
and Quality Handbook (LOK) and supporting documents. The QA process for<br />
Emergency Preparedness demonstrates a good high level <strong>review</strong> at <strong>the</strong> policy and<br />
functional level. This is carried out by independent <strong>review</strong>ers from ano<strong>the</strong>r power plant.<br />
To supplement <strong>the</strong> existing QA process, <strong>the</strong> plant is encouraged <strong>to</strong> implement an internal<br />
benchmark <strong>review</strong> against <strong>the</strong> detailed IAEA Requirements contained in EPR-Method<br />
107
2003. This <strong>review</strong> would be carried out by <strong>the</strong> plant every five years. This benchmarking<br />
would insure that <strong>the</strong>re are no gaps in <strong>the</strong> emergency plan following internal or external<br />
organization changes.<br />
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DETAILED EMERGENCY PLANNING AND PREPAREDNESS FINDINGS<br />
9.2 EMERGENCY PLAN<br />
9.2(a) Good Practice:<br />
The plant has developed a <strong>to</strong>ol that identifies strategies for solving technical problems<br />
during a nuclear emergency. This <strong>to</strong>ol is <strong>the</strong> Technical Handbook for Plant Operational<br />
Manager – Technisk Handbok for Anlaggningsledare (THAL).<br />
Using this <strong>to</strong>ol, <strong>the</strong> Plant Operational Manager (AL) presents <strong>the</strong> Site Emergency<br />
Direc<strong>to</strong>r (OL) with an assessment <strong>of</strong> <strong>the</strong> feasibility, data needs, resources, and expected<br />
results for solving technical problems that are not covered by General Disturbance<br />
Procedures. This high level view <strong>of</strong> <strong>the</strong> management <strong>of</strong> technical issues during an<br />
accident is unique in <strong>the</strong> Team’s opinion.<br />
Instead <strong>of</strong> entering directly in<strong>to</strong> Severe Accident Management Guidelines (SAMG), <strong>the</strong><br />
<strong>to</strong>ol gives management-level guidance on what is needed <strong>to</strong> solve <strong>the</strong> problem, who can<br />
help and what <strong>to</strong>ols can <strong>the</strong>y use. The THAL does not replace <strong>the</strong> SAMG, which are used<br />
by a separate group <strong>of</strong> engineering and <strong>safety</strong> analysis specialists. The THAL explains<br />
when <strong>to</strong> start <strong>the</strong> SAMG analysis and what <strong>to</strong> expect from <strong>the</strong> group <strong>of</strong> specialists.<br />
The THAL takes <strong>the</strong> approach that in order <strong>to</strong> be able <strong>to</strong> make decisions during a severe<br />
accident, different alternative strategies need <strong>to</strong> be considered. The THAL is a<br />
knowledge based handbook where such strategies are described, along with o<strong>the</strong>r<br />
essential information. The THAL also identifies <strong>the</strong> short term actions that are important<br />
for long term accident management. The THAL is organized by issues such as<br />
• Short term actions (minimizing <strong>the</strong> spread <strong>of</strong> radioactivity, core damage assessment,<br />
reac<strong>to</strong>r vessel integrity assessment, etc…)<br />
• Long term actions (containment pH adjustment, measuring activity and chemical<br />
parameters in <strong>the</strong> containment, hydrogen control, etc…)<br />
• Instrumentation available in <strong>the</strong> containment<br />
• Radiological environment (habitability)<br />
• Personal <strong>safety</strong> measures<br />
• Alternatives for electrical supply<br />
• Communication means<br />
• List <strong>of</strong> mobile equipment available in <strong>the</strong> region (pumps, genera<strong>to</strong>rs, etc…)<br />
• Operation at non affected reac<strong>to</strong>r units<br />
• Process systems relation<br />
Each issue is covered in a dedicated section that contains<br />
o Info<br />
o Strategy<br />
o References<br />
Using <strong>the</strong> THAL manual, <strong>the</strong> Plant Operational Manager (AL) can provide <strong>the</strong> Site<br />
Emergency Direc<strong>to</strong>r (EL) with a very good overview <strong>of</strong> <strong>the</strong> decisions he may have <strong>to</strong><br />
make during <strong>the</strong> emergency.<br />
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9.3 EMERGENCY PROCEDURES<br />
9.3(1) Issue: Events below <strong>the</strong> threshold for Alert or General Emergency are handled<br />
like normal <strong>operational</strong> issues by <strong>the</strong> plant, even if <strong>the</strong>y have an impact on <strong>the</strong><br />
<strong>safety</strong> <strong>of</strong> <strong>the</strong> personnel or <strong>the</strong> relations with <strong>the</strong> community.<br />
• The 1993 SKI ruling DNR-855/ad 1238/92 requires two emergency levels<br />
that trigger notification <strong>of</strong> <strong>the</strong> authorities (Alert, General Emergency)<br />
instead <strong>of</strong> <strong>the</strong> usual four levels contained in IAEA Safety Standard GS-R-2;<br />
para 4.19.<br />
• SKI and SSI have no problem if <strong>Forsmark</strong> decides <strong>to</strong> have additional alarm<br />
levels that don’t involve <strong>the</strong> authorities.<br />
• The plant has alarms for fire, gas leak and radiation (evacuation alarm).<br />
These alarms are not considered “Emergencies” by <strong>the</strong> plant, yet in<br />
combination with <strong>the</strong> two reportable emergency levels, <strong>the</strong>y meet <strong>the</strong> intent<br />
<strong>of</strong> <strong>the</strong> Safety Standard GS-R-2.<br />
• The Management and Quality Handbook (LOK) does not detail <strong>the</strong> range <strong>of</strong><br />
events, from plant disturbances that affect <strong>safety</strong> <strong>of</strong> personnel <strong>to</strong> severe<br />
accidents that should be covered by <strong>the</strong> emergency plan<br />
• Emergency Management Centre has not been used during a bomb threat or<br />
fire. These events could evolve in<strong>to</strong> a nuclear Alert or General Emergency.<br />
It would be prudent <strong>to</strong> muster key personnel (Duty Engineer – VHI) for<br />
<strong>the</strong>se events.<br />
• Once a room or hall is evacuated for a local Alarm (gas leak, radiation<br />
alarm, s<strong>team</strong> leak) <strong>the</strong> personnel is mustered at <strong>the</strong> Unit assembly point. The<br />
accounting process relies on grouping <strong>the</strong> evacuated persons in work <strong>team</strong>s<br />
that can quickly identify missing persons and on lists <strong>of</strong> personnel in <strong>the</strong><br />
controlled area that are produced by <strong>the</strong> Security Centre after <strong>the</strong> formal<br />
accounting process using <strong>the</strong> access cards is triggered.<br />
Dealing with disturbances without <strong>the</strong> resources and structure <strong>of</strong> <strong>the</strong> emergency plan can<br />
impair response and reduce <strong>the</strong> readiness <strong>of</strong> <strong>the</strong> organization if <strong>the</strong> emergency becomes<br />
more serious.<br />
Recommendation: The plant should create an emergency level “Alarm” that would<br />
apply <strong>to</strong> Unit disturbances that trigger protective actions for Unit personnel.<br />
For example: The plant could increase readiness <strong>of</strong> <strong>the</strong> on-site response organization by<br />
sending a Unit Operation Manager (Level 2) or Duty Engineer (VHI) <strong>to</strong> <strong>the</strong> control<br />
room. The plant could assign one person <strong>to</strong> prepare Emergency Management Centre and<br />
remain on standby until <strong>the</strong> “Alarm” is over.<br />
Basis: EPR-Method 2003. 2.1.5: “Alerts at facilities in threat category I, II or III<br />
involving an uncertain or significant decrease in <strong>the</strong> level <strong>of</strong> protection for <strong>the</strong> public or<br />
for people on <strong>the</strong> site. Upon declaration <strong>of</strong> this class <strong>of</strong> emergency, action shall be<br />
promptly taken <strong>to</strong> assess and mitigate <strong>the</strong> consequences <strong>of</strong> <strong>the</strong> event and <strong>to</strong> increase <strong>the</strong><br />
readiness <strong>of</strong> <strong>the</strong> on-site and <strong>of</strong>f-site response organizations as appropriate.”<br />
GS-G-2.1, Appendix IV, Table 10: “Facility Emergency: Event resulting in a major<br />
decrease in protection for on-site personnel; however, <strong>the</strong>se events cannot evolve in<strong>to</strong> a<br />
general or a site area emergency warranting <strong>the</strong> implementation <strong>of</strong> protective actions <strong>of</strong>f<br />
<strong>the</strong> site. - A fuel handling emergency; - An in-facility fire or o<strong>the</strong>r emergency not<br />
affecting <strong>safety</strong> systems; - Terrorist or criminal activity resulting in hazardous on-site<br />
conditions but with no potential <strong>to</strong> result in criticality or release <strong>of</strong>f <strong>the</strong> site that would<br />
warrant urgent protective actions. ”<br />
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DEFINITIONS<br />
DEFINITIONS - OSART MISSION<br />
Recommendation<br />
A recommendation is advice on how improvements in <strong>operational</strong> <strong>safety</strong> can be made in <strong>the</strong><br />
activity or programme that has been evaluated. It is based on IAEA Safety Standards or<br />
proven, good international practices and addresses <strong>the</strong> root causes ra<strong>the</strong>r than <strong>the</strong> symp<strong>to</strong>ms<br />
<strong>of</strong> <strong>the</strong> identified concern. It very <strong>of</strong>ten illustrates a proven method <strong>of</strong> striving for excellence,<br />
which reaches beyond minimum requirements. Recommendations are specific, realistic and<br />
designed <strong>to</strong> result in tangible improvements. Absence <strong>of</strong> recommendations can be interpreted<br />
as performance corresponding with proven international practices.<br />
Suggestion<br />
A suggestion is ei<strong>the</strong>r an additional proposal in conjunction with a recommendation or may<br />
stand on its own following a discussion <strong>of</strong> <strong>the</strong> pertinent background. It may indirectly<br />
contribute <strong>to</strong> improvements in <strong>operational</strong> <strong>safety</strong> but is primarily intended <strong>to</strong> make a good<br />
performance more effective, <strong>to</strong> indicate useful expansions <strong>to</strong> existing programmes and <strong>to</strong><br />
point out possible superior alternatives <strong>to</strong> ongoing work. In general, it is designed <strong>to</strong> stimulate<br />
<strong>the</strong> plant management and supporting staff <strong>to</strong> continue <strong>to</strong> consider ways and means for<br />
enhancing performance.<br />
Note: if an item is not well based enough <strong>to</strong> meet <strong>the</strong> criteria <strong>of</strong> a ‘suggestion’, but <strong>the</strong> expert<br />
or <strong>the</strong> <strong>team</strong> feels that mentioning it is still desirable, <strong>the</strong> given <strong>to</strong>pic may be described in <strong>the</strong><br />
text <strong>of</strong> <strong>the</strong> report using <strong>the</strong> phrase ‘encouragement’ (e.g. The <strong>team</strong> encouraged <strong>the</strong> plant<br />
<strong>to</strong>…).<br />
Good practice<br />
A good practice is an outstanding and proven performance, programme, activity or equipment<br />
in use that contributes directly or indirectly <strong>to</strong> <strong>operational</strong> <strong>safety</strong> and sustained good<br />
performance. A good practice is markedly superior <strong>to</strong> that observed elsewhere, not just <strong>the</strong><br />
fulfilment <strong>of</strong> current requirements or expectations. It should be superior enough and have<br />
broad application <strong>to</strong> be brought <strong>to</strong> <strong>the</strong> attention <strong>of</strong> o<strong>the</strong>r nuclear power plants and be worthy<br />
<strong>of</strong> <strong>the</strong>ir consideration in <strong>the</strong> general drive for excellence. A good practice has <strong>the</strong> following<br />
characteristics:<br />
− novel;<br />
− has a proven benefit;<br />
− replicable (it can be used at o<strong>the</strong>r plants);<br />
− does not contradict an issue.<br />
The attributes <strong>of</strong> a given ‘good practice’ (e.g. whe<strong>the</strong>r it is well implemented, or cost<br />
effective, or creative, or it has good results) should be explicitly stated in <strong>the</strong> description <strong>of</strong><br />
<strong>the</strong> ‘good practice’.<br />
Note: An item may not meet all <strong>the</strong> criteria <strong>of</strong> a ‘good practice’, but still be worthy <strong>to</strong> take<br />
note <strong>of</strong>. In this case it may be referred as a ‘good performance’, and may be documented in<br />
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<strong>the</strong> text <strong>of</strong> <strong>the</strong> report. A good performance is a superior objective that has been achieved or a<br />
good technique or programme that contributes directly or indirectly <strong>to</strong> <strong>operational</strong> <strong>safety</strong> and<br />
sustained good performance, that works well at <strong>the</strong> plant. However, it might not be necessary<br />
<strong>to</strong> recommend its adoption by o<strong>the</strong>r nuclear power plants, because <strong>of</strong> financial<br />
considerations, differences in design or o<strong>the</strong>r reasons.<br />
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Safety Standards<br />
LIST OF IAEA REFERENCES (BASIS)<br />
SF-1; Fundamental Safety Principles (Safety Fundamentals)<br />
Safety Series No.115; International Basic Safety Standards for Protection Against<br />
Ionizing Radiation and for <strong>the</strong> Safety <strong>of</strong> Radiation Sources<br />
Safety Series No.117; Operation <strong>of</strong> Spent Fuel S<strong>to</strong>rage Facilities<br />
NS-R-1; Safety <strong>of</strong> Nuclear Power Plants: Design Requirements<br />
NS-R-2; Safety <strong>of</strong> Nuclear Power Plants: Operation (Safety Requirements)<br />
NS-G-1.1; S<strong>of</strong>tware for Computer Based Systems Important <strong>to</strong> Safety in Nuclear<br />
Power Plants (Safety Guide)<br />
NS-G-2.1; Fire Safety in <strong>the</strong> Operation <strong>of</strong> Nuclear Power Plans (Safety Guide)<br />
NS-G-2.2; Operational Limits and Conditions and Operating Procedures for<br />
Nuclear Power Plants (Safety Guide)<br />
NS-G-2.3; Modifications <strong>to</strong> Nuclear Power Plants (Safety Guide)<br />
NS-G-2.4; The Operating Organization for Nuclear Power Plants (Safety Guide)<br />
NS-G-2.5; Core Management and Fuel Handling for Nuclear Power Plants (Safety<br />
Guide)<br />
NS-G-2.6; Maintenance, Surveillance and In-service Inspection in Nuclear Power<br />
Plants (Safety Guide)<br />
NS-G-2.7; Radiation Protection and Radioactive Waste Management in <strong>the</strong><br />
Operation <strong>of</strong> Nuclear Power Plants (Safety Guide)<br />
NS-G-2.8; Recruitment, Qualification and Training <strong>of</strong> Personnel for Nuclear<br />
Power Plants (Safety Guide)<br />
NS-G-2.9; Com<strong>mission</strong>ing for Nuclear Power Plants (Safety Guide)<br />
NS-G-2-10; Periodic Safety Review <strong>of</strong> Nuclear Power Plants (Safety Guide)<br />
NS-G-2.11; A System for <strong>the</strong> Feedback <strong>of</strong> Experience from Events in Nuclear<br />
Installations (Safety Guide)<br />
GS-R-1; Legal and Governmental Infrastructure for Nuclear, Radiation,<br />
Radioactive Waste and Transport Safety (Safety Requirements)<br />
GS-R-2; Preparedness and Response for a Nuclear or Radiological Emergency<br />
(Safety Requirements)<br />
GS-R-3; The Management System for Facilities and Activities (Safety<br />
Requirements)<br />
GS-G-2.1; Arrangement for Preparedness for a Nuclear or Radiological<br />
Emergency (Safety Guide)<br />
GS-G-3.1; Application <strong>of</strong> <strong>the</strong> Management System for Facilities and Activities<br />
(Safety Guide)<br />
50-C/SG-Q; Quality Assurance for Safety in Nuclear Power Plants and o<strong>the</strong>r<br />
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Nuclear Installations (Code and Safety Guides Q1-Q14)<br />
RS-G-1.1; Occupational Radiation Protection (Safety Guide)<br />
RS-G-1.2; Assessment <strong>of</strong> Occupational Exposure Due <strong>to</strong> Intakes <strong>of</strong> Radionuclides<br />
(Safety Guide)<br />
RS-G-1.3; Assessment <strong>of</strong> Occupational Exposure Due <strong>to</strong> External Sources <strong>of</strong><br />
Radiation (Safety Guide)<br />
RS-G-1.8; Environmental and Source Moni<strong>to</strong>ring for Purpose <strong>of</strong> Radiation<br />
Protection (Safety Guide)<br />
WS-G-6.1; S<strong>to</strong>rage <strong>of</strong> Radioactive Waste (Safety Guide)<br />
DS347; Conduct <strong>of</strong> Operations at Nuclear Power Plants (Draft Safety Guide)<br />
DS388; Chemistry Control in <strong>the</strong> Operation <strong>of</strong> Nuclear Power Plants (Draft Safety<br />
Guide)<br />
INSAG, Safety <strong>Report</strong> Series<br />
INSAG-4; Safety Culture<br />
INSAG-10; Defence in Depth in Nuclear Safety<br />
INSAG-12; Basic Safety Principles for Nuclear Power Plants, 75-INSAG-3 Rev.1<br />
INSAG-13; Management <strong>of</strong> Operational Safety in Nuclear Power Plants<br />
INSAG-14; Safe Management <strong>of</strong> <strong>the</strong> Operating Lifetimes <strong>of</strong> Nuclear Power Plants<br />
INSAG-15; Key Practical Issues In Streng<strong>the</strong>ning Safety Culture<br />
INSAG-16; Maintaining Knowledge, Training and Infrastructure for Research and<br />
Development in Nuclear Safety<br />
INSAG-17; Independence in Regula<strong>to</strong>ry Decision Making<br />
INSAG-18; Managing Change in <strong>the</strong> Nuclear Industry: The Effects on Safety<br />
INSAG-19; Maintaining <strong>the</strong> Design Integrity <strong>of</strong> Nuclear Installations Throughout<br />
Their Operating Life<br />
Safety <strong>Report</strong> Series No.11; Developing Safety Culture in Nuclear Activities<br />
Practical Suggestions <strong>to</strong> Assist Progress<br />
Safety <strong>Report</strong> Series No.21; Optimization <strong>of</strong> Radiation Protection in <strong>the</strong> Control<br />
<strong>of</strong> Occupational Exposure<br />
Safety <strong>Report</strong> Series No.48; Development and Review <strong>of</strong> Plant Specific<br />
Emergency Operating Procedures<br />
114
TECDOCs and IAEA Services Series<br />
IAEA Safety Glossary Terminology used in nuclear <strong>safety</strong> and radiation<br />
protection 2007 Edition<br />
Services series No.10; PROSPER Guidelines<br />
Services series No.12; OSART Guidelines<br />
TECDOC-489; Safety Aspects <strong>of</strong> Water Chemistry in Light Water Reac<strong>to</strong>rs<br />
TECDOC-744; OSART Guidelines 1994 Edition (Refer only chapter 10-15 for<br />
Pre-OSART, if applicable.)<br />
TECDOC-1141; Operational Safety Performance Indica<strong>to</strong>rs for Nuclear Power<br />
Plants<br />
TECDOC-1321; Self-assessment <strong>of</strong> <strong>safety</strong> culture in nuclear installations<br />
TECDOC-1329; Safety culture in nuclear installations - Guidance for use in <strong>the</strong><br />
enhancement <strong>of</strong> <strong>safety</strong> culture<br />
TECDOC 1446 OSART <strong>mission</strong> highlights 2001-2003<br />
TECDOC-1458; Effective corrective actions <strong>to</strong> enhance <strong>operational</strong> <strong>safety</strong> <strong>of</strong><br />
nuclear installations<br />
TECDOC-1477; Trending <strong>of</strong> low level events and near misses <strong>to</strong> enhance <strong>safety</strong><br />
performance in nuclear power plants<br />
TECDOC-955; Generic Assessment Procedures for Determining Protective<br />
Actions during a Reac<strong>to</strong>r Accident<br />
EPR-EXERCISE-2005; Preparation, Conduct and Evaluation <strong>of</strong> Exercises <strong>to</strong><br />
Test Preparedness for a Nuclear or Radiological Emergency, (Updating IAEA-<br />
TECDOC-953)<br />
EPR-METHOD-2003; Method for developing arrangements for response <strong>to</strong> a<br />
nuclear or radiological emergency, (Updating IAEA-TECDOC-953)<br />
EPR-ENATOM-2002; Emergency Notification and Assistance Technical<br />
Operations Manual<br />
115
ACKNOWLEDGEMENT<br />
The Government <strong>of</strong> Sweden and <strong>the</strong> staff <strong>of</strong> <strong>Forsmark</strong> Nuclear Power Plant provided valuable<br />
support <strong>to</strong> <strong>the</strong> OSART <strong>mission</strong> <strong>to</strong> <strong>Forsmark</strong> NPP. Throughout <strong>the</strong> whole OSART <strong>mission</strong>, <strong>the</strong><br />
<strong>team</strong> members felt welcome and enjoyed excellent cooperation and fruitful discussions with<br />
<strong>Forsmark</strong> Nuclear Power Plant managers and staff, and o<strong>the</strong>r local and national authorities.<br />
Information was provided openly and in <strong>the</strong> spirit <strong>of</strong> seeking improvements in <strong>operational</strong> <strong>safety</strong>.<br />
There was a rich exchange <strong>of</strong> knowledge and experience which contributed significantly <strong>to</strong> <strong>the</strong><br />
success <strong>of</strong> <strong>the</strong> <strong>mission</strong>. It also established many personal contacts that will not end with <strong>the</strong><br />
completion <strong>of</strong> <strong>the</strong> <strong>mission</strong> and sub<strong>mission</strong> <strong>of</strong> this report. The efforts <strong>of</strong> <strong>the</strong> plant counterparts,<br />
liaison <strong>of</strong>ficers, interpreters and <strong>the</strong> secretaries were outstanding. This was <strong>of</strong> significant support<br />
<strong>to</strong> <strong>the</strong> OSART <strong>team</strong> in order <strong>to</strong> complete its <strong>mission</strong> in a fruitful manner.<br />
The IAEA, <strong>the</strong> Division <strong>of</strong> Nuclear Installation Safety and its Operational Safety Section wish <strong>to</strong><br />
thank all those involved for <strong>the</strong> excellent working conditions during <strong>the</strong> <strong>Forsmark</strong> Nuclear Power<br />
Plant <strong>review</strong>.<br />
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TEAM COMPOSITION OSART MISSION<br />
LIPAR, Miroslav – IAEA<br />
Division <strong>of</strong> Nuclear Installation Safety<br />
Years <strong>of</strong> Nuclear Experience: 30<br />
Team Leader<br />
HENDERSON, Neil – IAEA<br />
Division <strong>of</strong> Nuclear Installation Safety<br />
Years <strong>of</strong> Nuclear Experience: 32<br />
Deputy Team Leader<br />
MITCHEL, Timothy - USA<br />
Arkansas Nuclear One NPP<br />
Years <strong>of</strong> Nuclear Experience: 26<br />
Review area: Management, organization and administration<br />
KOHLER, Thomas – Switzerland<br />
Kernkraftwerk Gosgen-Daniken AG<br />
Years <strong>of</strong> Nuclear Experience: 14<br />
Review area: Training and qualifications<br />
GEST, Pierre - France<br />
E.D.F (Electricité de France)<br />
Years <strong>of</strong> Nuclear Experience: 26<br />
Review area: Operations I<br />
TOTH, Alexander - Slovakia<br />
Slovenské elektrárne, a.s. - Enel<br />
Years <strong>of</strong> Nuclear Experience: 21<br />
Review area: Operations II<br />
VONKA, Tore - Finland<br />
Loviisa NPP<br />
Years <strong>of</strong> Nuclear Experience: 33<br />
Review area: Maintenance<br />
YOKOYAMA, Kenichi - Japan<br />
WANO - Tokyo<br />
Years <strong>of</strong> Nuclear Experience: 30<br />
Review area: Technical support<br />
NICHOLS, Robert - UK<br />
Years <strong>of</strong> Nuclear Experience: 43<br />
Review area: Operating experience feedback – <strong>Forsmark</strong> 25/7/06 event<br />
117
ZHUK, Yury – Russian Federation<br />
VNIIAES<br />
Years <strong>of</strong> Nuclear Experience: 27<br />
Review area: Operating experience feedback<br />
HORT, Milan – Czech Republic<br />
State Office for Nuclear Safety<br />
Years <strong>of</strong> Nuclear Experience: 24<br />
Review area: Radiation protection<br />
BOLZ, Michael - Germany<br />
EnBW Philipsburg<br />
Years <strong>of</strong> Nuclear Experience: 14<br />
Review area: Chemistry<br />
LEMAY, Francois - Canada<br />
International Safety Research<br />
Years <strong>of</strong> Nuclear Experience: 26<br />
Review area: Emergency planning and preparedness<br />
HODUL, Roman – Slovakia<br />
Bohunice NPP<br />
Years <strong>of</strong> Nuclear Experience: 18<br />
Observer<br />
HOLM, Fredrik - Sweden<br />
Oskarshamn NPP<br />
Years <strong>of</strong> Nuclear Experience: 10<br />
Observer<br />
CALVIN, Hakan – Sweden<br />
Ringhals NPP<br />
Years <strong>of</strong> Nuclear Experience: 20<br />
Observer<br />
118