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RIC 2009
Reactor Oversight Process Initiatives
Michael CheokSession Chair
Deputy Director
Division of Inspection & Regional Support
Office of Nuclear Reactor Regulation
March 10, 2009
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General Session Information• Badges and Identification – Please remember to visibly
display name badges throughout the duration of the RIC.
• Cell Phones and Pagers – At this time, please turn off or silence cell phones and pagers.
• Presentation Materials – All provided electronic presentation materials will be posted on the U.S. NRC RIC website at www.nrc.gov, keyword: RIC.
• Evaluations – Please provide us with your valuable input via the Session Evaluation Form or e-mail comments directly to [email protected].
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Presenters
• Doug Dalbey– Deputy Director, Flight Standards Service,
Federal Aviation Administration• Mont Smith
– Director of Safety, Air Transport Association of America
• William Noll– Site Vice President, Three Mile Island Unit 1
• Frederick Brown– Director, Division of Inspection & Regional
Support, NRR
By: Mr. Doug Dalbey By: Mr. Doug Dalbey
Deputy Director, Flight Standards ServiceDeputy Director, Flight Standards Service
Date: March 10, 2009Date: March 10, 2009
Federal AviationAdministration
Beyond the Regulations:
A look inside the safety culture of
the FAA and those we regulate
5 5Federal AviationAdministration
Nuclear Regulatory Commission Briefing
March 10, 2009
AGENDAAGENDA
• The Perfect StormThe Perfect Storm
• Mixed SignalsMixed Signals
• Beyond The RegulationsBeyond The Regulations
• IRT RecommendationsIRT Recommendations
• Risk Groups & IndicatorsRisk Groups & Indicators
• Continuous ImprovementContinuous Improvement
• Conclusion- Conclusion- “
The FAA’s Voluntary Disclosure Programs are vitally important to the fut
ure of aviation safety, and should be retained.”
6 6Federal AviationAdministration
Nuclear Regulatory Commission Briefing
March 10, 2009
The Perfect Storm – April 2008The Perfect Storm – April 2008
• FAA’s Reality TV Show
• A Tale Of Two Airlines & Two Airworthiness Directives
7 7Federal AviationAdministration
Nuclear Regulatory Commission Briefing
March 10, 2009
Mixed Signals
• Media• Public• FAA• Congress
– Too cozy– Too nitpicking
• Dept. of Transportation• White House
8 8Federal AviationAdministration
Nuclear Regulatory Commission Briefing
March 10, 2009
Area 4
Incorrect – No wrap on Back shell of connector and no tie tape
Correct – Wrap on connector and tie tape
9 9Federal AviationAdministration
Nuclear Regulatory Commission Briefing
March 10, 2009
Miscellaneous Pictures Taken Miscellaneous Pictures Taken During FAA Follow-up AuditDuring FAA Follow-up Audit
Chaffing
10 10Federal AviationAdministration
Nuclear Regulatory Commission Briefing
March 10, 2009
Beyond The Regulations“Voluntary Programs Under Fire”
• Voluntary Disclosure Reporting Program (VDRP)
• Flight Operational Quality Assurance Program (FOQA)
• Aviation Safety Action Program (ASAP)
11 11Federal AviationAdministration
Nuclear Regulatory Commission Briefing
March 10, 2009
Independent Review Team Recommendations• The FAA should retain the right to ground any plane
not in compliance with an applicable AD.
• The FAA should provide timely information about new AD requirements, in advance of compliance dates, to all relevant FAA field offices.
• The FAA’s Voluntary Disclosure Programs are vitally important to the future of aviation safety, and should be retained.
12 12Federal AviationAdministration
Nuclear Regulatory Commission Briefing
March 10, 2009
Risk Groups and Indicators
13 13Federal AviationAdministration
Nuclear Regulatory Commission Briefing
March 10, 2009
Continuous ImprovementContinuous Improvement
•Air Transportation Oversight System•ISO Registration•AVS Overview Course•Safety Issues Reporting System•Partnership with Industry•Lessons Learned Web Site•Flight Standards Information Management System•Internal Assistance Capability•Aviation Safety Information Analysis and Sharing (ASIAS)
14 14Federal AviationAdministration
Nuclear Regulatory Commission Briefing
March 10, 2009
15 15Federal AviationAdministration
Nuclear Regulatory Commission Briefing
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ConclusionConclusion
• Strike A Balance• Continually Analyze Risk• Trust But Verify• Listen To Your Workforce• Take Swift Action When Necessary
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SMS and Aviation Safety OversightReactor Oversight Process Initiatives
Mont J. Smith
Director, Safety – Air Transport Association of America, Inc.
March 10th, 2009
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How are Unsafe Conditions Addressed?
Air Carrier discovers problem not anticipated
by manufacturer
Air CarrierEngineering Order (EO)
Air Carrier reports to FAA via SDR – Service
Difficulty Report
FAA Certification Offices– e.g., Seattle ACO, Engine ECOs
OEM reports to ACO & develop Service
Bulletin if Airworthiness issue (optional if safety
“enhancement”)
If unsafe condition exists, under 14 USC39 ACO initiates an
Airworthiness Directive (AD)
“Lead Airline Coordination Process” - ATA Spec 111
ACO issues Notice of Proposed Rulemaking
Air Carrier reports to Original Equipment
Manufacturer
AD
or, Immediate Adopted Rule
Public comments
to NPRM
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Why Did the April 2008 Process Go Wrong?
• Air Carrier and FAA Certificate Management Office did not follow AD process to the letter
• Non-compliance was assessed based on failure to strictly adhere to Service Bulletin instructions beyond achievement of the safety objective – “prevent wiring bundle chafing”
• Service Bulletins and some EOs did not depict variations in as-delivered wiring bundle configurations
• Licensed mechanics made “on the spot” judgments to prevent chafing
• FAA Inspector guidance allows determination of “non-compliance” in the strictest sense without judgment of safety assurance
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Compliance vs. Safety
• Is there a difference?
• Should regulatory compliance be based on explicit instructions to the lowest level of detail or should standard practices and judgment be assumed at certain levels?
• Can you be “in compliance” but still “unsafe?”
• Is it possible to assess risk (probability of occurrence vs. severity) and manage expectations accordingly?
• Task for operators – adopt SMS
• Task for regulator – ensure SMS is working!
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What are Emerging Airline Safety Initiatives?
• Air Carrier - Voluntary Safety Reporting Systems
– Aviation Safety Action Program (ASAP)– Flight Operations Quality Assurance (FOQA)– Internal Evaluation Program– Maintenance Reliability Review Board (MRB)– Continuing Airworthiness Surveillance (CAS)– Voluntary Disclosure Reporting Program (VDRP) – Safety Management System (SMS)
• Regulator – Air Transportation Oversight Program (ATOS)– Safety Management System (SMS)
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Aviation Safety Information & Analysis System
A collaborative Government-Industry initiative on data sharing & analysis to proactively discover safety concerns before accidents or incidents occur, leading to timely mitigation and prevention
What is ASIAS…?
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Aviation Safety Information & Analysis System
Safety Reports
• Runway Incursion• Surface Incident• Operational Error / Operational
Deviation• Pilot Deviation• Vehicle or Pedestrian Deviation• National Transportation Safety
Board • Accident/Incident Data System• Service Difficulty Reports
De-Identified FOQA Data
De-Identified ASAP Data
Aviation Safety
Reporting System
• En route• Terminal• Airport
Surveillance Data
• Traffic Management Reroutes and Delays
• Airport Configuration and Operations
• Sector and Route Structure
• Procedures
ATC Information
• Bureau of Transportation Statistics
• Weather / Winds• Manufacturer Data• Avionics Data• Worldwide Accident Data
Other Information
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Aviation Safety Information & Analysis System
ASIAS Participants at Major US Airports
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Aviation Safety Information & Analysis System
Protective Airspace
Ground Proximity Warnings
Oakland Airport
Arrival Flight Tracks
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Aviation Safety Information & Analysis SystemTypical ASAP NarrativeDuring a right base leg for a visual approach, Air Traffic Control switched us to a new runway with our concurrence. Both pilots switched to the appropriate Instrument Landing System frequency as a backup for the visual approach. The localizer signal was confirmed, but no glide slope signal was obtained. We had already started the landing configuration sequence and were configured with flaps 15 degrees and landing gear down on a normal descent path. As pilot monitoring, I was attempting to discern why the glide slope was unavailable for the pilot flying. The 1000 foot call was made with an airspeed of 150 knots. V-target was 141 knots. Shortly thereafter, at 500 feet above ground level, we received the warning “too low, flaps.” The pilot flying called for flaps 30 degrees and the Before Landing Checklist. I complied but I should have directed a go around. The landing was completed without incident, and the taxi to the gate was uneventful. In an attempt to offer support to the pilot flying, I had allowed myself to become distracted during a critical phase of flight with an unnecessary piece of approach guidance for the type of approach being flown. Proper prioritization and application of pilot monitoring duties would certainly have prevented this. Pilot monitoring is also flying, just not necessarily “hands on.” Whether pilot flying or pilot monitoring, one should aviate first and avoid/contain unnecessary distractions through correct identification and prioritization of perceived problems.
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Aviation Safety Information & Analysis System
Digital Data Provides Insight about Flights: e.g., Unstable Approaches
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Safety Management Systems
Operational performance
Baseline performance
Organization
Predictive
Highly efficient
SystemAnalysisDesign
Assessment
Very efficient
Proactive
SurveysAuditsPerformanceAssessment
Efficient
Reactive
ASRSSDR
Insufficient
Accidentand incident
reports
Desirable management levels
HighMiddle
Low
Safety management levels
“Practical drift”
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Safety Management Systems
““Carelessness and overconfidence are more dangerous than deliberately Carelessness and overconfidence are more dangerous than deliberately accepted risk”…accepted risk”…Wilbur Wright, 1901Wilbur Wright, 1901
Wilbur Wright gliding, 1901Photographs: Library of Congress
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The Safety Continuum
William G. NollSite Vice PresidentThree Mile Island
And the Role of Oversight
30Three Mile IslandJanuary 15, 1979
31“The Front Fell Off”
32“The Front Fell Off”
1. Design2. Construction Material3. Staffing4. Risk Assessment5. The Environment
“Tanker Safety”
33“The Front Fell Off”
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The Auto Industry
In the 1970’s it was all mpg
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The Auto Industry
In the 1990’s it was all about
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The Auto Industry
Now it is all about being
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Our children will enjoy in their homes electrical energy too cheap to meter ... Lewis L. Strauss Chairman of the U.S. Atomic Energy Commission
Speech to the National Association of Science WritersSeptember 16th, 1954
Too Cheap to Meter ?
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TMITMINovemberNovember
19681968
TMITMINovemberNovember
19681968
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Adhering to the Nuclear Safety
Principles in goal setting, work
execution, business decisions and day-
to-day activities ensures the proper focus and balance
in operational execution
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Nuclear Energy
Is Green
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Why Regulatethe Nuclear Industry
orAny Industry
• Public Trust and Confidence
• Complex Technology and Design
• Potential to Impact the Environment
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Public Trust and Confidence
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Why Regulatethe Nuclear Industry
orAny Industry
• Public Trust and Confidence
• Complex Technology and Design
• Potential to Impact the Environment
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Complex Technology and Design
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Why Regulatethe Nuclear Industry
orAny Industry
• Public Trust and Confidence
• Complex Technology and Design
• Potential to Impact the Environment
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Environmental StewardshipA requirement for Nuclear Operations
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Safety Culture Principle # 5
Nuclear technology is recognized as special and unique.
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Safety Culture Principle # 8
Nuclear Safety Undergoes Constant Examination
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CORNERSTONE CHART
PUBLIC HEALTH & SAFETY AS A RESULT OF CIVILIAN NUCLEAR
REACTOR OPERATION
NRC’s Overall Safety Mission
Strategic Performance Areas
Reactor Safety
Radiation Safety
Safeguards
INITIATING EVENTS
MITIGATION SYSTEMS
BARRIER INTEGRIT
Y
EMERGENCY PREPAREDNES
S
Crosscutting AreasHUMAN
PERFORMANCE
SAFETY CONSCIOUS WORK ENVIRONMENT
PROBLEM IDENTIFICATION AND
RESOLUTION
PHYSICAL PROTECTIO
N
OCCUPATIONAL
PUBLIC
Self PolicingIdentifying Problems
Behaviors
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The Applicability of Air Safety Lessons-Learned to NRC Programs
March 10, 2009
Fred Brown, DirectorDivision of Inspection & Regional Support
Office of Nuclear Reactor Regulation (NRR)
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Regulatory Environment
• Relative Risk Perceptions
• Performance Feedback Loop
• Effect of Public Opinion
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Licensee’s Programs vs Independent Verification
• Baseline and Appendix C Inspections
• Temporary Instructions
• Role and Influence of the Residents
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Minimum Standards and Beyond
• Design Approval and Maintenance
• ROP – Inspection Findings vs Performance Indicators
• INPO’s Excellence Standards
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Safety Management Systems
Operational performance
Baseline performance
Organization
Predictive
Highly efficient
SystemAnalysisDesign
Assessment
Very efficient
Proactive
SurveysAuditsPerformanceAssessment
Efficient
Reactive
ASRSSDR
Insufficient
Accidentand incident
reports
Desirable management levels
HighMiddle
Low
Safety management levels
“Practical drift”
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Applied Insights
• Clear Standards, Rigorously Enforced
• Lowest Common Denominator
• The “Garrison Keillor” Conundrum
57 57Federal AviationAdministration
Nuclear Regulatory Commission Briefing
March 10, 2009
Risk Groups and Indicators
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Applied Insights
• Clear Standards, Rigorously Enforced
• Lowest Common Denominator
• The “Garrison Keillor” Conundrum
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Question & AnswerPeriod
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