1 RIC 2009 Reactor Oversight Process Initiatives Michael Cheok Session Chair Deputy Director...

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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.”

http://www.dot.gov/affairs/IRT_Report.pdf





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



March 10, 2009

Mixed Signals

• Media• Public• FAA• Congress

– Too cozy– Too nitpicking

• Dept. of Transportation• White House



March 10, 2009

Area 4

Incorrect – No wrap on Back shell of connector and no tie tape

Correct – Wrap on connector and tie tape



March 10, 2009

Miscellaneous Pictures Taken Miscellaneous Pictures Taken During FAA Follow-up AuditDuring FAA Follow-up Audit

Chaffing



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)



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.





March 10, 2009

Risk Groups and Indicators



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)

http://www.faa.gov/safety/programs_initiatives/oversight/atos/

http://www.faa.gov/news/fact_sheets/news_story.cfm?newsId=10198

http://accidents-ll.faa.gov/

http://fsims.faa.gov/

http://www.asias.faa.gov/portal/page?_pageid=56,398034,56_398041&_dad=portal&_schema=PORTAL

http://www.asias.faa.gov/portal/page?_pageid=56,398034,56_398041&_dad=portal&_schema=PORTAL



March 10, 2009



March 10, 2009

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

http://ktransit.com/airliners/USA/Northwest/Photos/northwest-A320-msp-050105-02.jpg

http://ktransit.com/airliners/USA/Jetblue/jetblue-A320-jfk-102106-02.jpg

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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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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

http://en.wikipedia.org/wiki/Image:ExpressJetLogo.png

http://www.frontierairlines.com/frontier/home.do;jsessionid=c22ca62b821802bf8b1f0f596044

http://www.jetblue.com/

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ASIAS Participants at Major US Airports

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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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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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““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”


1. Design2. Construction Material3. Staffing4. Risk Assessment5. The Environment

“Tanker Safety”

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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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orAny Industry




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Complex Technology and Design

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orAny Industry




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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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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



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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