Report of the OSART mission to the Oskarshamn nuclear power plant

NSNI/OSART/09/151
ORIGINAL: English
REPORT OF THE
OPERATIONAL SAFETY REVIEW TEAM
(OSART)
MISSION
TO THE
OSKARSHAMN
NUCLEAR POWER PLANT
SWEDEN
17 February – 5 March 2009
DIVISION OF NUCLEAR INSTALLATION SAFETY
OPERATIONAL SAFETY REVIEW TEAM MISSION
IAEA-NSNI/OSART/09/151

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

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

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

CONTENT
INTRODUCTION AND MAIN CONCLUSIONS...................................................................1
1. MANAGEMENT, ORGANIZATION AND ADMINISTRATION.................................3
2. TRAINING AND QUALIFICATIONS ..........................................................................12
3. OPERATIONS.................................................................................................................18
4. MAINTENANCE ............................................................................................................27
5. TECHNICAL SUPPORT ................................................................................................34
6. OPERATING EXPERIENCE FEEDBACK ...................................................................45
7. RADIATION PROTECTION .........................................................................................54
8. CHEMISTRY ..................................................................................................................59
9. EMERGENCY PLANNING AND PREPAREDNESS ..................................................62
DEFINITIONS.........................................................................................................................67
LIST OF IAEA REFERENCES (BASIS) ...............................................................................69
ACKNOWLEDGEMENT …………………………………………………………………...72
TEAM COMPOSITION OF THE OSART MISSION ...........................................................73

INTRODUCTION AND MAIN CONCLUSIONS
INTRODUCTION
At the request of the government of Sweden, an IAEA Operational Safety Review Team
(OSART) of international experts visited Oskarshamn Nuclear Power Plant from 17 February to
5 March 2009. The purpose of the mission was to review operating practices in the areas of
Management organization and administration; Training and qualification; Operations;
Maintenance; Technical support; Operating experience feedback, Radiation protection;
Chemistry; and Emergency planning and preparedness. In addition, an exchange of technical
experience and knowledge took place between the experts and their plant counterparts on how
the common goal of excellence in operational safety could be further pursued.
The OKG Nuclear Power Plant is situated on the Swedish east coast about 30 Km north of
Oskarshamn. The company is part of business area Electricity Generation within E.ON
Market Unit Nordic and is a subsidiary company to E.ON Kärnkraft Sverige AB. OKG is
owned by E.ON at 54,5 %. The remaining 45,5 % of the shares is owned by Swedish
subsidiaries to the Finnish energy group Fortum. The plant operates three BWR units. Unit 1
has 440 MW rated power and started commercial operation in 1972, unit 2 has 590 MW rated
power and started commercial operation in 1974, unit 3 has 1060 MW rated power and
started commercial operation in 1985. The OSART mission concentrated on unit 2 and
common site systems. OKG has 950 employees and about 300 long term contractors.
The Oskarshamn OSART mission was the 151st in the programme, which began in 1982.
The team was composed of experts from Armenia, Czech Republic, Finland, France,
Germany, Slovak Republic, South Africa, South Korea, Spain and the USA, together with the
IAEA staff members and one observer from Sweden. The collective nuclear power
experience of the team was approximately 250 years.
Before visiting the plant, the team studied information provided by the IAEA and the
Oskarshamn plant to familiarize themselves with the plant's main features and operating
performance, staff organization and responsibilities, and important programmes and procedures.
During the mission, the team reviewed many of the plant's programmes and procedures in depth,
examined indicators of the plant's performance, observed work in progress, and held in-depth
discussions with plant personnel.
Throughout the review, the exchange of information between the OSART experts and plant
personnel was very open, professional and productive. Emphasis was placed on assessing the
effectiveness of operational safety rather than simply the content of programmes. The
conclusions of the OSART team were based on the plant's performance compared with IAEA
safety standards and good international practices.
1

MAIN CONCLUSIONS
The OSART team concluded that the managers of Oskarshamn NPP are committed to
improving the operational safety and reliability of their plant. The team found good areas of
performance, including the following:
− An integrated management system which includes communication, quality structures and
documentation links. All employees receive training on how the management system
works and thereby gain easy access to documentation and indicators.
− The provision of effective and creative “hands-on” training such as those at the Barseback
facility.
− A comprehensive In-Service Inspection (ISI) programme which includes a database for
all ISI activities and also welding data.
− The use of an effective decontamination method for plant systems during outages has
contributed to significant occupational exposure reductions in the past few years.
A number of areas where improvements could be made in operational safety were offered by the
team. The most significant include the following:
− A consistent system for monitoring and screening corrective actions, according to their
impact on safety, and then tracking them until their effective implementation, is not in
place.
− Although the plant has procedures in place for the isolation and tagging of equipment,
those procedures and their implementation are, in some cases, not sufficient.
− A system for modification categorization, in accordance with the safety significance of
the modification, has not been established.
− The reporting, analysis and trending of low level events and near misses is not sufficient
to allow the systematic and consistent identification of event precursors.
Oskarshamn management expressed a determination to address the areas identified for
improvement and indicated a willingness to accept a follow up visit in about eighteen months.
2

1 MANAGEMENT, ORGANIZATION AND ADMINISTRATION
1.1 ORGANIZATION AND ADMINISTRATION
The organization of the company (corporate and plant) is clearly defined and documented.
All the documents concerning the organization can be accessed by people working on the
plant in a very efficient way via the internal internet called “Kärnan”. However, this
communication tool requires a voluntary action from the reader ; therefore some rules are not
known and not applied.
The main goals of the plant are discussed and approved annually by the OKG Board held at
the corporate level and reviewed in a regular manner inside the plant organization. High
priority is given to six “goal areas” including safety, production, environment, financial,
human resources and plant development. These priorities can only be changed by the
President.
Concerning the staffing, a formal analysis is conducted from the need expressed by the
departments and is combined at the plant level. The review process of the expressed needs
comprises two review meetings in March and in September in order to validate the decisions.
Furthermore, the plant has a long term succession plan for managers and specialists in order
to secure knowledge. The team considers this as a good performance.
With the actual projects (Plex = Safety upgrade and ageing replacement at unit 2, Nyans =
New physical protection at OKG, Puls = Safety upgrade and ageing replacement at unit 3),
the staffing will rise for several years until 2014. This staffing policy includes a very efficient
succession plan which is established for managers, specialists and coordinators and was
recognised by the team as a good performance.
1.2 MANAGEMENT ACTIVITIES
The plant uses 10 year and 3 year plans and an annual vision is done to identify the main
working periods. This vision is shared with the departments in a review meeting. The main
goals of the plant are then divided amongst the organization; every manager knows its own
objectives and contribution to the results of the plant. All the indicators are available in a very
visible manner via the intranet site so that personnel are informed.
External and internal surveys are performed to monitor the efficiency of the organisation. For
example, the WANO indicators and the internal E.ON indicators are used to compare the
trends with other plants.
In addition, about 25 internal audits are performed each year by the safety department of
OKG and further audits are conducted by E.ON.
3 MANAGEMENT, ORGANIZATION AND ADMINISTRATION

Concerning the human factors management, a survey is made every two or three years in
order to define what is to be done. A “manager on the field” program has been started, and
will be reinforced in the next years. This will be the mechanism to reinforce the managers
expectations concerning the staff behaviour on the field. Prejob briefings presently are
recommended in some areas but are not yet a mandatory approach across the whole plant.
The plant intends to improve this, in coherency with the identification of safety related
activities. The team has made a suggestion concerning better management assessment of
work activities.
The plant has a very effective organisation concerning the welfare of staff (including health
facilities and an efficient drug policy) and has also a very effective welcoming organisation,
for the many contractors that are arriving for the three main projects Puls, Plex and Nyans.
1.3 MANAGEMENT OF SAFETY
A safety policy is reviewed and approved at E.ON level by E.ON Nuclear Safety Council and
is very well known at the plant level. In this policy, the highest priority is given to safety and
in several cases a questioning attitude was applied. In these cases, the plant was placed in
conservative conditions.
The identification of safety related activities is under the responsibility of operating
personnel, but there is no complete pre-identification of safety activities (for example, for
recurrent activities); this identification could be improved in order to simplify the workload
analysis during the preparation of activities.
Concerning the use of deviation, the plant has shown several ways of using them to progress.
Some corrective actions are not followed.
Several good signs of safety culture were observed by the team during the review:
The corporate level managing director and the OKG president visibly support and regard
safety as a very high priority.
Since 2004 OKG has used Safety Culture ambassadors to develop and implement activities to
improve safety culture. Part of their working time is dedicated to the task of consistently
improving safety culture. They know the organization and add credibility to the training
events and seminars.
The team was reassured that the safe operation of the reactor has the highest priority, and if
the situation is unclear the reactor will be brought to a safe condition. In the past on several
occasions, there was a decision not to operate the plant in case of a doubt concerning the
safety functions, e.g. after the grid event in Forsmark 1 and when traces of explosives were
found at the entrance of the site.
4 MANAGEMENT, ORGANIZATION AND ADMINISTRATION

The team was able to sense an excellent work environment and stress-free atmosphere at the
plant. Openness and transparency are highly regarded values. All of this results in a situation
where staff are open and interested in their work. In order to achieve and sustain this, surveys
and walk-downs are organized to assess and improve work environment. There is an effort to
decrease stress as much as possible. Well designed offices, an obvious effort of preserving
the environment and historical buildings near the plant contribute to this situation. The plant
has established a ‘Welfare office’ for welcoming contractors to support their orientation after
arriving at the site.
Good housekeeping and material condition are evident throughout the plant which is even
more commendable if we consider that unit 2 has been in operation since 1974. As an
example, the reactor hall is kept in good order and clean, equipment is appropriately stored.
This definitely contributes to a safe work environment.
The plant has a systematic approach concerning safety culture. This approach includes
regular surveys, formal analysis and training. For example, the plant organizes training before
and during outages. The training scope was selected based on analysing past outage
experience for safety culture weaknesses. OKG conducted 6 one day training events followed
by about 40 days of individual coaching in 2007 for more than 80 team leaders and managers.
At the Barseback training facility, plant staff is additionally trained on safety culture and
human performance in the frame of practical exercises by performing real tasks to see
whether safety culture is embedded in their activities and whether a questioning attitude is
present in their practices.
At the same time there are other signs indicating that the effort to improve safety culture
should be maintained:
In the team’s opinion, roles regarding improper behaviour are somewhat unclear in the sense
that managers and supervisors are reluctant to remind staff about the necessity to follow
rules. The following examples support this opinion: during training, the trainees did not form
groups to discuss items of training as requested by the trainer; fire door of work permit office
of unit 1 is part of fire cell just adjacent to the entrance to unit 2 main control room,
nevertheless it remained open for extensive periods when no one was inside.
Staff is overly relying on experience without regard for current documentation. It is probably
also associated with the practice that some requirements are not exactly written down or
communicated. For example: it is accepted that every one is responsible for tracking
completion of his/her tasks; to decide about the scope of surveillance test result, judgment is
up to the person who performs the analysis; competence requirements for some job positions
are not defined; for scaffolding and industrial safety protective equipment, documented
requirements exist but staff does not know about them and therefore does not apply them.
The self-assessment process is not sufficiently effective at all levels of the organization,
partly due to lack of appropriate indicators and the evaluation process. For example:
performance indicators sometimes do not correspond to goals; there is no effectiveness
review of implemented corrective actions.
5 MANAGEMENT, ORGANIZATION AND ADMINISTRATION

Safety is discussed in many meetings at the plant, but it is not always explicitly the first topic
discussed in the agenda. This is valid for example for the monthly Departments management
meeting. The first point in the agenda are production issues, and this might convey the
impression that safety is not receiving priority attention.
In the last organizational survey in 2007, only 52 percent of OKG’s personnel agreed with the
statement “I feel encouraged to report new ideas or improvements”, while 33 percent were
not sure and 15 percent did not agree with the statement.
1.4 QUALITY ASSURANCE PROGRAMME
The plant has developed a very effective organization concerning the quality assurance. It is
supported by the “Kärnan” tool. The main roles and responsibilities are documented and this
helps to hold line managers accountable for the quality of performance in the areas for which
they are responsible. The team has recognised it as a good practice.
An effective QA monitoring system is implemented at the plant. It is based on a yearly
discussion between managers and is managed at weekly meetings which review the main
objectives or indicators of the plant.
1.5 INDUSTRIAL SAFETY PROGRAMME
The organisation for industrial safety is clear and well documented. The team has noticed that
the knowledge of the rules to be applied is not sufficiently shared among the staff. Therefore,
several rules are not applied; this could impair industrial safety and therefore safety during
projects when many contractors are working at the plant or during normal operation of the
plant. The team has made a suggestion in this area.
6 MANAGEMENT, ORGANIZATION AND ADMINISTRATION

DETAILED MANAGEMENT, ORGANIZATION AND ADMINISTRATION
FINDINGS
1.2 MANAGEMENT ACTIVITIES
1.2(1) Issue: Management assessment of work activities and correction of inadequate
behaviour are not consistently applied.
There are a number of management initiatives in this area, but the following were
observed by the team:
- Managers presence in the field is limited and insufficiently recorded (e.g.
outcomes, findings, etc.).
- A unique tool (QAF database) is not used for each field visit. It is therefore
difficult to get an overview.
- Outdated documents were observed to be being used by workers on several
occasions (EPP, operating procedures, and documents related to
modifications).
- Tolerance to inadequate behavior such as: staff not respecting the walk way
limitations, staff crossing open gates when it is clearly indicated to wait, staff
not wearing cards in a visible manner, many ladders not stored in a adequate
way, cars driving too fast.
- Some additional facts are listed in issues 3.4(2), 3.5(1), 4.5(1).
Lack of management assessment can lead to unsafe practices being adopted, while
remaining unknown from the management.
Suggestion: The plant should consider enhancing the application of management
assessment practices and correction of inadequate behaviour at the plant.
IAEA Basis
NS-G-2.4
5.22. The appropriate corrective actions should be identified and implemented as a
result of the monitoring and review of safety performance. Arrangements should be in
place to ensure that appropriate corrective actions in response to audit and review
findings are identified and taken. Progress in taking proposed actions needs to be
monitored to ensure that actions are completed within the appropriate time-scales. The
completed corrective actions should be reviewed to assess whether they have
adequately addressed the issues identified in the audits and reviews.
7 MANAGEMENT, ORGANIZATION AND ADMINISTRATION

GS-G-3.1
6.2. To avoid any decline in safety performance, senior management should remain
vigilant and objectively self-critical. As a key to this, objective assessment activities
should be established. The nature and types of assessment activity should be adjusted
to suit the size and product of the organization, should reduce the dangers of
complacency and should act as a counter to any tendency towards denial. In addition
to the early detection of any deterioration, an assessment of weaknesses in the
management system could also be used to identify potential enhancements of
performance and safety and to learn from both internal and external experience.
INSAG-15
3.6 Although employees often concentrate initially on industrial safety and issues
relating to plant conditions, involvement in and commitment to the improvement
process is likely to lead to a wider appreciation of issues of nuclear safety and
environmental issues, and to have broader benefits for the business in promoting a
culture of active involvement and teamwork.
INSAG-13
4.3 (88) There are other more general measures of safety performance that, whilst
providing more qualitative information, are an important adjunct to numerical
indicators. For example, observations of the behaviour of plant personnel can give an
indication of how safely they actually carry out work and comply with procedures and
good practices. Observing plant personnel performing work in the field and their
interactions with supervisors and managers can provide insight into the safety culture
at a plant.
8 MANAGEMENT, ORGANIZATION AND ADMINISTRATION

1.4 QUALITY ASSURANCE PROGRAMME
1.4(a) Good practice: The plant has developed an integrated management system which
includes communication, quality structures and documentation links.
The management system for the plant is organised in a simple and easily understood
manner in a computer based structure. This structure describes the plant’s operations
from business data through the requirements and description of tasks to the specific
instructions for practice. The management system ensures that the possible factors
which can affect the operation are taken into account in order to guarantee a high
quality of work.
The centre of this system is the Intranet “Kärnan”; it is managed by an internal
editorial group which has a combination of competences. Kärnan is designed from a
structure corresponding to the main goal of the plant (called “goal areas”). Each
document and indicator relative to the areas can be accessed easily, also a compact
vision is dedicated to communication.
All employees receive training on how the management system works. At training the
managers are involved by demonstrating and explaining what is most important for
their section. This gives co-workers many different possibilities of finding what they
need directly via a document number or via the structure of the organisation.
Some examples of positive outcomes include:
- Possibility for every worker to easily access the documentation.
- Plant staff knowledge about the Kärnan structure.
- A posting for indicators in coherence with the structure of the quality system.
9 MANAGEMENT, ORGANIZATION AND ADMINISTRATION

1.5 INDUSTRIAL SAFETY PROGRAMME
1.5(1) Issue: Plant management expectations with respect to industrial safety are not
adequately implemented in the field.
Although documentation relating to industrial safety work practices exist, the
following facts were observed:
- Inconsistent information is provided by plant personnel concerning the rules
for the use of industrial safety equipment when questions were asked in the
field.
- Rules concerning the use of acetone were not known by people using it on the
working area.
- Rules concerning scaffolding verification are not clearly understood by staff
and therefore not practiced.
- Two scaffolding workers did not wear any safety harness while they were
working at heights that could result in physical harm.
Without a good understanding and appreciation of the industrial safety rules, safety
could be affected.
Suggestion: Plant management should consider taking further efforts to ensure that its
expectations are implemented in the field with respect to industrial safety.
IAEA Basis: INSAG-15
3.5. Nearly all events, ranging from industrial and radiological accidents, incidents
and near misses to failures affecting nuclear safety, start with an unintentionally
unsafe act or an unacceptable plant condition or process. These have often been latent
and have gone undetected or been treated as ‘custom and practice’ and therefore been
ignored. Then, in combination with another challenge to the system, a further more
significant failure occurs. Minimizing existing latent shortcomings in working
practices or plant conditions is therefore vital in avoiding more serious events.
NS-G-2.4
3.5. To ensure that there is a clear understanding of responsibilities and relationships
between organizational units and between personnel within the operating
organization, detailed job specifications should be defined. In particular, these
relationships should be clearly defined for all activities having a direct or indirect
bearing on safety.
10 MANAGEMENT, ORGANIZATION AND ADMINISTRATION

ILO-OSH 2001
3.10.1.2. Hazard prevention and control procedures or arrangements should be
established and should:
...
(b) be reviewed and modified if necessary on a regular basis;
(c) comply with national laws and regulations, and reflect good practice; and
(d) consider the current state of knowledge, including information or reports from
organizations, such as labour inspectorates, occupational safety and health
11 MANAGEMENT, ORGANIZATION AND ADMINISTRATION

2 TRAINING AND QUALIFICATIONS
2.1 TRAINING POLICY AND ORGANIZATION
The team made a recommendation concerning the manner in the use of feedback from actual
plant performance.
Unlike many other plants in the world, there is no linkage between the plant work
management system and the training management system. It allows the potential for
assigning personnel to a task when they are not task qualified. The plant compensates for this
with strong line management knowledge and use of its learning management system. The
interface and contract control with external training providers is strong.
Attendance at scheduled training sessions is not as good as at many plants in the world. Nonattendance
indicators for the period from 2006 to 2008 were between 12.5 % and 9.3 % (not
including operator training). The training organization has recognized this problem and is
taking actions to improve training attendance. The plant is encouraged to continue with
improvement efforts in this area.
2.2 TRAINING FACILITIES, EQUIPMENT AND MATERIAL
The team found two good practices in this area, the first dealing with the use of “hands on”
training facilities at the plant and at other training locations, and the second dealing with the
high quality of training materials.
Plant modifications are always developed, implemented and trained in the simulator before
implementation. This process verifies that operators receive timely information needed for
plant operational needs. This is seen as a good performance.
The plant’s configuration and problems reporting systems are not the same as in use in the
simulator (OKG and KSU). This was changed during the on-site portion of the team’s
activities; KSU (at Oskarshamn) now matches the plant configuration system.
2.3 QUALITY OF THE TRAINING PROGRAMME
Training programs are supported by effective task analysis, job descriptions and training
requirements; however, there were two approved job descriptions for operations plant
engineers, plus portions of two others, that were found which contained knowledge and skills
sections that were blank (incomplete). The plant is encouraged to review all job descriptions
to ensure consistency and completeness.
2.7 TRAINING PROGRAMMES FOR TECHNICAL PLANT SUPPORT PERSONNEL
Each new trainee is provided with a mentor (or sponsor) to conduct the trainee’s initial
orientation. The mentor is tasked with providing informal orientation training that assists in
familiarizing the new person with the plan, information systems, and department-specific
practices. This practice results in greater new employee understanding of the history and
basis for the ways that operations and practices are conducted, as well as improved technical
knowledge transfer.
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TRAINING AND QUALIFICATION

2.8 TRAINING PROGRAMMES FOR MANAGEMENT AND SUPERVISORY
PERSONNEL
The use of the management development centre effectively screens new management
candidates for the desired skills. Areas for emphasis are identified for suitable candidates and
some candidates, not yet suited for management positions, are not placed in such positions.
2.9 TRAINING PROGRAMMES FOR TRAINING GROUP PERSONNEL
The team noted some instances of weak instructor performances. In addition, on-the-job
training (OJT) instructors (plant personnel) do not receive training on the expectations for
conducting OJT or task performance evaluations (TPE). The plant is encouraged to seek
improvements in the area of instructor skills, including instructor fostering of human
performance behaviours.
2.10 GENERAL EMPLOYEE TRAINING
“Clean System” foreign material exclusion training, required for plant access, for all plant
personnel and contractors is a positive corrective action taken for instances of fuel damage
that has occurred on the site. The team considers this as a good performance.
Contractors have not been trained in the use of the recently implemented “White Card”
program. This is included in Issue 6.2(1).
The plant is implementing the first round of human performance training on-site, but there is
no, as yet, periodic training in the use of human error prevention. The plant is encouraged to
continue its efforts in this area.
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TRAINING AND QUALIFICATION

DETAILED TRAINING AND QUALIFICATION FINDINGS
2.1 TRAINING POLICY AND ORGANIZATION
2.1(1) Issue: The plant is lacking several comprehensive review mechanisms that assist in
continuously and routinely improving the quality of training. Examples noted include
the following:
- Training management has not been routinely represented at plant status
meetings. At many stations, this occurs so that early identification of training
shortfalls and needs occur.
- Performance indicators used in the training organization are generally not
performance based. In addition, goals for current performance indicators (such
as training attendance) are not set so that more rapid improvement can occur.
- There is no use of qualification boards for final qualification of shift
supervisors. In addition, there is no integration of site interviews (by technical
managers) into the shift supervisor qualification process.
- When they occur, Management observations of training are rarely documented
for systematic collection and identification of training shortfalls and strengths.
- Manager observations of instructors by training and operations personnel are
often not “critical” (identifying needs improvement areas) so that instructor
performance improves. There is no metric in use that systematically measures
instructor performance. On-the-job training (OJT) instructors (plant personnel)
do not receive training on the expectations for conducting OJT or task
performance evaluations (TPE).
- Comprehensive self-assessments of training effectiveness are not used or do
not include external reviews to evaluate training’s impact on improving plant
performance.
- Student feedback forms could be better designed to seek trainee input on the
quality of training provided and they are also long (6 pages). In addition,
although there is a listing of trainee expectations, there is not such an
expectation for students to provide feedback.
- Operators do not critique the performance of the simulator model. The
critique of the quality of the scenarios could be improved. “As found”
evaluations of operator performance in the simulator are conducted, but are
not used in a systematic manner to improve ongoing training. Critiques,
conducted as part of simulator training, do not explicitly focus and track
“Whys?” to determine the reasons for performance shortfalls and strengths.
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TRAINING AND QUALIFICATION

- Only periodic (quarterly) operations training review committee meetings
(DUR) collect and discuss the operations training program needs and
completion. This meeting is generally not plant performance based. Similar
training boards for the review of maintenance and technical programs are just
starting.
Failure to identify training shortfalls, and strong aspects, in order to improve worker
knowledge and skills can result in recurrent human performance errors, rework, and
poor worker safety behaviors.
Recommendation: The plant should develop a more comprehensive review of the
numerous performance-based evaluative inputs from the plant and worker
performance in order to continuously and routinely improve the quality of training.
IAEA Basis: NS-G-2.8
4.44. A training plan should be prepared on the basis of the long term needs and goals
of the plant. This plan should be evaluated periodically in order to ensure that it is
consistent with current (and future) needs and goals. Factors which can change a
training plan include: commissioning experience, operational experience and
decommissioning experience at the plants of the operating organization; feedback of
operational experience from other plants; significant modifications to the plant or to
the operating organization; changes in regulatory requirements; and changes in the
State’s education system.
5.35. The training plan should be periodically reviewed and modified as necessary.
The review should cover the adequacy and effectiveness of the training with respect
to the actual performance of employees in their jobs. The review should also examine
training needs, training programmes, training facilities and the training materials
necessary to deal with changes to regulations, modifications to the facility and lessons
learned from experience in the industry.
5.36. The internal review of training undertaken at the plant or by the operating
organization should be an integral component of the on-site training system. The
review should cover all stages of the training system, the analysis of training needs,
and the design, development and implementation of the training programmes.
Training records should also be reviewed. Such a review should be undertaken by
persons other than those directly responsible for the training. Plant managers should
be directly involved in the evaluation of training programmes. Close co-operation
should be maintained in the training evaluation process between the plant
management, individual departments and the training unit.
5.40. Activities and practices in operating and maintenance, and compliance with
industrial and radiological safety standards, should be monitored to identify any
problems due to incorrect or insufficient training.
5.43. On the basis of the results of evaluations, an action plan to improve and correct
the training programmes should be developed and implemented. This may lead to
improvements in the conduct of training or to changes in the training programmes.
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TRAINING AND QUALIFICATION

5.44. An independent review of the plant’s training plan should be carried out by
external organizations. The external review should be considered complementary to
the internal evaluation in giving a different perspective to the evaluation of training
programmes. The results of the external review should be integrated with the results
of the internal evaluation, to identify necessary changes and improvements in the
training programmes.
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TRAINING AND QUALIFICATION

2.2 TRAINING FACILITIES, EQUIPMENT AND MATERIAL
2.2(a) Good practice: “Hands on” training
Many methods of providing effective and creative “hands on” training are available to
plant personnel. This form of training provides a realistic method for initial and
continuing training. Examples noted include the following:
- Plant personnel receive realistic “hands-on” human performance and safety
culture training, as well as maintenance fundamentals courses are provided at
the shutdown Barseback nuclear power plant.
- Plant utilizes a graphic simulator (G-Sim) as a platform for basic training for
operators. The simulator includes graphics that are similar to the plant and is
able to simulate neutronics effects seen when control rods are manipulated.
- The control room simulator is also used for field operator advanced basic
training (a 1-week course) and engineer on duty training – it is used as a tool
to highlight applied theoretical concepts and practical applications.
- Use of the flow-loop simulator capabilities (ETEC facility) provides a unique
opportunity to work with actual system measurement and control devices that
are very similar to those in use at OKG. In addition, a flow loop facility at the
shutdown Barseback plant provides opportunities to conduct training in a very
realistic environment.
- Prior to refueling activities at all three plants on-site, a one-tenth scale
refueling control system and simulator assist in preparing maintenance
workers for the task.
2.2(b) Good practice: Training materials.
The training provided to plant personnel benefits from the use of objective based, high
quality training materials. These materials include such features as detailed graphics
(i.e., colour, imbedded plant photos, and flow/logic diagrams). The materials are
developed early in the training process, using input from plant personnel and
instructors, in order to provide opportunity for quality review of their accuracy. Also
incorporated into many sets of training materials are innovative graphic simulations of
plant system operation. The training materials are standardized so that whatever plant
organization receives training, they each receive the same high quality materials. In
addition, the materials are utility system-wide available for use. This results in
enhanced understanding of system location, layout, interfaces, and design.
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TRAINING AND QUALIFICATION

3 OPERATIONS
3.1 ORGANIZATION AND FUNCTIONS
Operations organization and responsibilities are clearly defined in the procedures and can
easily be reached on the Intranet. Performance indicators are clearly defined and evaluated
for each unit. All actual status performance indicators are available on the intranet and
selected indicators are available on notice boards. Specific and measurable goals are set by
the unit. However, shift performance is not evaluated according to performance indicators
and the plant is encouraged to consider implementing such indicators.
Regular re-training on current status of the units, personnel, organizational and other
managerial topics are provided to the oncoming shift crew just before the beginning of a new
shift cycle. The team recognizes this as good performance.
A shift staffing analysis was performed by an independent organization (Institute for Energy
Technology). The analysis confirms that the existing requirement from the point of view of
reactor safety is sufficient (3 MCR operators and 2 field operators). However the
recommendation of this analysis is to increasing staffing to 4+3. The plant has plans to
increase to this staffing level.
3.2 OPERATIONS FACILITIES AND OPERATOR AIDS
The plant has an instruction called “Conduct of Operations at OKG” which describes the
production manager’s expectations and clarifies activities (e.g. concerning operator aids).
However, the plant expectation’s for controlling operator aids are not followed. The team
provided a suggestion to the plant in this area.
There are schematics of each floor with specifications for rooms, and equipment in
Emergency control room (ECR). The team recognizes this as a good performance.
3.3 OPERATING RULES AND PROCEDURES
Operators and Shift Supervisors are well trained and knowledgeable about operating limits
and conditions (OLC). However, during the review the entries about OLC were logged as any
other record in the shift supervisor (SS) logbook and were not highlighted for easy
identification. In the minutes from the daily review meeting only the identification of the
associated system relevant to the OLC was recorded and no additional information relative to
the time limits was included. Exact entry and exit times for safety system unavailability can
help prevent an unsafe condition caused by inadequate plant staff awareness and is an
important parameter for probabilistic risk assessment. The team encourages the plant to
improve this area.
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OPERATIONS

3.4 CONDUCT OF OPERATIONS
The presence of unnecessary personnel in the main control room is limited and working
conditions in the control room are quiet.
The plant has deficiencies in the organization and practices of key control and access control
of the safety related rooms. The team recommends that the plant improve measures to prevent
unauthorized access to systems and equipment important to safety.
During observations, the team discovered a lack in the policies and independent verification
in the conduct of operation in the main control room. It was noted that during a simulator
training session (Unit 1), the shift supervisor did not conduct any overt oversight of the power
reduction that was occurring. At many plants, reactivity manipulations must be peer checked
by the shift supervisor. Also, an operator in the main control room performed a surveillance
test for the diesel (safety system) alone. There is no requirement at the plant for independent
verification for all surveillance tests, involving equipment and systems important to safety.
The team encourages the plant to improve this situation.
The team observed field operator rounds and recognized that the relevant areas are covered
within specified intervals; however, deficiencies in the field are not consistently reported
according to the expectations. The team recommends that the plant should improve the
performance of the field operator rounds in terms of observing and reporting abnormalities
and deviations. This will help to ensure that the expectations of the management and
supervisors are carried out.
3.5 WORK AUTHORIZATIONS
The plant has not established a suitable system to implement isolation and tagging processes
to ensure the protection of personnel and equipment. The team made a recommendation to
improve this area.
A large number of unresolved failure reports were recognized by the team. The team
encourages the plant to decrease the number of unresolved failure reports.
The team recognized that the plant intends to plan work at least three weeks in advance of
execution. Planned activities are discussed in the established weekly planning meetings. The
weekly planning meeting is well structured and provides comprehensive information.
Ongoing and planned work, as well as operational orders or important failure reports are
presented and discussed. Work which is not handled during the weekly planning meetings is
handled by the daily operational review meeting where it is reviewed and approved for
execution. The team considered this as a good performance.
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OPERATIONS

3.6 FIRE PREVENTION AND PROTECTION PROGRAMME
The plant has established an efficient cooperation with the municipal fire brigade (ROK).
Therefore fire fighters, fire inspectors and commanders are educated according to national
standards with experience in on site firefighting and rescue activities. ROK also performs
initial training and refresher fire protection training for operating personnel to support the fire
brigade. The team sees the cooperation between OKG and ROK as a good performance.
However, during the review, the team observed that fire doors are not labeled. The plant’s
policy, that every door has to be closed except in the office building during day time, is not
clearly communicated and does not lead to the desired results. Furthermore, fire alarms can
be switched off for work. It is an accepted practice to leave the workplace unattended for 1
hour without switching on the fire alarms. The team encourages the plant to reconsider these
procedures.
During the review, the team observed several places with unnecessarily high fire loads,
mostly in areas that are not directly important to safety. However areas where safety related
spare parts are stored are also affected (e.g., wooden pallets in the storage building). This
does not fit into the strategy to keep the fire load as low as possible. The plant is encouraged
to furthermore decrease the fire load, wherever possible.
3.7 MANAGEMENT OF ACCIDENT CONDITIONS
During emergency or abnormal conditions, the shift supervisor performs a “critical safety
function check”. These procedures are well structured and suitably designed; however the
values related to the critical safety function check are not highlighted or provided in an
overview display. The team encourages the plant to highlight the relevant measuring
equipment or to have critical safety functions displayed. This would improve the oversight
role of the shift supervisor in stressful situations, like scrams.
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OPERATIONS

DETAILED OPERATIONS FINDINGS
3.2 OPERATIONS FACILITIES AND OPERATOR AIDS
3.2(1) Issue: The plant expectations for controlling operator aids are not followed.
The “Conduct of Operations at OKG” issued in January 2007 describes Production
manager’s expectations and clarifies activities concerning operator aids.
However the team observed the following facts during the review:
- Control room of condensate cleaning system: panel KNA had incorrect hand
written marks on the measurement instrumentation panels KNA1, KNA5. The
actual level is well below the hand marked low level set point which
automatically stops the pump.
- Hand written marks for “high level actuation” and “high level termination” set
points on the indicator 331K404.
- Hand written values for “high temperature (65°C) and “high-high temperature
(75°C) near the indicators 321K507 and 321K508.
- Hand made corrections on the panels KD10, KE10 and DG 211.
- Range of measurement system 711 written by hand and affixed on panels
JSR1 and JSR4.
Not having an efficient system for controlling operators aids could lead to the wrong
understanding and judgment of the safety system status.
Suggestion: The plant should consider improving adherence to the expectations for
controlling operator aids.
IAEA Basis: NS-G-2.14
6.17. The system for controlling operator aids should prevent the use of unauthorized
operator aids or other materials such as unauthorized instructions or labels of any kind
on equipment, local control panels in the plant, boards and measurement devices in
the work areas.
6.18. In addition, all operator aids should be reviewed periodically to determine
whether they are still necessary, whether the information in them needs to be changed
or updated, or whether they should be permanently incorporated as features or
procedures at the plant.
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OPERATIONS

3.4 CONDUCT OF OPERATIONS
3.4(1) Issue: The plant has not developed an effective key control system in the main control
room to prevent unauthorized access to systems and equipment important to safety.
The plant is using keys to secure the position of valves and access to certain rooms.
However this system is not sufficiently formalized and rigorously followed:
- No suitable procedure for key handling exists.
- The list of keys (reg nr 2005-06960) kept in the main control room (MCR)
was not up to date. The list of keys indicated 167 however 200 keys were
found in the locker.
- The shift turnover procedure (regnr 2005-06562) describes that it has to be
checked before shift turnover that all important keys are in place. There is no
requirement that the keys have to be checked during shift turnover. The key
cabinets were not opened during shift turnover.
- The keys to lock up the key cabinets are always in the locks and not securely
stored.
In the past keys to operational rooms and process rooms have been lost. For example
in 2006 nine keys were lost, of which six could not be found. In 2007 five keys were
lost of which one is still missing.
Without sufficient measures the unauthorised access to systems and equipment
important for safety can not be guaranteed.
Recommendation: The plant should develop and implement an effective key control
system in the main control room to prevent unauthorized access to systems and
equipment important to safety.
IAEA Basis:
NS-G-2.14
5.6. Specific measures should be developed and maintained to prevent unauthorized
access to systems and equipment important to safety. These measures should include
controlled access to certain rooms or compartments and an effective key control
system or other measures to prevent an unauthorized change in the position of, or an
unauthorized intervention affecting, certain important safety valves, transmitters,
breakers or other specified equipment. This access control system should not prevent
shift operators from effectively controlling the readiness of the safety systems and
should allow them to carry out prompt and timely operation of the equipment in
normal and abnormal plant conditions.
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OPERATIONS

3.4(2) Issue: The performance of the field operator rounds in terms of observing and
reporting abnormalities and deviations does not support keeping the plant condition at
a high standard.
The plant has suitable procedures for “Conduct of operations” as well as an “Overall
rounds instruction for operations”. However it was observed that the field rounds are
not performed in the requested way and that the expected observations by the
management and supervisors are not carried out.
- Values written from the field operators in their log sheets have been out of the
accepted limit without corrective measures made.
- Deficiencies in the unit have not been reported by the field operator who
performed his routine round such as oil leakages (e.g. pump 312P3).
- Protocol of a diesel surveillance test showed temperatures outside the accepted
range without any remedial measures being taken. The protocol from the next
surveillance test 2 weeks later showed also temperatures outside the accepted
range.
- Items such as oil barrels are not placed in dedicated places according to the
respective procedure.
- Label used to identify vibrations measurement point is hand written - also
other hand written labels have been found.
- Thermometers in battery rooms were not labeled.
- In the reactor building a box with keys on it was found but the labelling was
not clear in order to identify the purpose of the box.
- Several valves were found without labels, for example in the screening
building or at the diesel in room V01.16.
- Hand written information on I &C cabinets were found.
- In instruction D2.0.1 “Overall rounds instruction for operations” in chapter
7.4. “Protection against fire” is written “ …….check that the escape routes
are cleared and that the rescue routes are cleared for the rescue service and
firemen. Check that the fire load has not increased ……..”, however:
- Ladders were lying on the floor in an emergency exit route E8.03A.
- A large amount of cable was found in front of door E7.04B.
- A lot of unnecessary material (fire load) is stored in the room E8.030
which contains the inergen fire fighting system for the remote shut
down room.
- The shift supervisors are expected to sometimes control the operators in the
field. However it was confirmed that not all shift supervisors do so and there is
also no record of this.
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OPERATIONS

Without field operator rounds performed according to the expectations in terms of
observing and reporting abnormalities and deviations, the plant condition can not be
kept at high standard.
Recommendation: The plant should improve the performance of the field operator
rounds in terms of observing and reporting abnormalities and deviations to keep the
plant condition in a high standard.
IAEA Basis:
NS-R-2
2.3(4)…..The purpose of monitoring is to verify compliance with the stipulated
objectives for safe operation of the plant; to reveal deviations, deficiencies and
equipment failures; and to provide information for the purpose of taking timely
corrective action and making improvements. ….
NS-G-2.4
6.28. “… The operating organization of a site, therefore, should establish shift crews
for continuity of the responsibilities in the tasks of plant operation. Examples…:
to monitor whether there are any indications of deviations from normal operation by
plant walk-through”.
6.33. The shift crew should perform regular rounds through the plant. The shift
supervisor or authorized staff should also walk through the plant periodically.
NS-G-2.14
4.36. Factors that should typically be noted by shift personnel include:
-…inadequate labelling, foreign bodies and deficiencies necessitating maintenance or
other action;
-Indications of deviations from good housekeeping, for example …obstructions,
posting of signs and directions in rooms…;
-Deviations in fire protection, such as …accumulations of materials posing fire
hazards …;
INSAG-15
3.5 Nearly all events, ranging from industrial and radiological accidents, incidents and
near misses to failures affecting nuclear safety, start with an unintentionally
unsafe act or an unacceptable plant condition or process. These have often been latent
and have gone undetected or been treated as ‘custom and practice’ and therefore been
ignored. Then, in combination with another challenge to the system, a further more
significant failure occurs. Minimizing existing latent shortcomings in working
practices or plant conditions is therefore vital in avoiding more serious events.
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OPERATIONS

3.5 WORK AUTHORIZATIONS
3.5(1) Issue: The plant has not established a suitable system to implement isolation and
tagging processes to ensure the protection of personnel and equipment.
The plant has procedures in place for isolation and tagging. However, the plant staff
do not consistently follow these procedures and the procedures are not sufficient in all
aspects.
- Isolations have been performed without permission of the shift supervisor, for
example the instrumental isolations AGO nr. 47248 and AGO nr. 45058.
- Permission was given for work permit ABT nr. 105432 but not all the isolation
steps in the relevant process isolation AGO nr. 47362 have been done before.
- At isolation, the signatures are not done according to the expectations that
each step should be signed separately e.g. AGO nr. 45058.
- Isolation tags only have the isolation number, which means for example that
the tags don’t indicate the valve number and valve position (open or closed).
- A field operator was tagging a valve for isolation without checking against the
isolation list.
- There is no procedure to check process isolations after an extended time
period. Some isolations exist for more than one year without being checked.
- No installation inspection was carried out prior to the handing in of the work
permit. This resulted in the heat shield of a safety related cable tray left
opened in room R5.37 without compensatory measures introduced.
Without establishing and following a suitable system to ensure isolation and tagging
processes, the protection of personnel and equipment can not be assured.
Recommendation: The plant should establish a suitable system for isolation and
tagging, to ensure the protection of personnel and equipment.
IAEA Basis:
NS-G-2.14
7.2. The comprehensive work control system should cover any authorizations, permits
and certificates necessary for ensuring safety in the work area and for preventing
work activities from having undue effects on safety.
7.21. Guidance for the isolation and tagging processes should be established to ensure
the protection of personnel and equipment and status control of the tagging boundary
and all components within the boundary.
7.22. ….. Out of service systems and components should be identified by means of
appropriate signs and tags, both in the plant and in the control room. …….
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OPERATIONS

7.23 ….. Tags should be periodically reviewed for their accuracy and continued
applicability.
7.29. …. The worker or supervisor should only begin the job after verification that all
tags are in place and that the system or component has been isolated.
7.30. …. Requests for tags to be placed in the plant should be reviewed periodically
by management to verify the need for each request.
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OPERATIONS

4 MAINTENANCE
4.1 ORGANIZATION AND FUNCTIONS
The Maintenance group is well organized and the responsibilities within maintenance group
are clearly defined. However, the plant is encouraged to improve the interface with the
operations group regarding work permit authorization. See issue 3.5(1).
4.2 MAINTENANCE FACILITIES AND EQUIPMENT
The team found some examples of inadequately inspected lifting and scaffolding equipment.
The team made a suggestion with respect to the inspection of all lifting and scaffolding
equipment.
4.3 MAINTENANCE PROGRAMMES
The in-service inspection (ISI) program is well managed and comprehensive. It includes
many tasks which are put together to build one ISI program. The team recognized a good
practice in this area.
An ageing management program is implemented by the plant; however, there is no database
in this area which could be used for monitoring of activities of ageing components. The plant
is encouraged to develop and implement a system which could assure that all systems,
structures, and components are included in the program and the appropriate data is properly
updated.
4.4 PROCEDURES, RECORDS AND HISTORIES
The team found that there are some areas within procedures which require further attention.
For example, defining the requirements for tools and consumable materials used in activities,
procedures of safety-related equipment should be in accordance with plant templates, and the
scope of post-maintenance tests should be prescribed. The plant is encouraged to take the
appropriate actions.
The plant implemented a “BI-cycle” tool in order to perform maintenance analyses. This tool
uses historical data from different operational systems like fault reports, work requests, work
orders, history of maintenance and preventive maintenance tools. Historical data is useful and
available for reliability centred maintenance (5-6 analyses per year) and life cycle cost
analyses (one analysis per year) and for maintenance performance indicators. The team
considers the use of this tool as a good performance.
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MAINTENANCE

4.5 CONDUCT OF MAINTENANCE WORK
A requirement of the plant that all work orders must be reviewed by another engineer was
found as a good performance.
Plant staff does not follow plant policies in the area of work permits and ongoing work
activities. The team considered that without attention to details in the area of maintenance,
plant conditions may deteriorate and affect the overall reliability of the plant and, therefore,
the team made a suggestion in this area.
Pre job briefings (PJB) are required in the maintenance area and should be performed by
maintenance engineers before all work activities commence. The plant is encouraged to
comply with the PJB provisions for the main maintenance activities, ensuring written PJB
records are available and operational experience of the other units is included in the PJB
template. The plant is also encouraged to include post-job briefings into the evaluation of the
maintenance activities.
As a good performance, the plant implemented a comprehensive foreign material exclusion
program which includes both technical and organizational provisions.
4.6 MATERIAL CONDITIONS
There were some cases found of improper activities by maintenance or construction staff. The
plant has started with implementation of walkdowns by maintenance management. The plant
is encouraged to include all possible tasks into the list of walkdown activities.
4.8 SPARES PARTS AND MATERIALS
There is no temperature or humidity measurement within the safety-related spare parts
storage area.
Also there is no humidity measurement or a calibrated thermometer for the organic material
storage area. The temperature is checked randomly, however, the results are not recorded.
The team encourages the plant to monitor and trend the environmental conditions of such
storage areas.
An area of good performance is the system to keep traceability of welding rods for
maintenance activities. The team encourages the plant to implement the same system for
construction activities.
4.9 OUTAGE MANAGEMENT
As an area of good performance, the team identified the establishment of a force team if a
failure is detected during outage. This allows the plant to plan and qualify repair method(s)
and report on the subject according to the regulations in order to minimize the effect on safety
and on the time schedule.
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MAINTENANCE

DETAILED MAINTENANCE FINDINGS
4.2 MAINTENANCE FACILITIES AND EQUIPMENT
4.2(1) Issue: Some lifting and scaffolding equipment are not adequately inspected to ensure
safety.
• Some examples of inadequate lifting ropes were found at the storage holders:
- the inspection tag was missing
- date of inspection expired in 2008
- inspected but damaged.
• The plant has two procedures about lifting equipment -neither describes what to
do with damaged or not inspected ropes if they are found.
• It was declared by the plant responsible person that it is difficult to guarantee that
all lifting ropes are inspected as required by procedure.
• Two scaffoldings were found not inspected at the diesel building and compressor
room.
• Database of scaffoldings to be inspected for both maintenance and construction
activities is not adequate:
- handwritten deletions were made
- the numbering of scaffoldings was inconsistent and misleading (…14, 15,
30, 16).
Usage of not inspected or damaged lifting and scaffolding equipment can lead to
damage in the field activities on safety related equipment.
Suggestion: The plant should consider that all lifting and scaffolding equipment is
adequately inspected.
IAEA Basis:
NS-G-2.6
8.19. Plant management should provide suitable mobile lifting and transport facilities,
with clear indications of their lifting capacity... Examples of precautions taken include
regular examination and maintenance of lifting equipment, periodic testing, special
inspections before major operations involving lifting and rigging, and cautionary
notices limiting movements of loads over specified areas.
ILO Safety and health in construction
4.4.1. Scaffolds as prescribed by national laws or regulations should be inspected,
and the results recorded by a competent person:
(a) before being taken into use;
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MAINTENANCE

(b) at periodic intervals thereafter as prescribed for different types of scaffolds;
(c) after any alteration, interruption in use, exposure to weather or seismic conditions
or any other occurrence likely to have affected their strength or stability.
5.6.2. Lifting ropes should be installed, maintained and inspected in accordance with
manufacturers' instructions and national laws or regulations.
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MAINTENANCE

4.3 MAINTENANCE PROGRAMMES
4.3(a) Good Practice: Comprehensive In-Service Inspection (ISI) programme
The plant implemented comprehensive ISI program which includes the following
tasks:
- A tailor-made computer system has been developed for keeping track of all
ISI-related data. All ISI-affected tasks are stored in a database, together with
relevant information such as material composition, drawings, testing intervals,
historic testing protocols, relevant testing methods, photographs, room
location, environmental data etc. Excellent search-functions make it easy to
find, for example, components with the same material composition in cases of
generic problems. Also related structural verification reports are easily
accessible through direct links. The database is also used by and in interaction
with the third party control organization, and as a special feature the outage
testing plan is locked, not able to alter, once it is electronically checked and
signed by the third party control organization. By using the program, the ISIofficer
always has a good overview over both the upcoming inspections (the
program knows the required testing intervals of all objects and can by that
easily produce an outage testing plan) as well as historical testing data for
trending of results.
- ISI database is used as one of the bases for OKG Ageing Management
Program.
- All welds and inspection areas are given indexes for “probability of defects”
and “consequences of defects”. Qualified inspection techniques are used.
- Well in advance (> 3 years) the plant evaluates all ISI activities during the
upcoming outages, and decides if there are any needs to establish a repair
method for a certain area. The judgment is made by an expert panel with
representatives from different parts of the company. The recommendations are
presented for the plant manager for final decision. By this, the plant has a
proper time to develop a repair technique. If a crack is found during the ISI,
the repair can start immediately during the outage. The impact on the outage
length can then be minimized.
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MAINTENANCE

4.5 CONDUCT OF MAINTENANCE WORK
4.5(1) Issue: Some work handling processes and maintenance practices for work site
conditions are not adequately performed.
• Plant staff does not follow plant rules:
- Exchanges of leaders of working groups were not documented in an
appropriate way on work permits (like 108009, 104406, 104412, 104138
etc.). The change of the leaders is required to be documented in a work
permit.
- Extension of the validity of a work permit was not always documented as
required by the plant (like 96838 etc.).
• A number of work permits on which the signed start time of the work permit did
not correspond to the planned time frame of it (like work permit 683781, 90496,
104410 etc. ) was found
• The leader of a working group did not have a work permission nor a work order
• Work permits were found without signature in the work permit office (ABH) for
extending the validity after the valid date e.g. ABT Nr. 106025
• Contract workers left the workplace leaving uncontrolled tools and cables at the
Intake Building. The leader of the working group did not have a work permit nor a
work order (the work permit Nr. 106025 was subsequently found).
• Workers left the workplace unattended. There was water on the floor and tools
lying on the floor in an emergency exit route.
Without attention to details in the area of maintenance, plant conditions may
deteriorate and affect the overall reliability of the plant.
Suggestion: The plant should consider improving the work handling process and
maintenance practices for work site conditions.
IAEA Basis:
NS-G-2.14
7.2. The comprehensive work control system should cover any authorizations,permits
and certificates necessary for ensuring safety in the work area and forpreventing work
activities from having undue effects on safety. The followingspecific matters should
be considered:
- Authorizations for work orders
- The equipment isolation process, including work permits and tagging
- Permits for radiation work
- Precautions for industrial safety.
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MAINTENANCE

INSAG-15
3.5 Nearly all events, ranging from industrial and radiological accidents, incidents and
near misses to failures affecting nuclear safety, start with an unintentionally unsafe act
or an unacceptable plant condition or process. These have often been latent and have
gone undetected or been treated as ‘custom and practice’ and therefore been ignored.
Then, in combination with another challenge to the system, a further more significant
failure occurs. Minimizing existing latent shortcomings in working practices or plant
conditions is therefore vital in avoiding more serious events.
NS-G-2.6
3.8 Contractors should be subject to the same standards as plant staff, particularly in
the areas of professional competence, adherence to procedures and evaluation of
performance. Suitable steps should be taken to ensure that contractors conform to the
technical standards and the safety culture of the operating organization.
ILO Safety and Health in Construction:
3.1.2. All ... areas likely to pose danger to workers should be clearly indicated.
3.3.2. Loose materials which are not required for use should not be placed or allowed
to accumulate on the site so as to obstruct means of access to and egress from
workplaces and passageways.
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MAINTENANCE

5 TECHNICAL SUPPORT
5.1 ORGANIZATION AND FUNCTIONS
A highly educated and multidisciplinary team exists at the plant and their qualification is
adequate for the execution of all assigned tasks and they have good teamwork abilities.
Besides, the plant maintains a wide external cooperation within and outside the company that
was considered by the team as a good performance and an important opportunity for further
qualification and performance development as well as plant safety enhancement.
At OKG the Technical Support (TS) functions are clearly distributed across three
departments namely: Engineering Department, Maintenance Department and Production
Support Department. The responsibility of each department is well documented in the
organization and task distribution documents. The performance indicators do not cover the
whole range of goals and objectives and do not fully correspond with them. The team
encourages the plant to consider establishing performance indicators appropriate to measure
and demonstrate the effectiveness of the Technical Support function.
5.2 SURVEILLANCE PROGRAMME
A computer based tool for surveillance activities planning is in use. All surveillance tests are
carried out in accordance with corresponding procedures. However, it was noted that some
procedures do not include requirements for recording results and actions to be taken if
acceptance criteria cannot be met. The scope for evaluation and requirements for reporting of
the evaluation and trend results are not clearly communicated. The team made a suggestion in
this area.
5.3 PLANT MODIFICATION SYSTEM
The plant has established a well-defined categorisation system for plant systems and
components. In addition, a well structured and documented process for plant modifications on
the basis of the project model and a prioritization system for permanent modification is
implemented. However, the system for modification categorization in accordance with their
safety significance has not been established either for permanent or for temporary
modifications to plant configuration. The team made a recommendation in this area.
The plant modification system and flow path of the process are clearly presented in the
integrated set of administrative procedures which define plant expectations on how a
modification should be implemented and controlled. Nevertheless, the current plant practices
do not ensure proper management and control of temporary modifications. The team has
made a recommendation in this area.
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TECHNICAL SUPPORT

The plant modification system includes requirements for configuration control after a
modification is done, before commissioning. An overall configuration management
programme has not been yet established. The team encourages the plant to consider
development and implementation of such a programme.
5.4 REACTOR CORE MANAGEMENT (REACTOR ENGINEERING)
The core management functions are clearly specified in the plant core management
procedures.
The operational limits from the Cycle Specific Safety Report are continuously trended with
the core simulator and a comprehensive and rigorous approach is used for the calculations
and monitoring of the reactor core. Each month events and trend results are summarized in
the report to the plant manager. The fuel supplier performs independent calculations and
trending using their software codes for further comparison of results. The plant also performs
an independent validation of core software which the team considers as a good performance.
A wide range of computational tools for core management are used and adequately
maintained. However, it was noted that, in some cases, in-house developed software for offline
computer applications is in use without their proper authorization. Such a practice does
not ensure traceability and reproducibility of this software. The team encourages the plant to
consider appropriate authorization for the use of in-house developed software.
5.5 HANDLING OF FUEL AND CORE COMPONENTS
A comprehensive control and inspection process of new fuel assemblies and control rods is
established at the plant. It includes the quality control of the complete supply chain from the
procurement of uranium, enrichment design, fuel manufacturing and the fuel design and the
final assembly as well as conduct of acceptance inspection at the supplier’s premises. The
team considers this as a good performance.
Well organized training is provided for operators and maintenance personnel using a
simulator that is equipped with motors and transducers as at the refuelling machines. This
allows easy exchange of software between unit application as well as testing of components
and changes in software.
A comprehensive policy and full set of instructions are implemented at the plant that ensure
that thorough root cause investigations are conducted for failed fuel and that records on fuel
failure history are properly kept.
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TECHNICAL SUPPORT

The team noted good team work during planning and preparation of fuel handling operations
between Engineering, Production and Maintenance departments. In the procedures for
transport of spent fuel and core components, information is missing on what to do if an
incident or unexpected situation occurs during this activity. The plant is encouraged to
improve this situation.
5.6 COMPUTER BASED SYSTEMS IMPORTANT TO SAFETY
Three separate core calculation computational environments have been designed for
production, validation and development. They are separated both physically and with
firewalls. Except for the three computational environments at client level, three cluster
environments have been built in a corresponding manner. Such an approach with limited
rights to read, write or make changes provides a safe and secure computational environment.
The team considers this as a good practice.
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TECHNICAL SUPPORT

DETAILED TECHNICAL SUPPORT FINDINGS
5.2 SURVEILLANCE PROGRAMME
5.2(1) Issue: The content of surveillance procedures and subsequent analyses of the test
results do not ensure proactive identification of adverse trends in the performance of
equipment or persistent problems.
The plant surveillance programme requires conducting surveillance tests using
procedure for each test. However the team noted that:
- Test procedure 2-D2.5.435.1 does not include acceptance criteria and actions
to be taken if acceptance criteria cannot be met.
- Test procedure 2-D2.5.260.1 includes acceptance criteria, but does not include
requirements for recording results and actions to be taken if acceptance criteria
cannot be met.
- Test procedure 2-D2.5.314.1 does not include requirements for recording
results and does not include acceptance criteria and actions to be taken if
acceptance criteria cannot be met;
- The safety department and the engineering department are not involved in
evaluation process for each test.
- The results from the test of the gas turbine system (649) conducted 2009/02/19
in accordance with the procedure 2-D2.5.649.G13 was just signed by the
turbine operator and the copy of the protocol was sent to maintenance
department for evaluation.
- The person responsible for evaluation and trending of the results from the test
of gas turbine system (649) conducted 2009/02/19 explained that it is up to
him to decide the scope of evaluation and there are no clear requirements for
reporting the evaluation and trend results.
Without acceptance criteria and actions to be taken if acceptance criteria cannot be
met, the plant could miss the opportunity for timely identification of the declining
equipment performance and deviations from the design.
Suggestion: The plant should consider extension and improvement of the content of
surveillance procedures and subsequent analyses of the test results to ensure proactive
identification of adverse trends in the performance of equipment or persistent
problems.
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TECHNICAL SUPPORT

IAEA basis:
NS-G-2.6
5.3. Acceptance criteria and actions to be taken if acceptance criteria cannot be met
should be clearly specified in the procedures.
6.7. Once an activity for MS&I has been completed, the results should be reviewed by
a competent person other than the person who performed the activity. The review
should establish whether the activity was appropriate and was properly completed,
and should provide assurance that all results satisfy the acceptance criteria. If the
results are found not to meet the acceptance criteria, appropriate corrective action
should be initiated.
38
TECHNICAL SUPPORT

5.3 PLANT MODIFICATION SYSTEM
5.3(1) Issue: The system for modification categorization in accordance with their safety
significance has not been established either for permanent or for temporary
modifications to plant configuration.
The plant has a very well-structured and documented process for implementation of
modifications on the basis of the project model, which includes a safety assessment as
well as a prioritization system for permanent modifications. However, the team found
that after the initial safety review of proposed modifications they are not categorized:
- The path flow of the process is clearly presented in administrative procedures,
but does not include requirements on categorization (Description of OKG’s
project model 2007-11-28).
- The plant has not established a system for categorization of modifications
relating to plant configuration.
- A reviewed modification of the V19 ventilators for system 441 (project
number 117725 started in 2005 and completed in 2008), is not categorized.
- A reviewed temporary modification on component K104 of the system 354
(project number 185986) has not been categorized.
- There are no responsibilities assigned for categorization of modifications
relating to plant configuration.
- The plant has developed criteria for planning modifications using ten levels of
priority in four groups (reactor safety, availability/production, environment
and finances) which does not comply with IAEA requirements and
International practice (Prioritization and follow-up of modifications 2008-
26168).
Without clear established procedures for modification categorization in accordance
with their safety significance, and with subsequent appropriate thorough analysis, the
safety of the plant may be compromised.
Recommendation: The plant should establish a modification categorization system in
accordance with their safety significance for permanent and temporary modifications
relating to plant configuration.
39
TECHNICAL SUPPORT

IAEA basis:
NS-G-2.3
4.3. Following the completion of the initial process of safety assessment (see para.
4.8), the proposed modification should be categorized in accordance with its safety
significance. This categorization should follow an established procedure agreed with
the regulatory body.
4.6. The principles for managing modifications are the same for all categories, but in
each step of the modification process the categorization of the modifications
determines the depth and breadth of the safety review and the regulatory control
which should be applied.
4.7. The criteria applicable in determining the categorization for each specific
modification should be defined and documented in order to enable correct assessment
of the potential effect on safety.
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TECHNICAL SUPPORT

5.3(2) Issues: Current plant practices do not ensure proper management and control of
temporary modifications with respect of identification and timely resolution.
The plant has no defined time limits for temporary modifications and team noted a
number of temporary modifications having been in place for a long period as well as
deficiencies in the management and control of temporary modifications. Examples
include:
- The plant has made changes in systems which, are not treated as temporary
modifications. For example: electrical isolations due to category S1 failure
reports nr. 205524 and 206593.
- The total number of temporary modifications is 45, but 27 is stated in the list
for the weekly planning meeting.
- Electrical wire diagrams are not updated when the temporary modifications
are made.
- Control room indications for the reactor level measurement system (534) for
loss of coolant accident (LOCA) conditions are active, however the system is
considered to be removed from operations (WO 29461). It is treated as a
temporary modification starting from August 2005 until now, the work order
(WO) is still open. This situation is not indicated on the panels KE6 and KE7.
There is a defect tag in the relay room 2R7.13 near device 534K104 (in the
cabinet, not visible from outside).
- The drain line from pump 713P4, P5 was disconnected and flexible pipe
attached which passes through the wall in Room D2.22. This was not
identified as a temporary modification.
- The function (534K511) with accumulated alarms has been disconnected in
order not to disturb the normal operation and remains out of operation
awaiting the final solution in project Plex (started 2003-02-12, completion
date is 2012-08-01, modification was planned for 9 years).
- Electrical disconnection of the fan mechanical relay 861K201(started
2007-06-13, completion date 2012-06-13, modification was planned for
5 years).
- An isolation amplifier RA2-07 was installed (741K513) replacing an old relay
that consumed more electricity (started 2007-10-25, completion date 2013-10-
25, modification was planned for 6 years).
Without proper management and control of temporary modifications, the safety of the
plant may be compromised.
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TECHNICAL SUPPORT

Recommendation: The plant should ensure proper management and control of
temporary modifications with respect of identification and timely resolution.
IAEA basis: NS-G-2.3
3.2. The operating organization should establish a procedure to ensure the proper
design, review, control and implementation of all permanent and temporary
modifications.
6.3. The number of temporary modifications should be kept to a minimum. A time
limit should be specified for their removal or conversion into permanent
modifications.
6.5. The plant management should periodically review outstanding temporary
modifications to consider whether they are still needed, and to check that operating
procedures, instructions and drawings and operator aids conform to the approved
configuration. ….Those that are found to be needed permanently should be converted
in a timely manner according to the established procedure.
6.6. Temporary modifications should be clearly identified at the point of application
and at any relevant control position.
6.9. An appropriate procedure should be established to control temporary
modifications on the plant. The following areas should be covered in this procedure:
- Control of documentation, to ensure that all documentation — such as
operating flowsheets, operating manuals, maintenance manuals, emergency
procedures — reflects temporary modifications, to ensure that the plant
continues to be operated and maintained safely while the modification is in
place.
- Logging, labeling and tagging of temporary modifications in a distinctive
manner.
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TECHNICAL SUPPORT

5.6 COMPUTER BASED SYSTEMS IMPORTANT TO SAFETY
5.6(a) Good Practice: Safe and secure computational environment
Core and fuel section uses engineers working within all categories of tasks, including
development, validation and production. The same resources sometimes perform tasks
within all categories. This poses demands on both the environment of the core
calculations and on the resources in order to keep the different tasks apart. Three
separate core computational environments have been designed for production,
validation and development. These are separated both physically and with firewalls.
Except for the three computational environments at client level, three cluster
environments have been built in a corresponding manner. A function has also been
introduced through which the system administrator can rearrange the computer
capacity in the cluster from one environment to another.
The “production environment” has a clean catalogue index and uses only files and
software that are validated for production. There is no accessibility to the validation or
development environment.
The “validation environment” is a copy of the production environment with the
purpose of validating software and codes in an identical environment without
tampering with the real production files and inputs. It is only possible to read from the
production environment and not write to other environments.
The “development environment” is for programming, developing and testing. It
allows for copying of several files or software which is not allowed in the other
environments. It is only possible to read from, but not write to other environments.
These three different systems also have different colour schemes and the entire system
is handled by a system administrator who also handles the authorization levels of the
system giving higher security. An engineer working only with tasks in one
environment has no access to other environments resulting in less risk for mixing the
system.
The main advantages (compared to the old system) are:
Safety:
- No risk for mixing data, software, inputs and files for different purposes.
- Reduced risk for changing data, inputs and files by mistakes.
- Only validated software and only one version of each software is presented in
the production.
- Validation environment allows validating software without influencing
production files.
- Since there are only production files when working with production, the
catalogue index is clean.
43
TECHNICAL SUPPORT

Security:
- The systems are separated physically and with firewalls and there are three
different authorization levels.
- System administrator handle accounts, passwords and authorization.
- Limited or no accessibility between the environments.
44
TECHNICAL SUPPORT

6 OPERATING EXPERIENCE FEEDBACK
6.1 MANAGEMENT, ORGANIZATION AND FUNCTIONS OF THE OE
PROGRAMME
The plant has recently established a department specifically devoted to the OE process
development. This department (HO) has a comprehensive vision of the process and
effectively coordinates all the plants efforts to improve its efficiency. A multidisciplinary
committee (OKG-ERF) effectively screens the external and in-house OE. The plant has a
committee devoted to OE process oversight: the OEF-Forum. There is a comprehensive
vision of what this committee’s role has to be, although most of its responsibilities have been
recently introduced or are not in place yet. The team encourages the plant to consolidate this
committee in order to assess the effectiveness of the OE programme.
6.2 REPORTING OF OPERATING EXPERIENCE
The plant has not defined a threshold for reporting, and low level events and near-misses are
not being reported sufficiently in order to identify event precursors. This has resulted in the
plant experiencing some repetitive events. The team recommends that a reporting threshold
be defined and communicated to all personnel, and that notification of these types of events is
promoted.
6.4 SCREENING OF OPERATING EXPERIENCE INFORMATION
Preliminary reportable events are issued by the plant for those cases in which there is still not
enough information for decision-making. This proactive approach allows these events to be
screened promptly and their impact on safety to be determined. These preliminary reports
permit the plant to inform ERFATOM (a multidisciplinary forum with the attendance of all
Swedish plants and the Finnish Olkiluoto plant, KSU and Westinghouse) about them to allow
the other Nordic plants to screen the events. The team considers this as a good performance.
External OE is screened in the ERFATOM meeting twice a month using a comprehensive
and analytic template. Questioning attitude is demonstrated and event categorization is
discussed. ERFATOM members are senior and experienced engineers (including a Human
Performance expert) and add value to the screening process before events are sent to the plant
to validate applicability and define corrective actions. In urgent cases, ERFATOM has
effectively distributed relevant information to potentially affected plants. The team considers
this area as a good performance.
6.5 ANALYSIS
Analyses are performed on the selected events in accordance to their level of safety
significance, and the plant has incorporated the study of organisational root causes for the
most safety significant events. However, no timeframe for performing the analyses has been
established, and some significant events have been analyzed with some delay. The team
encourages the plant to define a time lapse for completing event investigations according to
their importance.
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OPERATING EXPERIENCE FEEDBACK

Extents of cause and extents of condition are not systematically assessed in safety significant
root cause analyses, and root cause analyses techniques could be improved by adding analysis
tools, specifically focused in the systematic detection of organizational and human factor
aspects, such as Human Performance Evaluation System (HPES) and Management and
Oversight Risk Tree (MORT), so no cause associated to these factors is omitted. The team
encourages the plant to improve the root cause analyses techniques to include such aspects.
The plant has established an event analyses on-call team to perform urgent analysis during
refuelling outages. The team considers this as a good practice.
6.6 CORRECTIVE ACTIONS
There is a lack of a consistent system to prioritize corrective actions according to their impact
on safety and track them onto their effective implementation. The team recommends the plant
establishing a unique safety prioritization scale and screening all corrective actions,
regardless of the system used to track them, according to the priorities included in this scale.
Also that for the most safety significant actions, their effectiveness in solving the root causes
is reviewed.
6.7 USE OF OPERATING EXPERIENCE
The plant has not implemented an integrated and systematic process to incorporate OE
lessons learned into its programs and activities, so some internal and external OE lessons
learned are not taken into account. The team made a suggestion in this area.
OE is effectively used in the validation of non-destructive testing. The team considers this as
a good performance.
6.8 DATABASE AND TRENDING OF OPERATING EXPERIENCE
Trending parameters/coding are not established in all systems used to manage events,
deficiencies, anomalies or deviations. The team encourages the plant to screen all these
systems and to assign a codification to all of them in order to trend their behaviour and
anticipate events.
6.9 ASSESSMENT AND INDICATORS OF OPERATING EXPERIENCE
The plant has performed a comprehensive gap analysis of the OE process following IAEA
and WANO standards, as well as Swedish regulations. The results of this self-assessment are
updated and tracked twice a year. The team considers this as a good performance.
The plant indicators only include two OE-related measures: Man-Technology-Organisation
analyses performed and repetitive events. No more OE indicators have been developed. With
this collection, it is not possible to track the effectiveness of the OE programme. The team
encourages the plant to develop a comprehensive set of OE indicators in order to assess the
effectiveness of the OE process.
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OPERATING EXPERIENCE FEEDBACK

DETAILED OPERATING EXPERIENCE FINDINGS
6.2 REPORTING OF OPERATING EXPERIENCE
6.2(1) Issue: Low level events and near misses are not reported, analyzed and effectively
trended to identify event precursors in a systematic and consistent manner.
The plant has implemented a well-structured operating experience process, with roles
and responsibilities clearly defined for the activities covered. However:
- The process does not specifically include “Identification”, which causes the
expectations and responsibilities associated with this activity to be spread
about in different procedures or instructions. In order to promote identification
of deviations, a clear definition of what should be reported and what procedure
or process must be followed to report are important.
- Expectations regarding the reporting level threshold have not been defined,
and there are different perceptions among plant personnel about what should
be reported.
- Despite current expectations regarding plant personnel responsibility in
reporting deficiencies, identifying minor events and near misses is not a
widely used practice (some departments have not issued any minor events and
the plant personnel do not have a simple way to identify those being reported).
The white card system is not known by some personnel interviewed.
- Some low level events investigations are only documented in meetings
minutes, which prevents the causes associated with these events from being
trended and incorporated into further analyses.
Trending parameters are not established in all systems used to manage events,
deficiencies, anomalies or deviations:
- Although there is a good and proactive vision (selection of coding,
development of a database, etc.), the plant has performed no trending within
the OE process.
- The database used to report quality non-conformances, environmental or
industrial safety minor events and minor deviations (QAF database) does not
include coding fields for trending.
The plant is not identifying event precursors due to the small number of low level
events being reported. This causes several of the more significant events to recur (fire
cells breaks, exceeding surveillance tests intervals and repetitive scrams).
Without a comprehensive, systematic and integrated low level events and near misses
reporting programme, the plant’s capability of identifying event precursors and
emergent issues by trending different event factors may be impaired. In addition,
other plant organisations cannot improve their performance without the information
gained from such trends.
Recommendation: The plant should define the desired reporting threshold for minor
notification of this kind of events. This information should be analyzed to determinate
causes and coded for trending in order to identify event precursors.
47
OPERATING EXPERIENCE FEEDBACK

IAEA Basis:
NS-G-2.11
I-1. “Low level operational events are those reported within the plant or operating
organization as anomalies, conditions or situations that are usually screened out in the
process of dealing with safety significant events (such as findings during testing, inservice
inspection or surveillance). They would form the majority among the reported
events at the plant. Individually they may appear to be unimportant. However, when
aggregated with other low level events they can reveal features or common patterns,
trends and recurring information that may be significant and useful for enhancing
plant safety.”
I-18. “...low level events, which include near misses, with aspects related to human
factors need to be reported to the operating organization. The operating organization
needs to retain information on such low level events, even if they do not reach the
threshold for reporting to the regulatory body.”
INSAG-15
3.5 “Failures and near misses are considered by organizations with good safety
cultures as lessons which can be used to avoid more serious events. There is thus a
strong drive to ensure that all events which have the potential to be instructed are
reported and investigated to discover the root causes, and that timely feedback is
given on the findings and remedial actions, both to the work groups involved and to
others in the organization and industry who might experience the same problem. This
horizontal communication is particularly important. Near misses are also very
important because they usually present a greater variability and volume of
information for learning. To achieve this, all employees need to be encouraged to
report even minor concerns.”
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OPERATING EXPERIENCE FEEDBACK

6.5 ANALYSIS
6.5(a) Good Practice: Timely capture of human factor and safety culture data during
refuelling outages
The plant has established an on-call team that it is constituted during outages to
collect event related data. This team is composed of thirteen skilled and experienced
personnel, including human factors and safety culture experts, and can be gathered
promptly in cases where a significant event could occur in the outage. The data will
be used for subsequent a root cause analysis for events having organizational or safety
culture related contributing factors.
As stated in the IAEA standards, the on-site investigation should be commenced as
soon as practicable after the event occurrence, in order to ensure that information is
not lost or diminished, interviewed personnel have a clear notion of the sequence of
events and evidence is not removed. This on-call investigation team allows the plant
to achieve these goals.
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OPERATING EXPERIENCE FEEDBACK

6.6 CORRECTIVE ACTIONS
6.6(1) Issue: A consistent system for prioritizing and screening corrective actions according
to their impact on safety, and tracking them until their effective implementation, is not
in place.
• The plant has established and communicated a safety policy that highlights safety
as the highest priority, and people in the plant are considered to be accountable for
effective tracking and timely implementation of their corrective actions. However:
- The database used to report quality non-conformances, environmental or
industrial safety minor events, and minor deviations (QAF database) does
not include any safety or environmental prioritization. The plant policy
regarding its management system requires these criteria to be taken into
account when evaluating deficiencies or deviations.
- Corrective or improvement actions included in the outage action list are
not prioritized.
- Some managers do not have a comprehensive understanding of the most
safety significant corrective actions to be implemented in their
organizations. Actions agreed in meetings are documented in the minutes,
and it is everyone’s responsibility to develop their own track list. The team
has checked some action tracking lists from different departments. No
safety prioritization was found in them.
• The plant has not implemented a unique database for safety issues, they currently
use ODU for Maintenance, Aladdin for documentation, QAF for quality, Plateau
for training, a specific database for OE, a specific database for the Safety
Coordinator, a specific database for outages corrective actions, etc. This results in
corrective actions that are not comprehensively evaluated according to their safety
significance and jointly scheduled for implementation.
- Not having a system to effectively manage all pending corrective actions
has been identified as one of the contributing factors to the recurrent
scrams at the plant (see report ref. 2009-04662).
- Not having a system to effectively manage all pending corrective actions
has been identified as one of the root causes to the repetitive events
regarding exceeded testing intervals (see report ref. 2007-03934).
- The RCA documented in the report 2008-17929 (Suspicious HTG because
of high T ratio in RV cooling water) identifies as one of the event’s root
causes “not having implemented experiences from Unit 3”, as some of the
corrective actions had still not been closed.
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OPERATING EXPERIENCE FEEDBACK

- Some of the corrective actions derived from an INES 1 event occurred in
2004 are not yet implemented in the plant (e.g., reviewing a maintenance
procedure MI 4203 to incorporate precautions about using PVC labelling
in high temperature environments, or training personnel in the event’s
lessons learned). As such, no compensatory measures have been
implemented.
- After the implementation of some software design changes in unit 1, a
partial scram test during power descent was recommended by the
engineering department. The test was not performed and the unit tripped
owing to high pressure in the reactor vessel in 2009 (see operation
assessment meeting minutes 2009-04622).
- 66 percent of corrective actions included in the access database used by
Production unit have no due date.
• Some corrective actions are not focused in the actual root causes of the event. In
addition, the effectiveness is not reviewed:
- Between 2002 and 2006, 13 events related to exceeding testing intervals
were reported from OKG. Although a RCA was performed in late 2006,
there have been two more recurrences of this type of event.
- Despite the repetitive number of fire cells breaks, corrective actions have
been defined individually for every single event and potential common
causes have not been considered.
- A formal and systematic effectiveness review is not performed for the
most safety significant corrective actions. The OE process and the
departments’ procedures do not require this review to be carried out.
Without an integrated criteria for prioritizing corrective actions according to their
impact on safety, and without an effective system to track them to final
implementation, event root and contributing causes could remain unresolved.
Recommendation: The plant should establish a consistent system for prioritizing and
screening corrective actions according to their impact on safety and track them to
their effective implementation.
IAEA Basis:
NS-G-2.11
5.6. “Corrective actions should therefore be prioritized. Those actions affecting safety
should be given the highest priority, while the actions that are desirable rather than
essential should be shown as such.”
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OPERATING EXPERIENCE FEEDBACK

5.7. “A tracking process should be implemented to ensure that all approved corrective
actions are completed in a timely manner and that those actions with long lead times
to completion remain valid at the time of their implementation in the light of later
experience or more recent developments. A periodic evaluation should be carried out
to constantly review the need for items in the pending corrective actions list and
separately to check the effectiveness of actions implemented.”
8.3. “(a) It should be verified that corrective actions arising from the process for the
feedback of operational experience are being implemented in a timely manner.
(b) The continuing need for each of the outstanding corrective actions should be
considered.
(c) The effectiveness of the solution of the original problems and the prevention of
their recurrence should be evaluated”.
INSAG-13
85. “... repeat events that have taken place on the plant; these provide a measure of the
failure to implement effective corrective actions”.
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OPERATING EXPERIENCE FEEDBACK

6.7 USE OF OPERATING EXPERIENCE
6.7(1) Issue: An integrated and systematic process to timely incorporate OE lessons learned
into plant programmes and activities is not implemented.
There are occasions in which the plant is not taking benefit of the external or in-house
operating experience lessons learned, such as:
- A Just-in-Time library has not been put in place, this results in OE information
not being easily accessible to the plant personnel and not being effectively
used during pre-job briefings:
- In July 2004, an INES Level 1 occurred in Unit 1 due to the use of
PVC labelling in instrumentation cables subjected to high
temperatures. This phenomenon was already known by the industry
and reported by different plants.
- The team has observed pre-job meetings for which the OE of the other units
was not available (e.g., WO 209027). The plant has confirmed that OE from
other OKG units is not systematically used while performing pre-jobs.
- The daily review meeting agenda does not include a specific section to discuss
internal/external OE lessons learned.
- Training materials do not identify those included OE commitments that should
be preserved. As such, there is the risk that in the future some of these
commitments could be deleted from training programmes.
- Some external OE information is waiting for evaluation by the assigned
departments (e.g. SOER 2007-2) or the time lapse taken by the departments to
assess it is excessively large (e.g., greater than 9 months for SOER 2008-1).
Without effectively integrating the in-house and industry OE lessons learned in the
organization’s programs and activities, repetitive or recurrent events may continue to
occur. This does not allow the plant to visualize the importance of the use of the OE
among its staff and may cause the plant to not take maximum advantage of some
plant/industry lessons learned.
Suggestion: The plant should consider developing a process to ensure that OE lessons
learned are included in the plant’s programmes and activities in a timely manner.
IAEA Basis:
NS-G-2.11
7.2. “... licensees should issue information relating to operating experience (e.g. in the
form of a synopsis of past events, team briefings, work briefings, so-called Just in
Time (JIT) information about events that have occurred elsewhere in similar plant
conditions, and lessons learned) when assigning plant work.”
“...Effective use of the feedback of the operating experience should be actively
encouraged and reinforced by plant managers and supervisors, including the use of
operating experience in refresher training for plant personnel.”
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OPERATING EXPERIENCE FEEDBACK

7 RADIATION PROTECTION
7.1 ORGANIZATION AND FUNCTIONS
The Radiation Protection function at the plant is well organized, competent and is
independent from the line organization as it reports directly to the President.
The unique RP technician competence evaluation system was established to ensure
strengthening of the RP function at the plant and the team has identified this as a good
practice.
7.2 RADIATION WORK CONTROL
Several radioactive sources at the chemical laboratory were stored in a metal box, not in a
shielded container designed for radiation exposure prevention. The plant is encouraged to
review its arrangements for storage of radioactive sources.
Daily surveys are performed at about 30 to 40 points in the radiation controlled area (RCA).
The hand held measuring device is self- checked, to ensure its correct functioning, with a
radioactive source at the health physics room just before its use. This is to ensure that the
radiation measuring device is maintained in an appropriate and efficient condition and the
team identified this as a good performance.
Measures to prevent spread of contamination inside RCA are not sufficiently comprehensive.
The team made a suggestion in this area.
7.3 CONTROL OF OCCUPATIONAL EXPOSURE
The high level radiation rooms were locked using two keys. Also, shielded source storage at
the radioactive waste building (HLA) is with a key security coding box and is only accessible
to three responsible persons (RP engineer, waste engineer and waste technician). This was
evaluated as a good performance by the team.
7.4 RADIATION PROTECTION INSTRUMENTATION, PROTECTIVE CLOTHING,
AND FACILITIES
The plant has an up-to-date tool, namely IMBA (Internal Monitoring Bioassay Analysis
program), which is useful in estimating intakes of 75 individual radioisotopes from
measurements of activity in the body or excreta and to quickly and precisely calculate
committed equivalent dose or committed effective dose. This was considered as a good
performance by the team.
7.5 RADIOACTIVE WASTE MANAGEMENT AND DISCHARGES
The plant has a very effective decontamination system, so called AMDA (Automated Mobile
Decontamination Appliance), that utilizes the CDRD-UV method to reduce environmental
and radiation exposure in four steps namely oxidation, reduction, decontamination and
destruction. The team evaluated this system as a good practice.
54
RADIATION PROTECTION

DETAILED RADIATION PROTECTION FINDINGS
7.1 ORGANIZATION AND FUNCTIONS
7.1(a) Good Practice: The plant has a unique and exclusive system to improve and ensure
the competency levels of Radiation Protection technicians.
The job classification for Radiation Protection technicians and contractors is a very
effective and efficient evaluation system for NPP radiation protection control.
The plant started to apply this system for its own Radiation Protection technician last
year. The reason was that RP man-power quality did not follow the demand of NPP
and had further decreased.
The quality of RP technician is categorized into three levels A, B and C according to
the job performance ability considering several evaluation factors. The competence is
evaluated and classified by consolidating the qualification examination, training,
social behavior, skill, knowledge and experience, etc. The categories and conditions
are standardized and described in the plant instructions.
Personal aptitude meeting is annually held by heads of all RP section and subsection
for judgment of suitability for RP work. Competency information is used by line
managers to determine upcoming training development needs for RP personnel.
The plant’s Radiation Protection managers evaluate RP technicians’ classification
every year. There are about 150 man-power resources to work at all NPP RP area.
It is very instructive that this evaluation system results in improving RP worker’s
quality and ultimately approaching the goal of both NPP and contractor sides in
satisfactory level.
55
RADIATION PROTECTION

7.2 RADIATION WORK CONTROL
7.2(1) Issue: Measures to prevent the spread of contamination inside the RCA are not
sufficiently comprehensive.
In general, the plant has low contamination levels and low dose rates inside the RCA.
However, some arrangements would be insufficient to avoid the spread of
contamination, should the “clean” conditions change:
- Some radiation dose rate survey devices, e.g. friskers at various strategic
points could be considered to prevent the spread of contamination within the
RCA or to the other unit or to the exit. There are no hand or shoe monitors at
the exit from rooms with potentially higher contamination e.g. reactor hall
spent fuel pool or at temporary RP step-over benches.
- There were 74 smears over 40 kBq/m 2 among 2075 smear surveys in 2007.
Therefore, the probability that unexpected contamination may occur in the
RCA and spread from one contaminated point to other areas can not be
excluded.
- One of six hand held radiation measuring devices in the RCA workshop was
not working properly, the marking indicated that its next calibration date was
September 2009.
- Maintenance workers on the training video were observed to be placing
disassembled parts of equipment and tools on the floor without using a plastic
sheet to prevent the spread of any contamination.
- Workers leaving the controlled area were observed to be placing articles such
as dosimeter, keys, notes on the floor of the contamination monitor and not in
the proposed place in the monitor.
- Plant personnel are allowed to wash contamination off, then re-scan without
notifying anybody of the contamination – this practice does not permit the
prevention of subsequent contaminations from the same source.
- Plastic packed waste, collected in RCA, was not labeled as to whether it was
contaminated or not. Contaminated, but appropriately marked waste, was not
stored in the designated area.
Without a more comprehensive approach, there is a probability that unexpected
contamination may occur and spread without any recognition and could cause further
potential exposure.
Suggestion: The plant should consider enhancing measures to prevent the spread of
contamination inside the Radiation Controlled Area.
56
RADIATION PROTECTION

IAEA Basis: NS-G-2.7
3.3 The operating organization “shall designate as a controlled area any area in which
specific protective measures or safety provisions are or could be required for:
(a) Controlling normal exposures or preventing the spread of contamination during
normal working conditions.
3.29. The equipment to be provided for measuring radiation and activity and for
sampling and analysis may include:
(d) personnel monitoring instruments, including:
(ii) contamination monitors, such as portal monitors and hand and shoe monitors.
I-1. The following is an example of how zones in a controlled area may be classified:
(d) Contamination zone: special protective measures are necessary, owing to actualor
potential air contamination or loose surface contamination in excess of a specified
level. Subdivisions may be considered on the basis of the levels of precautions
necessary in different areas of this zone.
57
RADIATION PROTECTION

7.5. RADIOACTIVE WASTE MANAGEMENT AND DISCHARGES
7.5(a) Good Practice: Use of effective decontamination method for the plant’s main highly
radioactive systems during outages has contributed to significant reduction of
occupational exposure in past years.
In 1989 and 1994, the plant had experienced two decontamination campaigns for the
reactor tank and its associated primary system at unit 1. Based on the experience of
these decontaminations, the plant had established a new decontamination system that
could be performed with efficiency and speed. Since this system, so called AMDA
(Automated Mobile Decontamination Appliance), had been used in 1996, radiation
dose exposure reduction with great efficiency has been achieved.
Decontamination of primary systems with DF (Decontamination Factor) between 10-
100 has been performed over 20 times at the units1, 2 and 3 until now.
For instance, as a result of decontamination of reactor cooling system and main
circulation cooling system in 1999, the dose saving was 12 manSv with DF 63.
Had this not implemented with efficient results, the necessary high activity work in
the reactor vessel could not be performed. A very valuable advantage is that it is
possible to reduce the doses to individuals and the collective dose at a reasonable cost.
All system decontaminations have been performed with the CORD-UV-method. The
CORD-UV is an abbreviation of Chemical Oxidation Reduction Decontamination and
Ultraviolet. The decontamination process consists of multiple-steps involving hot and
diluted solutions of weak acids in 2-3 cycles. The equipment is connected to
established tie-in points of the contaminated system in order to achieve a closed
circuit. Water is filled into the system and then circulation is begun. Cold and hot
leakage-checks are performed prior to dosing the chemicals.
As a result that the plant has continued to achieve significant ALARA goal to reduce
occupational exposure, this is remarkable.
58
RADIATION PROTECTION

8.1 ORGANIZATION AND FUNCTIONS
8 CHEMISTRY
At the Environmental department, a quality engineer is appointed to take care that
management’s expectations are taken into account in the procedures and documentation of
sections of the department. One company level specialist is nominated to the chemistry
section for special tasks related to chemistry. These special arrangements in chemistry section
are regarded as a good performance by the team.
8.2 CHEMISTRY CONTROL IN PLANT SYSTEMS
A materials balance is calculated every month for each corrosion product (Cr, Mn, Fe, Ni,
Co, Cu and Zn). The method reveals internal corrosion. In addition, the overall information
verifies the reliability of all measurements. The team views this as a good performance.
Chlorides and sulfates are known to be among the most aggressive impurities in BWR reactor
water. In order to handle these types of impurities, an Alpha value was developed. (Alpha
value is the cost of reducing the concentration of chlorides or sulfates by the value of 1
ppb/day.) The Alpha-value gives stability in the decision-making process and it was
considered to be a good performance.
The team identified, as a good practice, the recycling of resin from the condensate clean-up
system (CCU) and used for the purification of liquid wastes.
As a further good practice, the team also identified a simple, reliable and inexpensive
technique known as Concrete-OLA (On Line Activity), to monitor the dose rate on primary
piping during operation, despite the effect of dominating short lived nuclides (N-16 and O-
19).
8.6 QUALITY CONTROL OF OPERATIONAL CHEMICALS AND OTHER
SUBSTANCES
Even though the labeling and marking system covering all chemicals and other substances is
developed and implemented by the plant, there were some instances where some unlabelled
canisters and containers at several places in the Radiation Controlled Area were found. The
plant is encouraged for further improve the control of chemicals and other substances.
59
CHEMISTRY

DETAILED CHEMISTRY FINDINGS
8.2 CHEMISTRY CONTROL IN PLANT SYSTEMS
8.2(a) Good practice: On line dose rate measurement on primary piping during operation
(Concrete – OLA)
During operation the dose rate on the primary piping is strongly dependent on the
power level dominated by short lived nuclides such as N-16 and O-19 in the reactor
water. Therefore it is difficult to track the dose rate from the oxide layer on primary
piping during operation.
To get reliable results on the build up of activation products on pipelines, a nuclide
specific gamma detector would be needed. A nuclide specific gamma detector in the
vicinity of primary piping in the reactor building is problematic because of the need
for liquid nitrogen for the detector cooling as the surrounding temperature should not
be too high.
In order to get reliable data with conventional dose rates probes, a special technique
has been developed by using two dose rate probes, one in contact with the primary
piping and one behind a concrete wall.
The on-line dose rate measurement technique, Concrete-OLA, was first introduced at
unit 2 in late 2001 to track the build up of activated corrosion products on primary
piping. After starting zinc addition both at unit 1 and unit 2 in 2003 the technique was
found to be applicable for follow-up of the effects of zinc addition on the oxide layer.
The Concrete-OLA -technique is simple, reliable and inexpensive tool for water
chemistry control and track dose rate development during operation. The plant has
found it to be valuable in controlling the addition of depleted zinc to the final
feedwater line.
60
CHEMISTRY

8.2(b) Good practice: Recycling of condensate clean-up system resins
The plant has developed and implemented recycling of resin from condensate cleanup
system. Resins from the condensate clean-up system (CCU) are reused in the waste
building.
The ion exchange capacity of the resin in the CCU is during normal operation used to
a minor extent only. Even in cases of small condenser leakage there is still a
substantial amount of cation capacity left. The filters are normally back-washed as a
pressure difference defined for precoat filters is achieved.
In order to reduce the amount of radioactive waste, the resin from the CCU system is
reused in the handling system of liquid wastes. Water from floor drainage, usually
with high ion content, can be cleaned with the resin from the CCU system.
The radioactive releases to water using this technique have decreased and kept at a
constant level. The amount of powder resin saved since the introduction of the
technique is approximately 25 tons.
61
CHEMISTRY

9 EMERGENCY PLANNING AND PREPAREDNESS
9.1 EMERGENCY PROGRAMME
The plant initiated a complete re-assessment of the Emergency Planning and Preparedness
function which was subsequently performed by an external consultant. As a result more
resources have been made available for the Emergency Planning and Preparedness
organisation. The team identified this as a good performance. Future short term plans include
a resource analysis for support functions for the EPP organisation which will be reviewed by
all relevant on and off-site stakeholders.
Stakeholders and organisations in Emergency Planning and Preparedness participate in a
Regional Council where activities such as training plans, emergency exercises and experience
feedback relating to Emergency Planning and Preparedness are discussed four times per year.
The plant often participates in Working Groups formed to deal with specific technical issues
and action plans resulting from Council meetings. The establishment of a forum and the plant
involvement in the strengthening of cooperation and personal relations is regarded as a good
performance.
The Crisis Group at the plant is integrated into the emergency plan and handles posttraumatic
stress disorders and problems associated with fitness for duty during and after an
emergency. Up to twenty Crisis staff can provide support to plant staff and this awareness has
been communicated to plant staff and contact numbers are available on the intranet. This is
regarded as a good performance by the team.
9.2 RESPONSE FUNCTIONS
The on-site Public Information Group participates in an integrated public communication
strategy together with the off-site organisations from where consistent media messages and
press releases are transmitted. Seven dedicated staff are available to participate, and technical
persons are also trained to deal with media questions and press releases. The plant is
encouraged to document the role and functions of its Communication Group for emergency
purposes more clearly.
The notification arrangements and previous drills and exercises have shown that notification
to off-site authorities is promptly performed. As was observed during an on-site staff
exercise, the activation and notification of on-site responders was done timely using cell
phones in communicating with emergency standby staff. The team had identified a good
practice in this regard.
There are however no specific response time objectives documented for the classification of
an emergency, notification, activation and recommendations to the local authorities, apart
from the regulatory requirements. The plant is encouraged to develop response time
objectives in line with international guidance.
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EMERGENCY PLANNING AND PREPAREDNESS

9.4 EMERGENCY PROCEDURES
Comprehensive handbooks containing procedures and checklists for classification,
notification, activation, protective actions, coordination and response are utilized for
Emergency Planning and Preparedness. The handbooks are detailed and easy to follow and
are placed at different locations around the plant. The team encourages the plant to consider
some minor improvements for some of the information contained in a few procedures of the
handbooks for cross reference purposes.
9.5 EMERGENCY RESPONSE FACILITIES
The Emergency Command Centre has good communication facilities and layout. The
protection of this facility is very good as it is situated in a well protected bunker and
alternative facilities for a coordinated response are also available. The team has made a
suggestion with regards to the personal protection and contamination control in accessing
these facilities.
There are nine assembly points on site on strategic locations which provide protection against
radiation in the event of a release. The reception points are stocked with potassium iodide,
registration, a megaphone, registration sheets and a procedure containing instructions for the
first person that arrives at the reception point. The plant is encouraged to review the locations
and suitability of the assembly points as well as monitoring of radiological conditions during
an emergency.
9.6 EMERGENCY EQUIPMENT AND RESOURCES
The plant monitoring teams use a comprehensive range of radiation and contamination survey
meters that have adequate ranges for emergency surveys near the source of release and can
provide resources to support other plants or agencies in Sweden. The team regards this as a
good performance.
A comprehensive communications system which includes portable 2 way radios, 3 radio
communications systems on different channels, pager system, GSM mobile phones for use on
and off-site, installed landline phones, intercom phones, speaker systems and mini-call
system is used at the plant. The upgrade of communications systems and the improvement of
redundancy of the systems through a short term action plan is regarded as a good
performance.
The preparation and conduct of the drills is generally adequate and use is made of a webcam
during the conduct of the exercise to allow evaluation of responders. The plant is encouraged
to benchmark the evaluation criteria with those contained in the IAEA guidelines.
The plant has dedicated facilities and equipment for use during an emergency. The
Emergency Planning and Preparedness facilities and equipment are maintained and verified
by various groups on-site on an ongoing basis. The plant is encouraged to implement a more
formal process to ensure that review and checking of emergency equipment and facilities are
done in a systematic way.
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EMERGENCY PLANNING AND PREPAREDNESS

DETAILED EMERGENCY PLANNING AND PREPAREDNESS FINDINGS
9.2 RESPONSE FUNCTIONS
9.2(a) Good Practice: Communication between the on duty emergency planning and
preparedness staff by cellular phone.
Management and plant staff members are issued company cellular phones used on the
network of a cell phone operator in Sweden, which when entering the plant
automatically operate at a lower intensity of electromagnetic power in order to avoid
plant systems interferences and disturbances. The mobile phones are used in all
spheres of the plants activities and in the case of an emergency the systems allows a
zero delay and efficient means to relay emergency messages to standby persons at any
location on and off-site. The system allows prompt mobilization of resources during
classification and notification of an emergency as well as continuous updating and
exchanging of information with support functions for emergency decision makers.
The use of mobile phones in emergency communication enables the plant public
announcement system to be dedicated for important messages for the protection of
persons on site. In the case of an emergency it is also possible to allow the use of
private phones on site if necessary.
The use of cellular phones in drills and exercises has shown that the plant is able to
notify, classify and activate its emergency facilities in normal and outside normal
working hours in a timely manner. It was also used to good effect during a Staff Alert
at the plant in 2008, and the network proved to have sufficient capacity to handle the
situation.
In case of a breakdown of the national cell phone network which is part of the global
net, the indoor antenna system for communication radio TETRA, using digital radio
technology will be utilized. TETRA has an eight hour UPS battery backup. In
addition to TETRA the plant also has a blue-light-authority 80 MHz radio system and
a new digital RAKEL radio system. All indoor antennas are connected to two outdoor
antennas which are a backup of each other, and should this fail, direct communication
with the handheld radios is still possible.
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EMERGENCY PLANNING AND PREPAREDNESS

9.5 EMERGENCY RESPONSE FACILITIES
9.5(1) Issue: Arrangements for the protection of on duty staff and other persons on site at
emergency facilities in case of an emergency are not adequate.
More than one emergency facility for coordination of activities on site are available
for use by the plant. The following deficiencies were found:
- There are no specific radiological protection arrangements stipulated in the
procedures for on duty staff accessing the emergency facilities on-site in case
of an emergency.
- There is no contamination monitor at the entrance of the main emergency
facility to avoid possible spread of contamination.
- There is no contamination monitor at the entrance door of the alternative
emergency facility to avoid possible spread of contamination.
- Access to and activation of the alternative emergency facility in field
conditions involving radiation exposures and contamination spread have not
been exercised to the full extent.
Inappropriate protection arrangements for the emergency facilities increase the risk of
radiation exposures to emergency staff and persons on site during an emergency.
Suggestion: The plant should consider improving the arrangements for the protection
of on duty staff and other persons on site at emergency facilities in case of an
emergency.
IAEA Basis: GS-G-2.1,
Table 15: Operational support centre:
ready access to instruments, equipment and protective clothing needed by response
teams.
GS-R-2,
5.2: For facilities in threat category I or II emergency facilities shall be designated
where the following will be performed in the different phases of the response: the
coordination of on-site response actions; the co-ordination of local off-site response
actions (radiological and conventional); the co-ordination of national response
actions; co-ordination of public information; and co-ordination of off-site monitoring
and assessment. Several of these activities may be performed at a single centre and the
location may change in the different phases of the response. These emergency
facilities shall be suitably located and/or protected so as to enable the exposure of
emergency workers to be managed in accordance with international standards.
4.61: For facilities in threat category I, II or III the anticipated hazardous conditions in
which emergency workers may be required to perform response functions on or off
the site shall be identified.
65
EMERGENCY PLANNING AND PREPAREDNESS

4.62: Arrangements shall be made for taking all practicable measures to provide
protection for emergency workers for the range of anticipated hazardous conditions
(see para. 4.61) in which they may have to perform response functions on or off the
site56, 57. This shall include: arrangements to assess continually and to record the
doses received by emergency workers; procedures to ensure that doses received and
contamination are controlled in accordance with established guidance and
international standards; and arrangements for the provision of appropriate specialized
protective equipment, procedures and training for emergency response in the
anticipated hazardous conditions.
66
EMERGENCY PLANNING AND PREPAREDNESS

DEFINITIONS
DEFINITIONS – OSART MISSION
Recommendation
A recommendation is advice on what improvements in operational safety should be made in
that activity or programme that has been evaluated. It is based on IAEA Safety Standards or
proven, good international practices and addresses the root causes rather than the symptoms
of the identified concern. It very often illustrates a proven method of striving for excellence,
which reaches beyond minimum requirements. Recommendations are specific, realistic and
designed to result in tangible improvements. Absence of recommendations can be interpreted
as performance corresponding with proven international practices.
Suggestion
A suggestion is either an additional proposal in conjunction with a recommendation or may
stand on its own following a discussion of the pertinent background. It may indirectly
contribute to improvements in operational safety but is primarily intended to make a good
performance more effective, to indicate useful expansions to existing programmes and to
point out possible superior alternatives to ongoing work. In general, it is designed to stimulate
the plant management and supporting staff to continue to consider ways and means for
enhancing performance.
Note: if an item is not well based enough to meet the criteria of a ‘suggestion’, but the expert
or the team feels that mentioning it is still desirable, the given topic may be described in the
text of the report using the phrase ‘encouragement’ (e.g. The team encouraged the plant
to…).
Good practice
A good practice is an outstanding and proven performance, programme, activity or equipment
in use that contributes directly or indirectly to operational safety and sustained good
performance. A good practice is markedly superior to that observed elsewhere, not just the
fulfilment of current requirements or expectations. It should be superior enough and have
broad application to be brought to the attention of other nuclear power plants and be worthy
of their consideration in the general drive for excellence. A good practice has the following
characteristics:
− novel;
− has a proven benefit;
− replicable (it can be used at other plants);
− does not contradict an issue.
The attributes of a given ‘good practice’ (e.g. whether it is well implemented, or cost
effective, or creative, or it has good results) should be explicitly stated in the description of
the ‘good practice’.
67

Note: An item may not meet all the criteria of a ‘good practice’, but still be worthy to take
note of. In this case it may be referred as a ‘good performance’, and may be documented in
the text of the report. A good performance is a superior objective that has been achieved or a
good technique or programme that contributes directly or indirectly to operational safety and
sustained good performance, that works well at the plant. However, it might not be necessary
to recommend its adoption by other nuclear power plants, because of financial
considerations, differences in design or other reasons.
68

LIST OF IAEA REFERENCES (BASIS)
Safety Standards
• SF-1; Fundamental Safety Principles (Safety Fundamentals)
• Safety Series No.115; International Basic Safety Standards for Protection
Against Ionizing Radiation and for the Safety of Radiation Sources
• Safety Series No.117; Operation of Spent Fuel Storage Facilities
• NS-R-1; Safety of Nuclear Power Plants: Design Requirements
• NS-R-2; Safety of Nuclear Power Plants: Operation (Safety Requirements)
• NS-G-1.1; Software for Computer Based Systems Important to Safety in
Nuclear Power Plants (Safety Guide)
• NS-G-2.1; Fire Safety in the Operation of Nuclear Power Plans (Safety Guide)
• NS-G-2.2; Operational Limits and Conditions and Operating Procedures for
Nuclear Power Plants (Safety Guide)
• NS-G-2.3; Modifications to Nuclear Power Plants (Safety Guide)
• NS-G-2.4; The Operating Organization for Nuclear Power Plants (Safety
Guide)
• NS-G-2.5; Core Management and Fuel Handling for Nuclear Power Plants
(Safety Guide)
• NS-G-2.6; Maintenance, Surveillance and In-service Inspection in Nuclear
Power Plants (Safety Guide)
• NS-G-2.7; Radiation Protection and Radioactive Waste Management in the
Operation of Nuclear Power Plants (Safety Guide)
• NS-G-2.8; Recruitment, Qualification and Training of Personnel for Nuclear
Power Plants (Safety Guide)
• NS-G-2.9; Commissioning for Nuclear Power Plants (Safety Guide)
• NS-G-2-10; Periodic Safety Review of Nuclear Power Plants (Safety Guide)
• NS-G-2.11; A System for the Feedback of Experience from Events in Nuclear
Installations (Safety Guide)
• NS-G-2.14; Conduct of Operations at Nuclear Power Plants (Safety Guide)
• GS-R-1; Legal and Governmental Infrastructure for Nuclear, Radiation,
Radioactive Waste and Transport Safety (Safety Requirements)
• GS-R-2; Preparedness and Response for a Nuclear or Radiological Emergency
(Safety Requirements)
69

• GS-R-3; The Management System for Facilities and Activities (Safety
Requirements)
• GS-G-2.1; Arrangement for Preparedness for a Nuclear or Radiological
Emergency (Safety Guide)
• GS-G-3.1; Application of the Management System for Facilities and
Activities (Safety Guide)
• 50-C/SG-Q; Quality Assurance for Safety in Nuclear Power Plants and other
Nuclear Installations (Code and Safety Guides Q8-Q14)
• RS-G-1.1; Occupational Radiation Protection (Safety Guide)
• RS-G-1.2; Assessment of Occupational Exposure Due to Intakes of
Radionuclides (Safety Guide)
• RS-G-1.3; Assessment of Occupational Exposure Due to External Sources of
Radiation (Safety Guide)
• RS-G-1.8; Environmental and Source Monitoring for Purpose of Radiation
Protection (Safety Guide)
• WS-G-6.1; Storage of Radioactive Waste (Safety Guide)
• DS388; Chemistry Programme for Water Cooled Nuclear Power Plants (Draft
Safety Guide)
INSAG, Safety Report Series
• INSAG-4; Safety Culture
• INSAG-10; Defence in Depth in Nuclear Safety
• INSAG-12; Basic Safety Principles for Nuclear Power Plants, 75-INSAG-3
Rev.1
• INSAG-13; Management of Operational Safety in Nuclear Power Plants
• INSAG-14; Safe Management of the Operating Lifetimes of Nuclear Power
Plants
• INSAG-15; Key Practical Issues In Strengthening Safety Culture
• INSAG-16; Maintaining Knowledge, Training and Infrastructure for Research
and Development in Nuclear Safety
• INSAG-17; Independence in Regulatory Decision Making
• INSAG-18; Managing Change in the Nuclear Industry: The Effects on Safety
• INSAG-19; Maintaining the Design Integrity of Nuclear Installations
Throughout Their Operating Life
70

• Safety Report Series No.11; Developing Safety Culture in Nuclear Activities
Practical Suggestions to Assist Progress
• Safety Report Series No.21; Optimization of Radiation Protection in the
Control of Occupational Exposure
• Safety Report Series No.48; Development and Review of Plant Specific
Emergency Operating Procedures
TECDOC, IAEA Services Series etc.
• IAEA Safety Glossary Terminology used in nuclear safety and radiation
protection 2007 Edition
• Services series No.12; OSART Guidelines
• TECDOC-489; Safety Aspects of Water Chemistry in Light Water Reactors
• TECDOC-744; OSART Guidelines 1994 Edition (Refer only chapter 10-15
for Pre-OSART, if applicable.)
• EPR-EXERCISE-2005; Preparation, Conduct and Evaluation of Exercises to
Test Preparedness for a Nuclear or Radiological Emergency, (Updating IAEA-
TECDOC-953)
• EPR-METHOD-2003; Method for developing arrangements for response to a
nuclear or radiological emergency, (Updating IAEA-TECDOC-953)
• EPR-ENATOM-2002; Emergency Notification and Assistance Technical
Operations Manual
71

ACKNOWLEDGEMENT
The Government of Sweden and the staff of Oskarshamn Nuclear Power Plant provided valuable
support to the OSART mission to Oskarshamn NPP. Throughout the whole OSART mission, the
team members felt welcome and enjoyed excellent cooperation and fruitful discussions with
Oskarshamn Nuclear Power Plant managers and staff, and other local and national authorities.
Information was provided openly and in the spirit of seeking improvements in operational safety.
There was a rich exchange of knowledge and experience which contributed significantly to the
success of the mission. It also established many personal contacts that will not end with the
completion of the mission and submission of this report. The efforts of the plant counterparts,
liaison officers, interpreters and the secretaries were outstanding. This was of significant support
to the OSART team in order to complete its mission in a fruitful manner.
The IAEA, the Division of Nuclear Installation Safety and its Operational Safety Section wish to
thank all those involved for the excellent working conditions during the Oskarshamn Nuclear
Power Plant review.
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TEAM COMPOSITION OF THE OSART MISSION
EXPERTS
BROM, Jaroslav –Czech Republic
Temelin NPP
Years of nuclear experience: 20
Review area: Maintenance
GALLÉS, Quim – Spain
Asco-Vandellos Nuclear Association (ANAV)
Years of nuclear experience: 9
Review area: Operating experience
GROSSKOPF, Hartmut – Germany
Kernkraftwerk Philippsburg
Years of nuclear experience: 8
Review area: Operations II
HENDERSON Neil – IAEA
Division of Nuclear Installation
Years of nuclear experience: 32
Team Leader
HODUL, Roman – Slovak Republic
Slovenské elektrárne, a.s.-Enel
Years of nuclear experience: 19
Review area: Operations I
KIM, Jeong Keun - South Korea
Korea Hydro & Nuclear Power Co., Ltd
Years of nuclear experience: 22
Review area: Radiation protection
MAILLART, Herve – France
Civaux NPP
Years of nuclear experience: 12
Review area: Management, organization and administration
MALKHASYAN, Hakob – Armenia
Armenian NPP
Years of nuclear experience: 20
Review area: Technical support
MORTENSEN, George Keith – USA
Institute of Nuclear Power Operations (INPO)
Years of nuclear experience: 32
Review area: Training and qualification
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MULLER, Alan Eugene - South Africa
National Nuclear Regulator, South Africa
Years of nuclear experience: 17
Review area: Emergency planning and preparedness
SUKSI, Seija – Finland
Radiation and Nuclear Safety Authority, STUK
Years of Nuclear Experience: 30
Review area: Chemistry
VAMOS, Gabor – IAEA
Division of Nuclear Installation Safety
Years of nuclear experience: 31
Deputy Team Leader
OBSERVERS
KARLSSON, Carina - Sweden
Ringhals AB
Years of nuclear experience: 22
Observer
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