Good is not good enough1 September 2004
WANO’s BGM in Berlin, Germany on 12-14 October 2003 brought together nearly 400 nuclear utility CEOs and other top brass. The basic message they went away with was that in the demanding business of nuclear power being good is not good enough. But worst of all is thinking that you’re good. That’s when things really start to go bad. By James Varley
Not so long ago there were quite a few people in the nuclear power business who seemed to have trouble admitting to the existence of any problems whatsoever, let alone be willing to discuss them frankly in a public forum. But openness and transparency were among the themes of the World Association of Nuclear Operators (WANO) Biennial General Meeting (BGM) in Berlin and that was pretty much what we got.
Rolf Gullberg (chairman of the WANO Paris Centre) set the tone right from the outset: “Over the past few years, we have witnessed a high level of performance in the majority of nuclear plants around the world. But at the same time we have experienced some severe incidents. Let me remind you of them: Sizewell B – RPV head seal leakage; Philippsburg – incorrect boron concentration; Cattenom – fuel damage; Brunsbüttel – pipe break in RH spray system; Sellafield – data falsification; Davis Besse – RPV head corrosion; Tepco – data falsification; Paks – fuel damage.”
But if WANO is doing its job how can such things continue to happen and what can be done about them? These are concerns that WANO itself shares.
In his excellent closing speech to the conference Sig Berg (WANO managing director) raised some other crucial questions that WANO people need to be asking themselves: Have we prevented events? Have we identified downturns in performance? Have we helped to improve overall performance? Have we made a difference?
He also described an exercise recently undertaken by WANO to identify the common causes behind what he called “sentinel events”. These are events that “had important lessons relating to nuclear safety and had significant impact with the regulator and the public” (such as events of the kind listed above).
The following seem to have been among the common features of such incidents.
- There was an acceptance of degraded conditions – long-standing equipment problems, which individually may not have appeared burdensome, combined in such a way that significantly increased the risk to nuclear safety.
- There were perceived production pressures – producing a decision-making environment in which risks were not completely understood or considered.
- Senior management was distracted, sometimes becoming overly focused on a narrow aspect of a problem such as maintaining compliance with licence conditions – losing sight of the overall picture and circumstances.
- There was a failure to be self-critical – reinforcing the message that problems did not exist or were being adequately addressed.
- There were organisational oversight weaknesses – with lack of clarity in roles and responsibilities contributing to most events.
- And, “most deadly of all”, there was a belief that plant performance was good even when this was no longer true – with this sense of ‘goodness’ (perhaps bordering on arrogance) creating over-confidence, complacency, and in some cases a self-induced isolation from the rest of the industry.
The problems stemming from complacency – the “pit of self-satisfaction” and the “loss of motivation to learn from others” as Hajimu Maeda, WANO chairman, put it in his keynote speech – were a recurring theme of the conference. Particularly striking, in this context, were the candid presentations detailing events at Philippsburg and Davis Besse.
CONCENTRATION AT PHILIPPSBURG
Hans-Josef Zimmer of Philippsburg concluded: “Due to 17 years of successful operation, the staff had become isolated from how others in the industry operate. For example, they were unaware of the common industry practice of validating system readiness before continuing start-up activities. The staff, especially field workers and shift supervisors, failed to show an inquisitive and questioning attitude. For example asking questions such as: ‘Why is this specified valve already open or closed?’ Or: ‘Why is it still open?’ In a word, complacency.”
He also noted that there was no strong focus on possible degradation of safety margins and insufficient feedback of previous experience. In particular, “no lessons were learned from a precursor event in 2000” when “the same valve gave problems and caused an unexpected flow of demineralised water to the fuel pool.”
FENOC HEADS FOR TROUBLE
Even more alarming, but with some striking similarities, is the extraordinary saga of Davis Besse, vividly and frankly recounted by Robert Saunders of FirstEnergy Nuclear Operating Company (FENOC).
Once again we have a high performing plant (load factor of 99.7% in 2001 and regularly in the US top ten or 15 for the preceding decade). “Because Davis Besse was a strong performer, people from other plants benchmarked our performance, at least at first. Management and employees became both arrogant and complacent. And, ultimately, plant management failed to consider readily available industry data that could have resulted in earlier detection of the corrosion problem.”
It had been known for years that plants of the Davis Besse design and vintage were susceptible to the nozzle cracking that ultimately led to serious corrosion of the reactor vessel head. But lofty isolationism meant that industry experience was ignored.
Tangible hardware signs of the problem were also ignored or argued away. In the mid-90s boron was noticed around weep holes in the service structure of the head. By the end of the 90s solid rust coloured deposits were noted passing through weep holes. And by 2001-02, these boron deposits had become significant. In addition there were manifestations in the containment, going back to the mid-90s, that all was not well, including an “unidentified leak”, progressively increasing frequency of radiation monitor filter replacement (from monthly to daily) and an abnormal rise in air cooler core cleaning (from infrequent in the mid-90s to 18 times in 1999 and nine times in 2001 and 2002). But, incredibly, all this was explained away and not properly acted upon.
“Because personnel were living on the past glory of Davis Besse’s performance, management and employees became a little arrogant and defensive of their performance. They largely ignored industry information and became dismissive of criticism.”
Another telltale sign was that although the people in the control room are legally responsible for safe operation of the plant, in the Davis Besse case, the engineering department was driving activities and “engineers were running the plant.” On top of this the site watchdog – the quality assurance function – instead of being the “intrusive, in-your-face keeper of standards” – “had been marginalised,” while the strong production ethic meant that “equipment problems lingered and repairs were postponed while the plant stayed on line.”
Davis Besse might have been on the NRC’s list of trouble plants back in the mid-80s, but the intervening 15 years had seen a sustained recovery – so that just prior to the head corrosion crisis the plant was perceived as a world class performer.
FUEL FOR THOUGHT AT PAKS
Management failed to consider readily available industry data that could have resulted in earlier detection of the problem
A similar spectacular fall from grace has been experienced by Hungary’s Paks plant, following the INES Level 3 fuel damage event of 10 April 2003, which was described by Ales John (chairman of WANO Moscow Centre).
Somewhat worrying here is that Paks management seem to have been very active and conscientious members of WANO over the years, and yet, according to John, the fuel damage incident – essentially due to inadequate design and operation of fuel cleaning equipment – shows that “defence-in-depth was totally broken down.” There was an accumulation of mistakes in the “safety culture category,” with “strong over-reliance on a prominent company as a contractor” and lack of independent supervision.
The power plant had developed an environment that allowed “inadequate nuclear safety culture throughout the whole organisation” – a surprising finding in view of the plant’s good reputation prior to April 2003.
BE IN DIFFICULTY
How the mighty are fallen indeed. But none more so perhaps, particularly when you look at share prices, than British Energy (BE).
David Gilchrist, managing director, BE Generation, gave a heroically honest and enthralling account of what’s been going on at a company that meets no less than 20% of the UK’s electricity demand. One particular nuclear safety issue that BE must be getting adept at dealing with is how to maintain nuclear safety culture when you are a whisker away from insolvency.
But the particular focus of his presentation was what BE is doing to recover its performance and its experience as the first recipient of a WANO corporate review (the second being Electricité de France, EdF).
“We are a fourth quartile performer,” admitted Gilchrist, and figures he presented showed BE very much towards the bottom of the class for several key performance indicators. In the early 1990s the company managed to turn round the performance of the AGRs from the abysmal levels of the 80s, but since the late 90s there has been what Gilchrist called a “reversal of fortunes.” He observed that while colleagues were jumping on planes and rushing off to help North Americans run their nuclear plants, the performance of BE’s plants in its own backyard was sliding sharply (while the Americans, of course, have gone on to dramatically improve their average load factor, from about 60% 20 years ago to 90% now – equivalent to adding about 23,000MWe to the US grid).
BE underwent its WANO corporate review in July 2001, with a follow up in June 2003. It invited the review to get guidance from peers, to benchmark itself against world standards and to improve safety and reliability.
The 2001 review identified that the areas needing improvement were “just about everything.” For example, an unambiguous message that nuclear safety was paramount had not been spread throughout the organisation. The material condition of the stations was in significant need of improvement and was hampering reliability. The organisation was not aligned, top to bottom, to a corporate strategy with the clear lines of authority and accountability needed for nuclear excellence. The lack of a strong ‘operational focus’ from corporate down to the stations had led to insufficient attention being paid to the “problems and priorities that affect safe and reliable performance.” Last but not least there was the all too familiar failing that operating experience information, both from within BE and worldwide, was “not being used effectively by the line organisation to prevent the recurrence of operational events.”
What did the 2003 follow up show? “The good, the bad and the downright ugly,” in the words of Gilchrist. The company has identified the fundamentals (human performance, equipment reliability, work management and operational focus), it has the tools and it has the processes in place (such as work week management). But nuclear safety culture and leadership still need improvement, while there is still much to be done in the area of ‘organisational alignment’ (for example involving station directors in corporate decision making) and, overall, progress is “unacceptably slow.”
To speed things up BE has now embarked on what it calls the ‘Performance Improvement Project’ (PIP). This entails the bringing in of external resources and expertise (including WANO and a ‘consortium of partners’ led by Ove Arup), putting four new people on the board with nuclear experience (a novel idea for a nuclear operating company!), making the power stations themselves the focus of the organisation, and “focusing the whole company on improving plant performance.” Alongside this the company is also undergoing a major restructuring of its finances.
DUKE LEADS A GOOD LIFE
In marked contrast to BE’s recent fortunes, Mike Tuckman of Duke Power, was able to note that for his company at least “life is good” – a brave admission indeed in view of the conference’s heightened awareness of the problem of complacency, which was also recognised by Tuckman himself.
However Duke’s approach to the issue of stress corrosion cracking in vessel head Alloy 600 has been exemplary. In particular, as Tuckman said in his paper, it exemplifies the value of shared experience, with Duke keeping abreast of industry developments and able to benefit from EdF’s experiences with vessel head cracking in the early 90s.
Tuckman was also very ready to acknowledge the debt to WANO in helping his company achieve transparency and openness, which have in turn contributed to improved performance.
REAL PRACTICAL BENEFIT
Indeed, another recurrent theme of the event was the way speaker after speaker was able to point to cases where WANO programmes have been of real practical benefit. Although WANO is relatively young it is far from being just another nuclear organisation.
Bruno Lescoeur, director of generation and trading at EdF, for example, said: “No operator is above having problems” and thinks “WANO is a necessity,” while Graham Brown, COO of Ontario Power Generation, described the role of WANO as ‘pivotal’ in efforts to improve performance at Pickering for example. “If you only play football locally,” he said, “you don’t realise how different the higher levels are. This is where WANO is invaluable.”
But as Walter Hohlefelder, chairman of E.ON Energie observed: “WANO cannot afford to sit back on its laurels.” Above all it “cannot afford to become a self-obsessed bureaucratic organisation with functionaries travelling around the world.”
So far, and unlike some other organisations one could think of, WANO is very successfully avoiding this pitfall. However, the very fact that serious incidents continue to occur means that there is always scope for improvement.
Oleg Saraev, general director of Rosenergoatom, and the newly elected president of WANO, commented that a “more powerful magnifying glass was needed” to pick up precursors earlier from the mass of operating plant data.
Looking to the future, Sig Berg also emphasised the need to identify and act on deteriorating performance. He effectively summed up the thrust of the meeting as follows: “We are an interconnected international community that depends on each other. We cannot and we must not tolerate complacency, arrogance or isolationism – anywhere in this industry. If we are not actively learning from each other we should be concerned. If a member is not participating in WANO, we should be concerned. If we see a downturn in a member’s performance, we should be concerned.”
This essentially sets the agenda for the next phase in WANO’s evolution.
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