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Re: [Root_Cause_State_of_the_Practice] Extent

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  • bruce.hart@srs.gov
    Just a couple of thoughts: If you continue operating your business with status quo, you have to recognize that you have accepted the risk of liability which
    Message 1 of 27 , Oct 1, 2008
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      Just a couple of thoughts:
      If you continue operating your business with status quo, you have to recognize that you have accepted the risk of liability which could ultimately result in you being put out of business by fines, lawsuits, criminal charges, etc.  

      Then, too, you might luck out and not ever have a bad day.

      B.



      Oldnuke640@...
      Sent by: Root_Cause_State_of_the_Practice@yahoogroups.com

      09/30/2008 08:59 PM

      Please respond to
      Root_Cause_State_of_the_Practice@yahoogroups.com

      To
      Root_Cause_State_of_the_Practice@yahoogroups.com
      cc
      Subject
      Re: [Root_Cause_State_of_the_Practice] Extent






      If one is unable to generate the money to fund the safety requirements/enhancements/corrective actions etc., then how does one cause/pay for these actions to be completed?  They do not come out of the air, unless you are the printer of the money....

       
      Every organization has to live within their means.  Even the Federal Government cannot print an unlimited amount of money with out eventually paying the consequences.  




      Looking for simple solutions to your real-life financial challenges? Check out WalletPop for the latest news and information, tips and calculators.


    • DR WILLIAM CORCORAN
      Tedd and Bruce,   The heart of safety is to be able to notice an anomaly and to envision the disaster of which it is a harbinger.   It is the failure to
      Message 2 of 27 , Oct 1, 2008
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        Tedd and Bruce,
         
        The heart of safety is to be able to notice an anomaly and to envision the disaster of which it is a harbinger.
         
        It is the failure to envision the disaster that keeps management from taking action. Davis-Besse management would, in my opinion, have shutdown the plant had they been able to envision the disaster that the clogged radiation monitor filters were a harbinger of.
         
        Do you have some less inflammatory examples.


        Take care,
         
        Bill Corcoran
        Mission: Saving lives, pain, assets, and careers through thoughtful inquiry.
        Motto: If you want safety, peace, or justice, then work for competency, integrity, and transparency.
         
        W. R. Corcoran, Ph.D., P.E.
        NSRC Corporation
        21 Broadleaf Circle
        Windsor, CT 06095-1634
        Voice and voice mail: 860-285-8779
         
        Subscribe to "The Firebird Forum" by sending an e-mail to TheFirebirdForum-subscribe@yahoogroups.com
         


        --- On Wed, 10/1/08, bruce.hart@... <bruce.hart@...> wrote:
        From: bruce.hart@... <bruce.hart@...>
        Subject: Re: [Root_Cause_State_of_the_Practice] Extent
        To: Root_Cause_State_of_the_Practice@yahoogroups.com
        Date: Wednesday, October 1, 2008, 5:22 AM


        Just a couple of thoughts:
        If you continue operating your business with status quo, you have to recognize that you have accepted the risk of liability which could ultimately result in you being put out of business by fines, lawsuits, criminal charges, etc.  

        Then, too, you might luck out and not ever have a bad day.

        B.



        Oldnuke640@aol. com
        Sent by: Root_Cause_State_ of_the_Practice@ yahoogroups. com
        09/30/2008 08:59 PM
        Please respond to
        Root_Cause_State_ of_the_Practice@ yahoogroups. com

        To
        Root_Cause_State_ of_the_Practice@ yahoogroups. com
        cc
        Subject
        Re: [Root_Cause_ State_of_ the_Practice] Extent






        If one is unable to generate the money to fund the safety requirements/ enhancements/ corrective actions etc., then how does one cause/pay for these actions to be completed?  They do not come out of the air, unless you are the printer of the money....
         
        Every organization has to live within their means.  Even the Federal Government cannot print an unlimited amount of money with out eventually paying the consequences.  




        Looking for simple solutions to your real-life financial challenges? Check out WalletPop for the latest news and information, tips and calculators.

      • Mike
        Jack There are many times when cost is a legitimate factor. The recent radioisotopes plant (NRU) shutdown in Canada is a case in point. The Canadian regulator
        Message 3 of 27 , Oct 1, 2008
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          Jack
           
          There are many times when cost is a legitimate factor. The recent radioisotopes plant (NRU) shutdown in Canada is a case in point. The Canadian regulator shutdown the plant on a safety issue involving a back up safety system. While the licensee was remiss in installing this back up in a timely manner, the action of the regulator removed a major source of medical isotopes putting peoples lives at risk. The regulator did not back down citing safety at all costs.
           
          The Parliament stepped in and reversed the decision on the basis that the probability of the event driving the safety back system up was extremely remote while the possibility of hurting people was extremely high (because of the missing isotopes).
           
          In many scenarios risk and consequence are important factors that should drive different outcomes.
           
          Mike
           
          Hi,
           
          The one thing that I found offensive about this writeup was the combination of nuclear anything and cost.  They just do not fit together.  Safety must come first, and cost will land where it will, period.  I just do not understand the concept of cutting back in nuclear to save money.
           
          Jack Stanford
          ----- Original Message -----
          Sent: Tuesday, September 30, 2008 8:28 PM
          Subject: RE: [Root_Cause_State_of_the_Practice] Extent

          Jack,
           
          Of course cost is a factor.  To deny it is to close one's eyes to reality.
           
          The key is to keep the relative priorities straight.
          1) Safety
          2) Quality
          3) Performance
          4) Cost
           
          Then again, these are not mutually exclusive from one another and there are synergies between them.  Organizations that understand the relationship between quality and performance often have the best safety performance and lowest cost.
           
          Terry Herrmann

          --- On Tue, 9/30/08, jack.stanford@ att.net <jack.stanford@ att.net> wrote:
          From: jack.stanford@ att.net <jack.stanford@ att.net>
          Subject: RE: [Root_Cause_ State_of_ the_Practice] Extent
          To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
          Date: Tuesday, September 30, 2008, 3:14 PM

          Hi,
           
          The one thing that I found offensive about this writeup was the combination of nuclear anything and cost.  They just do not fit together.  Safety must come first, and cost will land where it will, period.  I just do not understand the concept of cutting back in nuclear to save money.
           
          Jack Stanford
           
           
          ------------ -- Original message from DR WILLIAM CORCORAN <williamcorcoran@ sbcglobal. net>: ------------ --

          Mike,
           
          Thanks.
           
          The article is typical in that it doesn't even mention any of the causes of the extent.
           
          What are the factors that resulted in the problem getting to be as widespread as it was?

          Take care,
           
          Bill Corcoran
          Mission: Saving lives, pain, assets, and careers through thoughtful inquiry.
          Motto: If you want safety, peace, or justice, then work for competency, integrity, and transparency.
           
          W. R. Corcoran, Ph.D., P.E.
          NSRC Corporation
          21 Broadleaf Circle
          Windsor, CT 06095-1634
          Voice and voice mail: 860-285-8779
           
          Subscribe to "The Firebird Forum" by sending an e-mail to TheFirebirdForum- subscribe@ yahoogroups. com
           


          --- On Tue, 9/30/08, Van Leuken, Mike <mike.van.leuken@ calgary.ca> wrote:
          From: Van Leuken, Mike <mike.van.leuken@ calgary.ca>
          Subject: RE: [Root_Cause_ State_of_ the_Practice] Extent
          To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
          Date: Tuesday, September 30, 2008, 2:03 PM

          Or the tampered with Tylenol how many years back. Or, in Canada, Maple Leaf Foods and the listeriosis thing, link below  http://www.ctv. ca/servlet/ ArticleNews/ story/CTVNews/ 20080823/ recall_listeria_ 080823
          Mike van Leuken.
          NOTICE -
          This communication is intended ONLY for the use of the person or entity named above and may contain information that is confidential or legally privileged. If you are not the intended recipient named above or a person responsible for delivering messages or communications to the intended recipient, YOU ARE HEREBY NOTIFIED that any use, distribution, or copying of this communication or any of the information contained in it is strictly prohibited. If you have received this communication in error, please notify us immediately by telephone and then destroy or delete this communication, or return it to us by mail if requested by us. The City of Calgary thanks you for your attention and co-operation.

          From: Root_Cause_State_ of_the_Practice@ yahoogroups. com [mailto:Root_ Cause_State_ of_the_Practice@ yahoogroups. com] On Behalf Of DR WILLIAM CORCORAN
          Sent: 2008 September 30 9:04 AM
          To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
          Subject: RE: [Root_Cause_ State_of_ the_Practice] Extent

          Bill Salot and all,
           
          Extent is in the news every day. There is little evidence that there is much grasp of it.
           
          What is the extent of cause and the cause of extent of the current melamine scandal:
           
          How can the rootician community continue to be part of turning a blind eye to extent of cause and cause of extent?

          Take care,
           
          Bill Corcoran
          Mission: Saving lives, pain, assets, and careers through thoughtful inquiry.
          Motto: If you want safety, peace, or justice, then work for competency, integrity, and transparency.
           
          W. R. Corcoran, Ph.D., P.E.
          NSRC Corporation
          21 Broadleaf Circle
          Windsor, CT 06095-1634
          Voice and voice mail: 860-285-8779
           
          Subscribe to "The Firebird Forum" by sending an e-mail to TheFirebirdForum- subscribe@ yahoogroups. com
           


          --- On Tue, 9/30/08, Salot, William <william.salot@ honeywell. com> wrote:
          From: Salot, William <william.salot@ honeywell. com>
          Subject: RE: [Root_Cause_ State_of_ the_Practice] Extent
          To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
          Date: Tuesday, September 30, 2008, 9:33 AM

          Bill C,

           

          I learned a lot from the DOE paper below.  Thanks for sending it.

          For me, three issues jump out.

          1. Does DOE have a similar paper on “extent of cause”?  Their “extent of condition” philosophy in 2006 seems broad enough to cover both.   Note this excerpt which apparently addresses both:  “If, however, the source of the failure to use the respirator properly is inadequate training and such equipment is used in many places around the site, it would be appropriate to conduct an Extent of Condition evaluation.”  The “training” is a “cause” of the “failure to use the respirator properly”.

          1. Is this forum about RCA or about management systems?  In other words, are “causal analysis” (RCA) and “extent of condition evaluation” just two of many different “management indicators” in a “management system”?  Based on the following excerpt, DOE seems to think so: “A robust and active management system will use assessment, issues management, causal analysis, Extent of Condition evaluation, trending and other management indicators to understand what is happening at a facility, activity or site.”

          1. Who provides training on “extent of condition evaluation”?  I don’t hear RCA consultants offering to help us satisfy the following DOE guideline:  “All individuals charged with Extent of Condition responsibility should be trained on how to perform an Extent of Condition evaluation so there is a uniform approach to Extent of Condition evaluations at a site. ”

          If you keep answering my questions, I’ll soon become wise beyond my years (now 79).

          Bill Salot

           

          From: Root_Cause_State_ of_the_Practice@ yahoogroups. com [mailto:Root_ Cause_State_ of_the_Practice@ yahoogroups. com] On Behalf Of DR WILLIAM CORCORAN
          Sent: Tuesday, September 30, 2008 8:03 AM
          To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
          Subject: [Root_Cause_ State_of_ the_Practice] Extent

          Bill Salot,

           

          Please scroll down for some DOE contractor philosophy on "extent."

          Take care,
           
          Bill Corcoran
          Mission : Saving lives, pain, assets, and careers through thoughtful inquiry.
          Motto: If you want safety, peace, or justice, then work for competency, integrity, and transparency.
           
          W. R. Corcoran, Ph.D., P.E.
          NSRC Corporation
          21 Broadleaf Circle
          Windsor , CT 06095-1634
          Voice and voice mail: 860-285-8779

           

          Subscribe to "The Firebird Forum" by sending an e-mail to TheFirebirdForum- subscribe@ yahoogroups. com

           


           

          This is the html version of the file http://www.bnl. gov/qmo/linkable _files/pdf/ ISMS%20Documents /EOC%20EFCOG% 202006.pdf.
          Google automatically generates html versions of documents as we crawl the web.

          Page 1

          White Paper: Extent Of Condition

          Evaluations

          August 2006

          Prepared by the EFCOG Price-Anderson Amendments Act

          Working Group

          (Task Team led by Richard Steele, Sandia National Laboratories)

          This white paper is being issued for a 6-month period where feedback and improvement suggestions are

          being solicited from users. The document, along with feedback and improvement suggestions, will be

          reassigned to the EFCOG ISM Working Group; Feedback & Improvement Subgroup for continued

          maintenance and possible conversion into a Contractor Implementation Guide.


          Page 2

          I. Introduction

          Extent of Condition is generally defined as a generic implication of a failure,

          malfunction, deficiency, defective item, weakness or problem; i.e., the actual or potential

          applicability for an event or condition to exist in other activities, projects, programs,

          facilities or organizations. The use of an Extent of Condition evaluation is a critical

          component in our goal to find and fix problems before they become events. Further, it is

          encouraged by the Department of Energy (DOE) Office of Enforcement. This paper has

          been developed with the cooperation of the Office of Enforcement by the Energy Facility

          Contractors Operating Group (EFCOG) Price-Anderson Amendments Act Working

          Group to provide guidance to the DOE contractor community as part of the program to

          appropriately address nuclear safety and occupational safety and health ( OSH ) concerns.

          The Nuclear Safety Management Rule, 10 CFR 830, identifies several areas, including

          training, work processes, procurement and the identification and control of items,

          services and requirements, that could benefit from appropriate use of Extent of Condition

          evaluations. An Extent of Condition evaluation contributes to feedback and improvement

          loops, which are implemented through the Integrated Safety Management System

          processes.

          There are interrelationships between and among Extent of Condition evaluation, causal

          analysis and corrective actions which suggests the reviewer should have flexibility in

          problem solving for safety problems. Some issues will be self evident candidates for an

          Extent of Condition evaluation at the inception of problem identification. Others,

          however, might not become logical candidates until a causal analysis is underway.

          Occasionally, the need for an Extent of Condition evaluation might not become clear

          until the corrective action process has begun. It is important to maintain an inquiring

          mind throughout the process and avoid a checklist mentality. This means Extent of

          Condition evaluation, root cause and corrective actions must be considered throughout

          the process. New information learned could result in reanalysis of a portion of the

          process previously reviewed. Appropriate use of Extent of Condition evaluations will

          enhance nuclear safety and be cost effective for the contractor because problems will be

          identified and addressed before they become events.

          A key element of an effective corrective evaluation process for a nuclear safety or OSH

          noncompliance is the determination of extent of condition with respect to potential

          impact on operations. A fully defined and well established Extent of Condition

          evaluation process will assist in the identification of matters transcending a particular

          event or organizational boundary. Identifying and correcting these cross-cutting issues,

          deficiencies, weaknesses, or problems will reduce risk and operating costs and result in a

          safer working environment through the detection and correction of both latent and

          obvious adverse conditions. A graded approach is encouraged, with matters of greater

          potential consequence receiving greater attention than matters of lesser consequence.

          Thus, the decision on how to conduct an Extent of Condition evaluation will be tailored

          to the facts and circumstances of the particular matter. A robust and active management


          Page 3

          system will use assessment, issues management, causal analysis, Extent of Condition

          evaluation, trending and other management indicators to understand what is happening at

          a facility, activity or site. The Extent of Condition evaluation process does not stand

          alone. It is a key element in the overall continuous improvement cycle. An Extent of

          Condition evaluation may contribute to the causal analysis by confirming an underlying

          programmatic issue.

          II. Recommendations

          Managers should consider performing an Extent of Condition evaluation every time an

          issue is identified. Key questions to consider may include:

          Have I seen this before?

          If I am seeing it again, why?

          Is the management system deficient in some way since this circumstance

          occurred? How?

          Could other activities and facilities at the site be experiencing the same problem?

          To what extent does this problem have an impact or potential impact on the

          project or activity?

          Can this matter affect the ability of my company to conduct work safely and in

          compliance with requirements at the site?

          Consideration of Extent of Condition evaluation should be captured as part of each

          corrective action management plan. Companies should formally integrate Extent of

          Condition evaluations into the graded approach used for corrective action management.

          There should be criteria for determining when a formal Extent of Condition evaluation is

          required and when an informal review may be acceptable. For example, a company may

          require a formal determination of

        • WILLIAM L. RIGOT
          Dr. Bill, I ve been working within my organization to begin a discussion of what it means to be a High Reliability Organization (HRO), and I ve been borrowing
          Message 4 of 27 , Oct 1, 2008
          • 0 Attachment

            Dr. Bill,

             

            I've been working within my organization to begin a discussion of what it means to be a High Reliability Organization (HRO), and I've been borrowing freely from Drs. Karl Weick and Kathleen Sutcliff's book Managing the Unexpected.  They have 5 principles for HRO's.   The first is a preoccupation with failure.  This gets to the heart of what you were saying earlier, that the good organizations look at an anomaly, realize that it isn't, and visualize where it could lead them.  The worst organizations on one extreme purposefully ignore anomalies.  At the other extreme, they are so focused on analyzing everything, that they never do anything, because they are frozen in fear that they'll be wrong.  The best organizations are able to make good risk based decisions that move the organization along.

             

            I heard a great presentation by Dave Czufin, the VP Engineering for Exelon this summer at the INPO Engineering Human Performance Conference (at Davis-Besse).  He talked about 10 bad things that had happened in his career that he wasn't proud of, but wanted others to learn from.  The examples led to  a couple of points that I carried away.  The first was that the nuclear power industry, and especially Engineering, is moving toward an understanding of the risk based decisions that they make every day.  Dave's point was that risk is based on consequence and frequency.  But where consequence and frequency are highly variable, managers need to put in place good mechanisms to measure the effects of their decisions to ensure that they got what they wanted.  When you think about this, it's the basic elements of a Failure Modes and Effects analysis.  The second point Dave made was the two questions he got into the habit of asking over the course of his career that led to greater success.  The first question is "What if I'm wrong?".  The second is "Where is this going?"  My guess is that if Davis-Besse managers and engineers had asked those questions, they likely would not be where they ended up (i.e. without a job, or in jail, with the utility shut down and massively fined). 

             

            Bill Rigot

            --- In Root_Cause_State_of_the_Practice@yahoogroups.com, DR WILLIAM CORCORAN <williamcorcoran@...> wrote:
            >
            > Tedd and Bruce,
            >  
            > The heart of safety is to be able to notice an anomaly and to envision the disaster of which it is a harbinger.
            >  
            > It is the failure to envision the disaster that keeps management from taking action. Davis-Besse management would, in my opinion, have shutdown the plant had they been able to envision the disaster that the clogged radiation monitor filters were a harbinger of.
            >  
            > Do you have some less inflammatory examples.
            >
            >
            >
            >
            > Take care,
            >  
            > Bill Corcoran
            > Mission: Saving lives, pain, assets, and careers through thoughtful inquiry.
            > Motto: If you want safety, peace, or justice, then work for competency, integrity, and transparency.
            >  
            > W. R. Corcoran, Ph.D., P.E.
            > NSRC Corporation
            > 21 Broadleaf Circle
            > Windsor, CT 06095-1634
            > Voice and voice mail: 860-285-8779
            >
            >  
            > Subscribe to "The Firebird Forum" by sending an e-mail to TheFirebirdForum-subscribe@yahoogroups.com
            >  
            >
            > --- On Wed, 10/1/08, bruce.hart@... bruce.hart@... wrote:
            >
            > From: bruce.hart@... bruce.hart@...
            > Subject: Re: [Root_Cause_State_of_the_Practice] Extent
            > To: Root_Cause_State_of_the_Practice@yahoogroups.com
            > Date: Wednesday, October 1, 2008, 5:22 AM
            >
            >
            >
            >
            >
            >
            >
            > Just a couple of thoughts:
            > If you continue operating your business with status quo, you have to recognize that you have accepted the risk of liability which could ultimately result in you being put out of business by fines, lawsuits, criminal charges, etc.  
            >
            > Then, too, you might luck out and not ever have a bad day.
            >
            > B.
            >
            >
            >
            >
            >
            >
            >
            > Oldnuke640@aol. com
            > Sent by: Root_Cause_State_ of_the_Practice@ yahoogroups. com
            > 09/30/2008 08:59 PM
            >
            >
            >
            >
            > Please respond to
            > Root_Cause_State_ of_the_Practice@ yahoogroups. com
            >
            >
            >
            >
            >
            >
            > To
            > Root_Cause_State_ of_the_Practice@ yahoogroups. com
            >
            >
            > cc
            >
            >
            >
            > Subject
            > Re: [Root_Cause_ State_of_ the_Practice] Extent
            >
            >
            >
            >
            >
            >
            >
            >
            >
            >
            >
            >
            >
            >
            >
            > If one is unable to generate the money to fund the safety requirements/ enhancements/ corrective actions etc., then how does one cause/pay for these actions to be completed?  They do not come out of the air, unless you are the printer of the money....
            >  
            > Every organization has to live within their means.  Even the Federal Government cannot print an unlimited amount of money with out eventually paying the consequences.  
            >
            >
            >
            >
            >
            > Looking for simple solutions to your real-life financial challenges? Check out WalletPop for the latest news and information, tips and calculators.
            >

          • Van Leuken, Mike
            Here s a first stab: For the listeriosis thing extent of condition: 20 people dead in Canada. Financial losses by Maple Leaf Foods and possibly resultant job
            Message 5 of 27 , Oct 2, 2008
            • 0 Attachment
              Here's a first stab:
               
              For the listeriosis thing extent of condition: 20 people dead in Canada. Financial losses by Maple Leaf Foods and possibly resultant job loses.
               
              Melamine in the powered milk thing: aside form the deaths which I don't know the number for there is also the huge number of products of Chinese manufacture that are being recalled. Any company that used/uses milk powder made in China is major panic mode right now, I would imagine. Pretty much every grocery store in the world is now expending time and resources checking their shelves for any product that uses the tainted milk powered.
               
              Mike van Leuken.


              From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of Salot, William
              Sent: 2008 September 30 7:33 AM
              To: Root_Cause_State_of_the_Practice@yahoogroups.com
              Subject: RE: [Root_Cause_State_of_the_Practice] Extent

              Bill C,

              I learned a lot from the DOE paper below.  Thanks for sending it.

              For me, three issues jump out.

              1. Does DOE have a similar paper on “extent of cause”?  Their “extent of condition” philosophy in 2006 seems broad enough to cover both.   Note this excerpt which apparently addresses both:  “If, however, the source of the failure to use the respirator properly is inadequate training and such equipment is used in many places around the site, it would be appropriate to conduct an Extent of Condition evaluation.”  The “training” is a “cause” of the “failure to use the respirator properly”.

              1. Is this forum about RCA or about management systems?  In other words, are “causal analysis” (RCA) and “extent of condition evaluation” just two of many different “management indicators” in a “management system”?  Based on the following excerpt, DOE seems to think so: “A robust and active management system will use assessment, issues management, causal analysis, Extent of Condition evaluation, trending and other management indicators to understand what is happening at a facility, activity or site.”

              1. Who provides training on “extent of condition evaluation”?  I don’t hear RCA consultants offering to help us satisfy the following DOE guideline:  “All individuals charged with Extent of Condition responsibility should be trained on how to perform an Extent of Condition evaluation so there is a uniform approach to Extent of Condition evaluations at a site. ”

              If you keep answering my questions, I’ll soon become wise beyond my years (now 79).

              Bill Salot

              From: Root_Cause_State_ of_the_Practice@ yahoogroups. com [mailto:Root_ Cause_State_ of_the_Practice@ yahoogroups. com] On Behalf Of DR WILLIAM CORCORAN
              Sent: Tuesday, September 30, 2008 8:03 AM
              To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
              Subject: [Root_Cause_ State_of_ the_Practice] Extent

              Bill Salot,

              Please scroll down for some DOE contractor philosophy on "extent."

              Take care,
               
              Bill Corcoran
              Mission : Saving lives, pain, assets, and careers through thoughtful inquiry.
              Motto: If you want safety, peace, or justice, then work for competency, integrity, and transparency.
               
              W. R. Corcoran, Ph.D., P.E.
              NSRC Corporation
              21 Broadleaf Circle
              Windsor , CT 06095-1634
              Voice and voice mail: 860-285-8779

              Subscribe to "The Firebird Forum" by sending an e-mail to TheFirebirdForum- subscribe@ yahoogroups. com

               


              This is the html version of the file http://www.bnl. gov/qmo/linkable _files/pdf/ ISMS%20Documents /EOC%20EFCOG% 202006.pdf.
              Google automatically generates html versions of documents as we crawl the web.

              Page 1

              White Paper: Extent Of Condition

              Evaluations

              August 2006

              Prepared by the EFCOG Price-Anderson Amendments Act

              Working Group

              (Task Team led by Richard Steele, Sandia National Laboratories)

              This white paper is being issued for a 6-month period where feedback and improvement suggestions are

              being solicited from users. The document, along with feedback and improvement suggestions, will be

              reassigned to the EFCOG ISM Working Group; Feedback & Improvement Subgroup for continued

              maintenance and possible conversion into a Contractor Implementation Guide.

              I. Introduction

              Extent of Condition is generally defined as a generic implication of a failure,

              malfunction, deficiency, defective item, weakness or problem; i.e., the actual or potential

              applicability for an event or condition to exist in other activities, projects, programs,

              facilities or organizations. The use of an Extent of Condition evaluation is a critical

              component in our goal to find and fix problems before they become events. Further, it is

              encouraged by the Department of Energy (DOE) Office of Enforcement. This paper has

              been developed with the cooperation of the Office of Enforcement by the Energy Facility

              Contractors Operating Group (EFCOG) Price-Anderson Amendments Act Working

              Group to provide guidance to the DOE contractor community as part of the program to

              appropriately address nuclear safety and occupational safety and health ( OSH ) concerns.

              The Nuclear Safety Management Rule, 10 CFR 830, identifies several areas, including

              training, work processes, procurement and the identification and control of items,

              services and requirements, that could benefit from appropriate use of Extent of Condition

              evaluations. An Extent of Condition evaluation contributes to feedback and improvement

              loops, which are implemented through the Integrated Safety Management System

              processes.

              There are interrelationships between and among Extent of Condition evaluation, causal

              analysis and corrective actions which suggests the reviewer should have flexibility in

              problem solving for safety problems. Some issues will be self evident candidates for an

              Extent of Condition evaluation at the inception of problem identification. Others,

              however, might not become logical candidates until a causal analysis is underway.

              Occasionally, the need for an Extent of Condition evaluation might not become clear

              until the corrective action process has begun. It is important to maintain an inquiring

              mind throughout the process and avoid a checklist mentality. This means Extent of

              Condition evaluation, root cause and corrective actions must be considered throughout

              the process. New information learned could result in reanalysis of a portion of the

              process previously reviewed. Appropriate use of Extent of Condition evaluations will

              enhance nuclear safety and be cost effective for the contractor because problems will be

              identified and addressed before they become events.

              A key element of an effective corrective evaluation process for a nuclear safety or OSH

              noncompliance is the determination of extent of condition with respect to potential

              impact on operations. A fully defined and well established Extent of Condition

              evaluation process will assist in the identification of matters transcending a particular

              event or organizational boundary. Identifying and correcting these cross-cutting issues,

              deficiencies, weaknesses, or problems will reduce risk and operating costs and result in a

              safer working environment through the detection and correction of both latent and

              obvious adverse conditions. A graded approach is encouraged, with matters of greater

              potential consequence receiving greater attention than matters of lesser consequence.

              Thus, the decision on how to conduct an Extent of Condition evaluation will be tailored

              to the facts and circumstances of the particular matter. A robust and active management

              system will use assessment, issues management, causal analysis, Extent of Condition

              evaluation, trending and other management indicators to understand what is happening at

              a facility, activity or site. The Extent of Condition evaluation process does not stand

              alone. It is a key element in the overall continuous improvement cycle. An Extent of

              Condition evaluation may contribute to the causal analysis by confirming an underlying

              programmatic issue.

              II. Recommendations

              Managers should consider performing an Extent of Condition evaluation every time an

              issue is identified. Key questions to consider may include:

              Have I seen this before?

              If I am seeing it again, why?

              Is the management system deficient in some way since this circumstance

              occurred? How?

              Could other activities and facilities at the site be experiencing the same problem?

              To what extent does this problem have an impact or potential impact on the

              project or activity?

              Can this matter affect the ability of my company to conduct work safely and in

              compliance with requirements at the site?

              Consideration of Extent of Condition evaluation should be captured as part of each

              corrective action management plan. Companies should formally integrate Extent of

              Condition evaluations into the graded approach used for corrective action management.

              There should be criteria for determining when a formal Extent of Condition evaluation is

              required and when an informal review may be acceptable. For example, a company may

              require a formal determination of Extent of Condition evaluation for matters that are

              reported into the noncompliance tracking system (NTS) or event reports of significance

              category 2 or above in the Occurrence Reporting and Processing System (ORPS). A

              further example of a candidate for formal Extent of Condition evaluation consideration

              would include repetitive or programmatic issues.

              The breadth of the Extent of Condition evaluation should be driven by the potential safety

              impact and probability of occurrence, as appropriate. The evaluation can be narrow or

              broad, depending in part on whether the issue is unique or potentially transcends

              organizational boundaries. (An example of the former is addressing ineffective

              procedures that are particular to a unique activity at the site. An example of the latter is a

              determination that the procedure for changing out HEPA filters is inadequate, and such

              filters are used in many facilities at the site.)

              Extent of Condition evaluations should either be performed by an appropriate subject

              matter expert (SME) or by staff personnel that have been trained and understands Extent

              of Condition evaluations and the substance of the issue. Such individuals will need a

              particular knowledge of the area under study for the entire site. When considering the

              breadth of an investigation for Extent of Condition evaluation, managers should be aware

              of the benefits of eliminating a programmatic problem and the costs of failing to address

              a problem before it becomes an event.

              III. The following criteria should be considered for an Extent of Condition evaluation:

              Causal Factors.

              A key element of the corrective action process is the

              determination of causes. Understanding an issue’s causes, including apparent,

              contributing, direct, or root, as part of the issue’s investigative phase, will have a

              definitive influence on Extent of Condition evaluations and resulting

              determinations. Similarly, an understanding of Extent of Condition issues could

              play a useful role in cause analysis. For example, in a case where an electrical

              safety noncompliance occurred because of failure to maintain equipment to

              current standards, an Extent of Condition evaluation will look at all similar pieces

              of equipment to determine if there are other examples at the site of a failure to

              upgrade standards. In fact, if such examples are numerous, it might lead to a fresh

              review of equipment maintenance requirements in general at the site. Thus, the

              Extent of Condition evaluations will contribute to more accurate identification of

              the underlying issue. Similarly, such a review could indicate that the issue is

              confined to a single piece of equipment or a single building. It is important to

              remember that in many situations it is not possible to conduct a causal analysis

              until the Extent of Condition is identified. The important thing is to have an

              inquiring mind and respond to the facts as they develop.

              Uniqueness. Uniqueness is another consideration in deciding the formality needed

              to evaluate Extent of Condition. If the issue uniquely relates to a single activity or

              process at the site, a graded approach to the formality and documentation of an

              Extent of Condition evaluation should be considered. On the other hand, if the

              issue is found to be generic or programmatic, then it is likely that an Extent of

              Condition evaluation should be performed and documented. For example, a

              failure to use a respirator properly in a particular facility may be considered

              unique if that is the only facility on site that utilized respirators. If, however, the

              source of the failure to use the respirator properly is inadequate training and such

              equipment is used in many places around the site, it would be appropriate to

              conduct an Extent of Condition evaluation. In at least some circumstances, the

              question of uniqueness may only be answerable after some preliminary Extent of

              Condition evaluation.

              Recurrence. If the issue under study is similar to other issues that have occurred at

              the site, then an Extent of Condition evaluation of the site as a whole may be

              warranted, probably in conjunction with a root cause analysis.

              Seriousness (Potential or Actual). Factors to consider with respect to the

              seriousness of the matter under consideration include the potential for physical

              harm, environmental impact, public perceptions and regulatory and contractual

              performance requirements. Issues that do not meet the criteria being adverse to

              quality may not be appropriate candidates for an extensive Extent of Condition

              evaluation. Matters involving multiple failures, on the other hand, would make

              such an evaluation more appropriate.

              Cost. It is expected that managers will make decisions regarding an Extent of

              Condition evaluation using the graded approach that takes the potential safety

              impact and cost into consideration.

              IV. EOC Evaluation Process

              As part of the corrective action planning process, the individuals assigned the task of

              reviewing, critiquing and investigating individual significant noncompliance matters or

              lower threshold issues and safety concerns, should have initial responsibility for making a

              determination on the breadth of Extent of Condition evaluation that would be appropriate.

              Other individuals responsible for occurrence reporting, Price-Anderson reporting, and

              lessons learned should have familiarity with the process as well. All individuals charged

              with Extent of Condition responsibility should be trained on how to perform an Extent of

              Condition evaluation so there is a uniform approach to Extent of Condition evaluations at

              a site.

              Individuals conducting Extent of Condition evaluations should have appropriate expertise

              in the areas being evaluated and across the site. They should also have the problem

              solving skills to understand the corrective actions needed to resolve issues on a site-wide

              basis. Subject matter experts should be utilized in appropriate circumstances. The level

              of effort required for the evaluation will depend on the significance and complexity of the

              issue. For more complex cases, formal lines of inquiry may need to be developed and

              implemented. Outside of the context of events, issues may be identified through

              management and independent assessment processes.

              This behavior should be

              encouraged. An Extent of Condition evaluation could be developed from an assessment

              finding or because in a manager’s professional judgment something needs to be reviewed

              more closely. Some Extent of Condition evaluations may only require a review of

              documents while others may require a walk-down of a facility. Efforts should be made to

              avoid a “checklist” mentality. Regardless of the level of evaluation performed, the

              results should be documented either within an existing process (e.g. corrective action

              management or assessments) or in a report format.

              In summary, the following steps should be considered and incorporated into the Extent of

              Condition evaluation as appropriate:

              Review the background and circumstances that led to identification of the issue or

              condition triggering the review. There may be multiple issues or conditions that

              should be evaluated.

              Assure the level of effort will help identify all relevant causal factors.

              Evaluate the issue or condition for uniqueness, recurrence and potential or actual

              consequences.

              Determine what issues require follow-up and whether an SME needs to be utilized <

              (Message over 64 KB, truncated)

            • DR WILLIAM CORCORAN
              The most expensive employee in your QA department is your customer. Take care,   Bill Corcoran Mission: Saving lives, pain, assets, and careers through
              Message 6 of 27 , Oct 2, 2008
              • 0 Attachment
                "The most expensive employee in your QA department is your customer."

                Take care,
                 
                Bill Corcoran
                Mission: Saving lives, pain, assets, and careers through thoughtful inquiry.
                Motto: If you want safety, peace, or justice, then work for competency, integrity, and transparency.
                 
                W. R. Corcoran, Ph.D., P.E.
                NSRC Corporation
                21 Broadleaf Circle
                Windsor, CT 06095-1634
                Voice and voice mail: 860-285-8779
                 
                Subscribe to "The Firebird Forum" by sending an e-mail to TheFirebirdForum-subscribe@yahoogroups.com
                 


                --- On Thu, 10/2/08, Van Leuken, Mike <mike.van.leuken@...> wrote:
                From: Van Leuken, Mike <mike.van.leuken@...>
                Subject: [Root_Cause_State_of_the_Practice] Extent of Condition
                To: Root_Cause_State_of_the_Practice@yahoogroups.com
                Date: Thursday, October 2, 2008, 10:13 AM

                Here's a first stab:
                 
                For the listeriosis thing extent of condition: 20 people dead in Canada. Financial losses by Maple Leaf Foods and possibly resultant job loses.
                 
                Melamine in the powered milk thing: aside form the deaths which I don't know the number for there is also the huge number of products of Chinese manufacture that are being recalled. Any company that used/uses milk powder made in China is major panic mode right now, I would imagine. Pretty much every grocery store in the world is now expending time and resources checking their shelves for any product that uses the tainted milk powered.
                 
                Mike van Leuken.


                From: Root_Cause_State_ of_the_Practice@ yahoogroups. com [mailto:Root_ Cause_State_ of_the_Practice@ yahoogroups. com] On Behalf Of Salot, William
                Sent: 2008 September 30 7:33 AM
                To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                Subject: RE: [Root_Cause_ State_of_ the_Practice] Extent

                Bill C,

                I learned a lot from the DOE paper below.  Thanks for sending it.

                For me, three issues jump out.

                1. Does DOE have a similar paper on “extent of cause”?  Their “extent of condition” philosophy in 2006 seems broad enough to cover both.   Note this excerpt which apparently addresses both:  “If, however, the source of the failure to use the respirator properly is inadequate training and such equipment is used in many places around the site, it would be appropriate to conduct an Extent of Condition evaluation.”  The “training” is a “cause” of the “failure to use the respirator properly”.

                1. Is this forum about RCA or about management systems?  In other words, are “causal analysis” (RCA) and “extent of condition evaluation” just two of many different “management indicators” in a “management system”?  Based on the following excerpt, DOE seems to think so: “A robust and active management system will use assessment, issues management, causal analysis, Extent of Condition evaluation, trending and other management indicators to understand what is happening at a facility, activity or site.”

                1. Who provides training on “extent of condition evaluation”?  I don’t hear RCA consultants offering to help us satisfy the following DOE guideline:  “All individuals charged with Extent of Condition responsibility should be trained on how to perform an Extent of Condition evaluation so there is a uniform approach to Extent of Condition evaluations at a site. ”

                If you keep answering my questions, I’ll soon become wise beyond my years (now 79).

                Bill Salot

                From: Root_Cause_State_ of_the_Practice@ yahoogroups. com [mailto:Root_ Cause_State_ of_the_Practice@ yahoogroups. com] On Behalf Of DR WILLIAM CORCORAN
                Sent: Tuesday, September 30, 2008 8:03 AM
                To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                Subject: [Root_Cause_ State_of_ the_Practice] Extent

                Please scroll down for some DOE contractor philosophy on "extent."

                Take care,
                 
                Bill Corcoran
                Mission : Saving lives, pain, assets, and careers through thoughtful inquiry.
                Motto: If you want safety, peace, or justice, then work for competency, integrity, and transparency.
                 
                W. R. Corcoran, Ph.D., P.E.
                NSRC Corporation
                21 Broadleaf Circle
                Windsor , CT 06095-1634
                Voice and voice mail: 860-285-8779

                Subscribe to "The Firebird Forum" by sending an e-mail to TheFirebirdForum- subscribe@ yahoogroups. com

                 


                This is the html version of the file http://www.bnl. gov/qmo/linkable _files/pdf/ ISMS%20Documents /EOC%20EFCOG% 202006.pdf.
                Google automatically generates html versions of documents as we crawl the web.

                Bill Salot,

                Page 1

                White Paper: Extent Of Condition

                Evaluations

                August 2006

                Prepared by the EFCOG Price-Anderson Amendments Act

                Working Group

                (Task Team led by Richard Steele, Sandia National Laboratories)

                This white paper is being issued for a 6-month period where feedback and improvement suggestions are

                being solicited from users. The document, along with feedback and improvement suggestions, will be

                reassigned to the EFCOG ISM Working Group; Feedback & Improvement Subgroup for continued

                maintenance and possible conversion into a Contractor Implementation Guide.


                I. Introduction

                Extent of Condition is generally defined as a generic implication of a failure,

                malfunction, deficiency, defective item, weakness or problem; i.e., the actual or potential

                applicability for an event or condition to exist in other activities, projects, programs,

                facilities or organizations. The use of an Extent of Condition evaluation is a critical

                component in our goal to find and fix problems before they become events. Further, it is

                encouraged by the Department of Energy (DOE) Office of Enforcement. This paper has

                been developed with the cooperation of the Office of Enforcement by the Energy Facility

                Contractors Operating Group (EFCOG) Price-Anderson Amendments Act Working

                Group to provide guidance to the DOE contractor community as part of the program to

                appropriately address nuclear safety and occupational safety and health ( OSH ) concerns.

                The Nuclear Safety Management Rule, 10 CFR 830, identifies several areas, including

                training, work processes, procurement and the identification and control of items,

                services and requirements, that could benefit from appropriate use of Extent of Condition

                evaluations. An Extent of Condition evaluation contributes to feedback and improvement

                loops, which are implemented through the Integrated Safety Management System

                processes.

                There are interrelationships between and among Extent of Condition evaluation, causal

                analysis and corrective actions which suggests the reviewer should have flexibility in

                problem solving for safety problems. Some issues will be self evident candidates for an

                Extent of Condition evaluation at the inception of problem identification. Others,

                however, might not become logical candidates until a causal analysis is underway.

                Occasionally, the need for an Extent of Condition evaluation might not become clear

                until the corrective action process has begun. It is important to maintain an inquiring

                mind throughout the process and avoid a checklist mentality. This means Extent of

                Condition evaluation, root cause and corrective actions must be considered throughout

                the process. New information learned could result in reanalysis of a portion of the

                process previously reviewed. Appropriate use of Extent of Condition evaluations will

                enhance nuclear safety and be cost effective for the contractor because problems will be

                identified and addressed before they become events.

                A key element of an effective corrective evaluation process for a nuclear safety or OSH

                noncompliance is the determination of extent of condition with respect to potential

                impact on operations. A fully defined and well established Extent of Condition

                evaluation process will assist in the identification of matters transcending a particular

                event or organizational boundary. Identifying and correcting these cross-cutting issues,

                deficiencies, weaknesses, or problems will reduce risk and operating costs and result in a

                safer working environment through the detection and correction of both latent and

                obvious adverse conditions. A graded approach is encouraged, with matters of greater

                potential consequence receiving greater attention than matters of lesser consequence.

                Thus, the decision on how to conduct an Extent of Condition evaluation will be tailored

                to the facts and circumstances of the particular matter. A robust and active management


                Page 2

                system will use assessment, issues management, causal analysis, Extent of Condition

                evaluation, trending and other management indicators to understand what is happening at

                a facility, activity or site. The Extent of Condition evaluation process does not stand

                alone. It is a key element in the overall continuous improvement cycle. An Extent of

                Condition evaluation may contribute to the causal analysis by confirming an underlying

                programmatic issue.

                II. Recommendations

                Managers should consider performing an Extent of Condition evaluation every time an

                issue is identified. Key questions to consider may include:

                Have I seen this before?

                If I am seeing it again, why?

                Is the management system deficient in some way since this circumstance

                occurred? How?

                Could other activities and facilities at the site be experiencing the same problem?

                To what extent does this problem have an impact or potential impact on the

                project or activity?

                Can this matter affect the ability of my company to conduct work safely and in

                compliance with requirements at the site?

                Consideration of Extent of Condition evaluation should be captured as part of each

                corrective action management plan. Companies should formally integrate Extent of

                Condition evaluations into the graded approach used for corrective action management.

                There should be criteria for determining when a formal Extent of Condition evaluation is

                required and when an informal review may be acceptable. For example, a company may

                require a formal determination of Extent of Condition evaluation for matters that are

                reported into the noncompliance tracking system (NTS) or event reports of significance

                category 2 or above in the Occurrence Reporting and Processing System (ORPS). A

                further example of a candidate for formal Extent of Condition evaluation consideration

                would include repetitive or programmatic issues.

                The breadth of the Extent of Condition evaluation should be driven by the potential safety

                impact and probability of occurrence, as appropriate. The evaluation can be narrow or

                broad, depending in part on whether the issue is unique or potentially transcends

                organizational boundaries. (An example of the former is addressing ineffective

                procedures that are particular to a unique activity at the site. An example of the latter is a

                determination that the procedure for changing out HEPA filters is inadequate, and such

                filters are used in many facilities at the site.)

                Extent of Condition evaluations should either be performed by an appropriate subject

                matter expert (SME) or by staff personnel that have been trained and understands Extent

                of Condition evaluations and the substance of the issue. Such individuals will need a

                particular knowledge of the area under study for the entire site. When considering the

                breadth of an investigation for Extent of Condition evaluation, managers should be aware


                Page 3

                of the benefits of eliminating a programmatic problem and the costs of failing to address

                a problem before it becomes an event.

                III. The following criteria should be considered for an Extent of Condition evaluation:

                Causal Factors.

                A key element of the corrective action process is the

                determination of causes. Understanding an issue’s causes, including apparent,

                contributing, direct, or root, as part of the issue’s investigative phase, will have a

                definitive influence on Extent of Condition evaluations and resulting

                determinations. Similarly, an understanding of Extent of Condition issues could

                play a useful role in cause analysis. For example, in a case where an electrical

                safety noncompliance occurred because of failure to maintain equipment to

                current standards, an Extent of Condition evaluation will look at all similar pieces

                of equipment to determine if there are other examples at the site of a failure to

                upgrade standards. In fact, if such examples are numerous, it might lead to a fresh

                review of equipment maintenance requirements in general at the site. Thus, the

                Extent of Condition evaluations will contribute to more accurate identification of

                the underlying issue. Similarly, such a review could indicate that the issue is

                confined to a single piece of equipment or a single building. It is important to

                remember that in many situations it is not possible to conduct a causal analysis

                until the Extent of Condition is identified. The important thing is to have an

                inquiring mind and respond to the facts as they develop.

                Uniqueness. Uniqueness is another consideration in deciding the formality needed

                to evaluate Extent of Condition. If the issue uniquely relates to a single activity or

                process at the site, a graded approach to the formality and documentation of an

                Extent of Condition evaluation should be considered. On the other hand, if the

                issue is found to be generic or programmatic, then it is likely that an Extent of

                Condition evaluation should be performed and documented. For example, a

                failure to use a respirator properly in a particular facility may be considered

                unique if that is the only facility on site that utilized respirators. If, however, the

                source of the failure to use the respirator properly is inadequate training and such

                equipment is used in many places around the site, it would be appropriate to

                conduct an Extent of Condition evaluation. In at least some circumstances, the

                question of uniqueness may only be answerable after some preliminary Extent of

                Condition evaluation.

                Recurrence. If the issue under study is similar to other issues that have occurred at

                the site, then an Extent of Condition evaluation of the site as a whole may be

                warranted, probably in conjunction with a root cause analysis.

                Seriousness (Potential or Actual). Factors to consider with respect to the

                seriousness of the matter under consideration include the potential for physical

                harm, environmental impact, public perceptions and regulatory and contractual

                performance requirements. Issues that do not meet the criteria being adverse to

                quality may not be appropriate candidates for an extensive Extent of Condition

                evaluation. Matters involving multiple failures, on the other hand, would make

                such an evaluation more appropriate.


                Page 4

                Cost. It is expected that managers will make decisions regarding an Extent of

                Condition evaluation using the graded approach that takes the potential safety

                impact and cost into consideration.

                IV. EOC Evaluation Process

                As part of the corrective action planning process, the individuals assigned the task of

                reviewing, critiquing and investigating individual significant noncompliance matters or

                lower threshold issues and safety concerns, should have initial responsibility for making a

                determination on the breadth of Extent of Condition evaluation that would be appropriate.

                Other individuals responsible for occurrence reporting, Price-Anderson reporting, and

                lessons learned should have familiarity with the process as well. All individuals charged

                with Extent of Condition responsibility should be trained on how to perform an Extent of

                Condition evaluation so there is a uniform approach to Extent of Condition evaluations at

                a site.

                Individuals conducting Extent of Condition evaluations should have appropriate expertise

                in the areas being evaluated and across the site. They should also have the problem

                solving skills to understand the corrective actions needed to resolve issues on a site-wide

                basis. Subject matter experts should be utilized in appropriate circumstances. The level

                of effort required for the evaluation will depend on the significance and complexity of the

                issue. For more complex cases, formal lines of inquiry may need to be developed and

                implemented. Outside of the context of events, issues may be identified through

                management and independent assessment processes.

                This behavior should be

                encouraged. An Extent of Condition evaluation could be developed from an assessment

                finding or because in a manager’s professional judgment something needs to be reviewed

                more closely. Some Extent of Condition evaluations may only require a review of

                documents while others may require a walk-down of a facility. Efforts should be made to

                avoid a “checklist” mentality. Regardless of the level of evaluation performed, the

                results should be documented either within an existing process (e.g. corrective action

                management or assessments) or in a report format.

                In summary, the following steps should be considered and incorporated into the Extent of

                Condition evaluation as appropriate:

                Review the background and circumstances that led to identification of the issue or

                condition triggering the review. There may be multiple issues or conditions that

                should be evaluated.

                Assure the level of effort will help identify all relevant causal factors.

                Evaluate the issue or condition for uniqueness, recurrence and potential or actual

                consequences.

                Determine what issues require follow-up and whether an SME needs to be utilized

                in the evaluation.

                Determine the breadth of facilities and activities at the site that might be similarly

                situated.


                Page 5

                Consider what might have been inadequate in previous assessments,

                investigations, critique results and cause determinations if this is a repetitive

                problem.

                Identify and/or investigate the extent of applicability to other activities, processes,

                equipment, programs, facilities, operations and organizations.

                Assure involvement by both the appropriate subject matter expert and manager in

                the development of findings.

                Document such findings and assure incorporation of the findings in development

                of corrective actions. Recognize that the problem solving loop might require

                going back to Extent of Condition issues during implementation of a corrective

                action plan if new information or insights develop during the implementation

                process.

                A properly scoped, implemented and documented Extent of Condition evaluation can

                help identify and correct problems before they become events. This will save contractor

                and DOE resources and create a safer, better managed work environment.

                NOTICE -
                This communication is intended ONLY for the use of the person or entity named above and may contain information that is confidential or legally privileged. If you are not the intended recipient named above or a person responsible for delivering messages or communications to the intended recipient, YOU ARE HEREBY NOTIFIED that any use, distribution, or copying of this communication or any of the information contained in it is strictly prohibited. If you have received this communication in error, please notify us immediately by telephone and then destroy or delete this communication, or return it to us by mail if requested by us. The City of Calgary thanks you for your attention and co-operation.
              • Oldnuke640@aol.com
                I think that the management at Davis-Besse believed in the leak-before-break scenario. They figured that - if the CRDM nozzle had a crack (as the NRC had
                Message 7 of 27 , Oct 2, 2008
                • 0 Attachment
                  I think that the management at Davis-Besse believed in the "leak-before-break" scenario.  They figured that - if the CRDM nozzle had a crack (as the NRC had said it probably did - the leak rate would slowly increase until tech spec UNIDENTIFIED LEAKAGE limits were exceeded.  Then, they could shut down without penalty or criticism from First Energy.  They would be prudent. 
                   
                  I doubt that leak-before-break would have happened based on the characterization of the site.  But nobody (not NRC, industry, NEI etc) thought that a football sized hole could develop on the RPV head without a major increase in the leak rate.  20x20 hindsight is so wonderful...we can be SOOO smart. 
                   
                   




                  Looking for simple solutions to your real-life financial challenges? Check out WalletPop for the latest news and information, tips and calculators.
                • DR WILLIAM CORCORAN
                  Tedd,   The type of thinking you describe is often called making a facilitative assumption. A facilitative assumption is one that facilitates doing or
                  Message 8 of 27 , Oct 3, 2008
                  • 0 Attachment
                  • Page 6

                    Tedd,
                     
                    The type of thinking you describe is often called making a facilitative assumption. A facilitative assumption is one that facilitates doing or continuing to do that which was desired.
                     
                    See the attached reflective analysis.
                     
                    Hindsight should be used to refine foresight. (You can quote me.)
                     


                     
                    Take care,
                     
                    Bill Corcoran
                    Mission: Saving lives, pain, assets, and careers through thoughtful inquiry.
                    Motto: If you want safety, peace, or justice, then work for competency, integrity, and transparency.
                     
                    W. R. Corcoran, Ph.D., P.E.
                    NSRC Corporation
                    21 Broadleaf Circle
                    Windsor, CT 06095-1634
                    Voice and voice mail: 860-285-8779
                     
                    Subscribe to "The Firebird Forum" by sending an e-mail to TheFirebirdForum-subscribe@yahoogroups.com
                     


                    --- On Thu, 10/2/08, Oldnuke640@... <Oldnuke640@...> wrote:
                    From: Oldnuke640@... <Oldnuke640@...>
                    Subject: Re: [Root_Cause_State_of_the_Practice] Extent
                    To: Root_Cause_State_of_the_Practice@yahoogroups.com
                    Date: Thursday, October 2, 2008, 9:26 PM

                    I think that the management at Davis-Besse believed in the "leak-before- break" scenario.  They figured that - if the CRDM nozzle had a crack (as the NRC had said it probably did - the leak rate would slowly increase until tech spec UNIDENTIFIED LEAKAGE limits were exceeded.  Then, they could shut down without penalty or criticism from First Energy.  They would be prudent. 
                     
                    I doubt that leak-before- break would have happened based on the characterization of the site.  But nobody (not NRC, industry, NEI etc) thought that a football sized hole could develop on the RPV head without a major increase in the leak rate.  20x20 hindsight is so wonderful... we can be SOOO smart. 
                     
                     




                    Looking for simple solutions to your real-life financial challenges? Check out WalletPop for the latest news and information, tips and calculators.
                  • JTTH
                    In Licensing Space, LBB cannot be applied to material with an active degradation mechanism (boric acid). As you note, that doesn t prevent the misapplication
                    Message 9 of 27 , Oct 3, 2008
                    • 0 Attachment
                      In Licensing Space, LBB cannot be applied to material with an active degradation mechanism (boric acid).  As you note, that doesn't prevent the misapplication of the concept by someone who is trying to rationalize their behavior/decision-making.  Most such persons operate by their opinion and other opinions they choose to hear (screen out the disention and factual information that should be considered), which I believe is your point.
                       
                      JTTH

                      On Fri, Oct 3, 2008 at 4:24 AM, DR WILLIAM CORCORAN <williamcorcoran@...> wrote:

                      Tedd,
                       
                      The type of thinking you describe is often called making a facilitative assumption. A facilitative assumption is one that facilitates doing or continuing to do that which was desired.
                       
                      See the attached reflective analysis.
                       
                      Hindsight should be used to refine foresight. (You can quote me.)
                       


                       
                      Take care,
                       
                      Bill Corcoran
                      Mission: Saving lives, pain, assets, and careers through thoughtful inquiry.
                      Motto: If you want safety, peace, or justice, then work for competency, integrity, and transparency.
                       
                      W. R. Corcoran, Ph.D., P.E.
                      NSRC Corporation
                      21 Broadleaf Circle
                      Windsor, CT 06095-1634
                      Voice and voice mail: 860-285-8779
                       
                      Subscribe to "The Firebird Forum" by sending an e-mail to TheFirebirdForum-subscribe@yahoogroups.com
                       


                      --- On Thu, 10/2/08, Oldnuke640@... <Oldnuke640@...> wrote:
                      From: Oldnuke640@... <Oldnuke640@...>
                      Subject: Re: [Root_Cause_State_of_the_Practice] Extent
                      To: Root_Cause_State_of_the_Practice@yahoogroups.com
                      Date: Thursday, October 2, 2008, 9:26 PM

                      I think that the management at Davis-Besse believed in the "leak-before- break" scenario.  They figured that - if the CRDM nozzle had a crack (as the NRC had said it probably did - the leak rate would slowly increase until tech spec UNIDENTIFIED LEAKAGE limits were exceeded.  Then, they could shut down without penalty or criticism from First Energy.  They would be prudent. 
                       
                      I doubt that leak-before- break would have happened based on the characterization of the site.  But nobody (not NRC, industry, NEI etc) thought that a football sized hole could develop on the RPV head without a major increase in the leak rate.  20x20 hindsight is so wonderful... we can be SOOO smart. 
                       
                       




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                    • DR WILLIAM CORCORAN
                      JT,   Thanks.   Can you send us a link to a discussion of leak-before-break (LBB)?   It sounds like one of those ideas used to support a false sense of
                      Message 10 of 27 , Oct 5, 2008
                      • 0 Attachment
                        JT,
                         
                        Thanks.
                         
                        Can you send us a link to a discussion of "leak-before-break" (LBB)?
                         
                        It sounds like one of those ideas used to support a false "sense of complacency."
                         
                        In one of my earlier incarnations I argued LBB in a meeting with Harold Denton and others. After the meeting he took me into his office, presumably just to discuss the next meeting. While we were talking he fiddled with a section of pipe that had clearly broken before leaking. He did not need to make his point. I dropped the LBB argument for a hardware change.

                        Take care,
                         
                        Bill Corcoran
                        Mission: Saving lives, pain, assets, and careers through thoughtful inquiry.
                        Motto: If you want safety, peace, or justice, then work for competency, integrity, and transparency.
                         
                        W. R. Corcoran, Ph.D., P.E.
                        NSRC Corporation
                        21 Broadleaf Circle
                        Windsor, CT 06095-1634
                        Voice and voice mail: 860-285-8779
                         
                        Subscribe to "The Firebird Forum" by sending an e-mail to TheFirebirdForum-subscribe@yahoogroups.com
                         


                        --- On Fri, 10/3/08, JTTH <xcelnuclearguy@...> wrote:
                        From: JTTH <xcelnuclearguy@...>
                        Subject: Re: [Root_Cause_State_of_the_Practice] Extent
                        To: Root_Cause_State_of_the_Practice@yahoogroups.com
                        Date: Friday, October 3, 2008, 10:33 AM

                        In Licensing Space, LBB cannot be applied to material with an active degradation mechanism (boric acid).  As you note, that doesn't prevent the misapplication of the concept by someone who is trying to rationalize their behavior/decision- making.  Most such persons operate by their opinion and other opinions they choose to hear (screen out the disention and factual information that should be considered), which I believe is your point.
                         
                        JTTH

                        On Fri, Oct 3, 2008 at 4:24 AM, DR WILLIAM CORCORAN <williamcorcoran@ sbcglobal. net> wrote:
                        Tedd,
                         
                        The type of thinking you describe is often called making a facilitative assumption. A facilitative assumption is one that facilitates doing or continuing to do that which was desired.
                         
                        See the attached reflective analysis.
                         
                        Hindsight should be used to refine foresight. (You can quote me.)
                         


                         
                        Take care,
                         
                        Bill Corcoran
                        Mission: Saving lives, pain, assets, and careers through thoughtful inquiry.
                        Motto: If you want safety, peace, or justice, then work for competency, integrity, and transparency.
                         
                        W. R. Corcoran, Ph.D., P.E.
                        NSRC Corporation
                        21 Broadleaf Circle
                        Windsor, CT 06095-1634
                        Voice and voice mail: 860-285-8779
                         
                        Subscribe to "The Firebird Forum" by sending an e-mail to TheFirebirdForum- subscribe@ yahoogroups. com
                         


                        --- On Thu, 10/2/08, Oldnuke640@aol. com <Oldnuke640@aol. com> wrote:
                        From: Oldnuke640@aol. com <Oldnuke640@aol. com>
                        Subject: Re: [Root_Cause_ State_of_ the_Practice] Extent
                        To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                        Date: Thursday, October 2, 2008, 9:26 PM

                        I think that the management at Davis-Besse believed in the "leak-before- break" scenario.  They figured that - if the CRDM nozzle had a crack (as the NRC had said it probably did - the leak rate would slowly increase until tech spec UNIDENTIFIED LEAKAGE limits were exceeded.  Then, they could shut down without penalty or criticism from First Energy.  They would be prudent. 
                         
                        I doubt that leak-before- break would have happened based on the characterization of the site.  But nobody (not NRC, industry, NEI etc) thought that a football sized hole could develop on the RPV head without a major increase in the leak rate.  20x20 hindsight is so wonderful... we can be SOOO smart. 
                         
                         




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                      • Oldnuke640@aol.com
                        I am not an expert in this area so I would defer to someone who is... but here goes my best explanation as I understand it. I am sure someone who is familiar
                        Message 11 of 27 , Oct 5, 2008
                        • 0 Attachment
                          I am not an expert in this area so I would defer to someone who is... but here goes my best explanation as I understand it.  I am sure someone who is familiar with this area can explain it more accurately. 
                           
                          The use of the "leak before break" approach is allowable for low pressure piping systems - class 3 piping etc.  If a low pressure pipe has developed a flaw (an "indication" or a pit that has not yet coroded through the pipe wall) it is allowable to characterize the flaw using NDT (determine the flaw size and orientation), analyze the flaw using a pipe analysis method (figure out whether it is susceptible to rapid failure) and show that if the flaw were to propogate further, a small leak would occur prior to a full blow pipe rupture.  If this can be shown (there are various AMSE code cases that apply here) then it will be allowable to continue to operate the pipe with the flaw until it begins to leak - when it must be taken out of service and repaired.  "Leak before break" makes sense because the pressure inside the pipe is low.  Once the leak begins, the leaking stream of fluid will neither cause impingment concerns (HLEB), nor cause the leak to increase in size rapidly due to errosion.  This approach allows a low pressure piping system to continue to operate until the next outage when it can be properly repaired without shutting down the reactor in the middle of a run. 
                           
                          For high pressure or high temperature applications, AMSE does not allow the use of "leak before break" because the high energy in the line will cause impingement damage or rapid errosion of the leak site.  LLB can never be applied to the pressure boundary of the RCS.  Yet some folks in the late 1990s believed that it should apply.  This was one of the reasons (although not the only or best reason) why the NRC and industry tried to modify 10CFR50.46 - the LOCA rule.  The LOCA rule states that the plant has to be designed for a double-ended guillotine break of the largest pipe - which for a Westinghouse PWRs is the RCS pipe cold leg.  Having never seen a pipe of this size rupture before, there were some who wanted to reduce this design requirement to a smaller pipe size.  Had this rule change been successful, it would have allowed smaller sized containments, smaller capacity ECCS systems and would not have required utilities to "take credit" for containment accident over pressure for ECCS NPSH for large power uprates. 
                           
                          The LOCA rule change has not been approved.  The "experts" could not agree that this was the right or safe thing to do.  I think the effort died (or at least stopped) when Chairman Diaz left the NRC.  He was hoping to get it approved before he left office. 
                           
                           
                           
                           




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                        • JTTH
                          Actually many plants have RCS piping and RCS branch lines licensed for leak-before-break, with sound reasoning. I can provide (later) an excerpt from a recent
                          Message 12 of 27 , Oct 5, 2008
                          • 0 Attachment
                            Actually many plants have RCS piping and RCS branch lines licensed for leak-before-break, with sound reasoning.  I can provide (later) an excerpt from a recent EPRI update which provides a good nuclear layperson summary of LBB.
                             
                            If someone wants to dig further, they're on their own...it's outside my field of expertise, so I hesitate to comment any further on any other aspects of your reply.
                             
                            I've never heard of it being licensed for anything but piping.  I doubt if anyone was actually considering this at DB, although someone may have been rationalizing the logic.
                             
                            JTTH
                            On Sun, Oct 5, 2008 at 2:04 PM, <Oldnuke640@...> wrote:

                            I am not an expert in this area so I would defer to someone who is... but here goes my best explanation as I understand it.  I am sure someone who is familiar with this area can explain it more accurately. 
                             
                            The use of the "leak before break" approach is allowable for low pressure piping systems - class 3 piping etc.  If a low pressure pipe has developed a flaw (an "indication" or a pit that has not yet coroded through the pipe wall) it is allowable to characterize the flaw using NDT (determine the flaw size and orientation), analyze the flaw using a pipe analysis method (figure out whether it is susceptible to rapid failure) and show that if the flaw were to propogate further, a small leak would occur prior to a full blow pipe rupture.  If this can be shown (there are various AMSE code cases that apply here) then it will be allowable to continue to operate the pipe with the flaw until it begins to leak - when it must be taken out of service and repaired.  "Leak before break" makes sense because the pressure inside the pipe is low.  Once the leak begins, the leaking stream of fluid will neither cause impingment concerns (HLEB), nor cause the leak to increase in size rapidly due to errosion.  This approach allows a low pressure piping system to continue to operate until the next outage when it can be properly repaired without shutting down the reactor in the middle of a run. 
                             
                            For high pressure or high temperature applications, AMSE does not allow the use of "leak before break" because the high energy in the line will cause impingement damage or rapid errosion of the leak site.  LLB can never be applied to the pressure boundary of the RCS.  Yet some folks in the late 1990s believed that it should apply.  This was one of the reasons (although not the only or best reason) why the NRC and industry tried to modify 10CFR50.46 - the LOCA rule.  The LOCA rule states that the plant has to be designed for a double-ended guillotine break of the largest pipe - which for a Westinghouse PWRs is the RCS pipe cold leg.  Having never seen a pipe of this size rupture before, there were some who wanted to reduce this design requirement to a smaller pipe size.  Had this rule change been successful, it would have allowed smaller sized containments, smaller capacity ECCS systems and would not have required utilities to "take credit" for containment accident over pressure for ECCS NPSH for large power uprates. 
                             
                            The LOCA rule change has not been approved.  The "experts" could not agree that this was the right or safe thing to do.  I think the effort died (or at least stopped) when Chairman Diaz left the NRC.  He was hoping to get it approved before he left office. 
                             
                             
                             
                             




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                          • T. Herrmann (Yahoo)
                            Here s a link to an explanation of LBB for those who are interested.   http://www.structint.com/tekbrefs/sib96131/SIB96131.html   Terry Herrmann ... From:
                            Message 13 of 27 , Oct 5, 2008
                            • 0 Attachment
                              Here's a link to an explanation of LBB for those who are interested.
                               
                               
                              Terry Herrmann

                              --- On Sun, 10/5/08, JTTH <xcelnuclearguy@...> wrote:
                              From: JTTH <xcelnuclearguy@...>
                              Subject: Re: [Root_Cause_State_of_the_Practice] "leak-before-break" (LBB)?
                              To: Root_Cause_State_of_the_Practice@yahoogroups.com
                              Date: Sunday, October 5, 2008, 2:05 PM

                              Actually many plants have RCS piping and RCS branch lines licensed for leak-before- break, with sound reasoning.  I can provide (later) an excerpt from a recent EPRI update which provides a good nuclear layperson summary of LBB.
                               
                              If someone wants to dig further, they're on their own...it's outside my field of expertise, so I hesitate to comment any further on any other aspects of your reply.
                               
                              I've never heard of it being licensed for anything but piping.  I doubt if anyone was actually considering this at DB, although someone may have been rationalizing the logic.
                               
                              JTTH
                              On Sun, Oct 5, 2008 at 2:04 PM, <Oldnuke640@aol. com> wrote:
                              I am not an expert in this area so I would defer to someone who is... but here goes my best explanation as I understand it.  I am sure someone who is familiar with this area can explain it more accurately. 
                               
                              The use of the "leak before break" approach is allowable for low pressure piping systems - class 3 piping etc.  If a low pressure pipe has developed a flaw (an "indication" or a pit that has not yet coroded through the pipe wall) it is allowable to characterize the flaw using NDT (determine the flaw size and orientation) , analyze the flaw using a pipe analysis method (figure out whether it is susceptible to rapid failure) and show that if the flaw were to propogate further, a small leak would occur prior to a full blow pipe rupture.  If this can be shown (there are various AMSE code cases that apply here) then it will be allowable to continue to operate the pipe with the flaw until it begins to leak - when it must be taken out of service and repaired.  "Leak before break" makes sense because the pressure inside the pipe is low.  Once the leak begins, the leaking stream of fluid will neither cause impingment concerns (HLEB), nor cause the leak to increase in size rapidly due to errosion.  This approach allows a low pressure piping system to continue to operate until the next outage when it can be properly repaired without shutting down the reactor in the middle of a run. 
                               
                              For high pressure or high temperature applications, AMSE does not allow the use of "leak before break" because the high energy in the line will cause impingement damage or rapid errosion of the leak site.  LLB can never be applied to the pressure boundary of the RCS.  Yet some folks in the late 1990s believed that it should apply.  This was one of the reasons (although not the only or best reason) why the NRC and industry tried to modify 10CFR50.46 - the LOCA rule.  The LOCA rule states that the plant has to be designed for a double-ended guillotine break of the largest pipe - which for a Westinghouse PWRs is the RCS pipe cold leg.  Having never seen a pipe of this size rupture before, there were some who wanted to reduce this design requirement to a smaller pipe size.  Had this rule change been successful, it would have allowed smaller sized containments, smaller capacity ECCS systems and would not have required utilities to "take credit" for containment accident over pressure for ECCS NPSH for large power uprates. 
                               
                              The LOCA rule change has not been approved.  The "experts" could not agree that this was the right or safe thing to do.  I think the effort died (or at least stopped) when Chairman Diaz left the NRC.  He was hoping to get it approved before he left office. 
                               
                               
                               
                               




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                            • DR WILLIAM CORCORAN
                              Terry,   I pasted the info below.   Perhaps a member will comment. Take care,   Bill Corcoran Mission: Saving lives, pain, assets, and careers through
                              Message 14 of 27 , Oct 5, 2008
                              • 0 Attachment
                                Terry,
                                 
                                I pasted the info below.
                                 
                                Perhaps a member will comment.

                                Take care,
                                 
                                Bill Corcoran
                                Mission: Saving lives, pain, assets, and careers through thoughtful inquiry.
                                Motto: If you want safety, peace, or justice, then work for competency, integrity, and transparency.
                                 
                                W. R. Corcoran, Ph.D., P.E.
                                NSRC Corporation
                                21 Broadleaf Circle
                                Windsor, CT 06095-1634
                                Voice and voice mail: 860-285-8779
                                 
                                Subscribe to "The Firebird Forum" by sending an e-mail to TheFirebirdForum-subscribe@yahoogroups.com
                                 

                                Expertise : Fracture Mechanics
                                NUREG-1061, Vol. 3 provides the evaluation methodology for LBB analysis. The following provides a summary of the methodology:
                                • Address all of the prerequisites regarding applicability of LBB to the particular piping system under consideration.
                                • Calculate through-wall critical flaw sizes for the various locations of interest using Pressure + Deadweight + Thermal + Seismic Load Combination.
                                • Calculate leakage through half of the critical flaw size (leakage flaw size) using Pressure + Deadweight + Thermal Load Combination.
                                • Calculate the critical stress for the leakage flaw size and ensure a safety factor of 2.
                                • Ensure that the leakage through the leakage flaw size can be detected by the plant's leak detection system.
                                • Perform a fatigue crack growth evaluation to demonstrate that a part through-wall flaw that will be acceptable by ASME Section XI standards will not grow significantly during service.
                                The application of LBB evaluation to plant operating components is shown below:

                                Applications and Benefits
                                LBB methodology has been successfully applied in a number of nuclear power plants. The driving force for such evaluations has been the realization of technical and economic benefits. Some representative applications and their associated benefits are summarized below:
                                • In the past, LBB analysis has been used in lieu of retrofitted pipe break protection for older plants evaluated under the NRC Systematic Evaluation Program.
                                • LBB analysis can justify the removal of pipe whip restraints for enhanced accessibility and inservice inspections (e.g., when performing induction heating stress improvement of stainless steel piping).
                                • LBB analysis can justify the elimination of pipe break restraints and shields during the installation of new or replacement piping systems.
                                • LBB analysis can demonstrate reduced safety significance of pipe cracking concerns, such as BWR stainless steel piping, cast pipe, valves and pumps, or low toughness weldment materials.
                                • LBB analysis can reduce equipment qualification requirements for the environmental effects of postulated pipe breaks.
                                Structural Integrity Associates (SI) has performed LBB analyses for both pressurized water reactors (PWRs) and boiling water reactors (BWRs) for a variety of components including the following:
                                • Pressurizer surge and accumulator lines
                                • Feedwater, main steam and reactor water cleanup lines
                                • Recirculation systems
                                • Valve castings
                                • Numerous small diameter piping systems.
                                Additionally, SI has developed special in-house computer programs to facilitate LBB evaluations based on the requirements of NUREG-1061, Vol. 3.
                                If you would like to obtain additional information regarding LBB analysis or SI's capabilities in this area, please contact SI.

                                Leak-Before-Break Evaluation
                                SIB-96-131

                                What is Leak-Before-Break (LBB)?
                                The concept of LBB implies that any crack or defect which develops in a component will grow to a through-wall configuration, and can be detectable by plant monitoring systems before reaching a size that would significantly reduce margins to component rupture.
                                When is LBB Applied?
                                The original application of LBB was for the elimination of protective structures such as pipe whip restraints, jet impingement shields, etc., which provide protection against high energy line breaks. Recently, LBB has been used as part of overall safety assessments for leaving real or postulated flaws in service for some operating period.
                                LBB Methodology
                                LBB analyses are based on advanced fracture mechanics techniques and include the following aspects:
                                • critical flaw size evaluation
                                • leakage calculation
                                • crack propagation analysis
                                • ultrasonic flaw detection/sizing
                                • leak detection
                                • service experience.
                                Representative results of an LBB evaluation are shown in the following figure:

                                 



                                --- On Sun, 10/5/08, T. Herrmann (Yahoo) <tjhsbh79@...> wrote:
                                From: T. Herrmann (Yahoo) <tjhsbh79@...>
                                Subject: Re: [Root_Cause_State_of_the_Practice] "leak-before-break" (LBB)?
                                To: Root_Cause_State_of_the_Practice@yahoogroups.com
                                Date: Sunday, October 5, 2008, 5:34 PM

                                Here's a link to an explanation of LBB for those who are interested.
                                 
                                 
                                Terry Herrmann

                                --- On Sun, 10/5/08, JTTH <xcelnuclearguy@ gmail.com> wrote:
                                From: JTTH <xcelnuclearguy@ gmail.com>
                                Subject: Re: [Root_Cause_ State_of_ the_Practice] "leak-before- break" (LBB)?
                                To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                                Date: Sunday, October 5, 2008, 2:05 PM

                                Actually many plants have RCS piping and RCS branch lines licensed for leak-before- break, with sound reasoning.  I can provide (later) an excerpt from a recent EPRI update which provides a good nuclear layperson summary of LBB.
                                 
                                If someone wants to dig further, they're on their own...it's outside my field of expertise, so I hesitate to comment any further on any other aspects of your reply.
                                 
                                I've never heard of it being licensed for anything but piping.  I doubt if anyone was actually considering this at DB, although someone may have been rationalizing the logic.
                                 
                                JTTH
                                On Sun, Oct 5, 2008 at 2:04 PM, <Oldnuke640@aol. com> wrote:
                                I am not an expert in this area so I would defer to someone who is... but here goes my best explanation as I understand it.  I am sure someone who is familiar with this area can explain it more accurately. 
                                 
                                The use of the "leak before break" approach is allowable for low pressure piping systems - class 3 piping etc.  If a low pressure pipe has developed a flaw (an "indication" or a pit that has not yet coroded through the pipe wall) it is allowable to characterize the flaw using NDT (determine the flaw size and orientation) , analyze the flaw using a pipe analysis method (figure out whether it is susceptible to rapid failure) and show that if the flaw were to propogate further, a small leak would occur prior to a full blow pipe rupture.  If this can be shown (there are various AMSE code cases that apply here) then it will be allowable to continue to operate the pipe with the flaw until it begins to leak - when it must be taken out of service and repaired.  "Leak before break" makes sense because the pressure inside the pipe is low.  Once the leak begins, the leaking stream of fluid will neither cause impingment concerns (HLEB), nor cause the leak to increase in size rapidly due to errosion.  This approach allows a low pressure piping system to continue to operate until the next outage when it can be properly repaired without shutting down the reactor in the middle of a run. 
                                 
                                For high pressure or high temperature applications, AMSE does not allow the use of "leak before break" because the high energy in the line will cause impingement damage or rapid errosion of the leak site.  LLB can never be applied to the pressure boundary of the RCS.  Yet some folks in the late 1990s believed that it should apply.  This was one of the reasons (although not the only or best reason) why the NRC and industry tried to modify 10CFR50.46 - the LOCA rule.  The LOCA rule states that the plant has to be designed for a double-ended guillotine break of the largest pipe - which for a Westinghouse PWRs is the RCS pipe cold leg.  Having never seen a pipe of this size rupture before, there were some who wanted to reduce this design requirement to a smaller pipe size.  Had this rule change been successful, it would have allowed smaller sized containments, smaller capacity ECCS systems and would not have required utilities to "take credit" for containment accident over pressure for ECCS NPSH for large power uprates. 
                                 
                                The LOCA rule change has not been approved.  The "experts" could not agree that this was the right or safe thing to do.  I think the effort died (or at least stopped) when Chairman Diaz left the NRC.  He was hoping to get it approved before he left office. 
                                 
                                 
                                 
                                 




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                              • JTTH
                                Here are excerpts from EPRI on LBB genesis and related program status (from publicly available Materials newsletter) As noted in the SIA link, inspection is an
                                Message 15 of 27 , Oct 6, 2008
                                • 0 Attachment
                                  Here are excerpts from EPRI on LBB genesis and related program status (from publicly available Materials newsletter)
                                   
                                  As noted in the SIA link, inspection is an element in supporting leak prevention (lack of inspection was a contributor to DB lack of detecting source of leakage and resulting RVH degradation).  Failure to inspect was a "safety rule" that was not followed (see p 11, second to last paragraph in Bill's paper...following the rules is no absolute guarantee, but it helps). 
                                   
                                  The "Leak Detection" element noted in the SIA discussion would be containment atmosphere radioactive contamination monitoring, humidity monitoring, or other methods used to detect a leak after it develops. It appeared that some of these low level signs were available to DB, but assumed to be acceptable as the real scenario and potential consequence were not fully considered (see reference to "flange leaks" in Bill's paper, p11, and resulting p 12 and 13 discussion).
                                   
                                  JTTH
                                   

                                  xLPR—Extremely Low Probability of Rupture

                                  Within the United States regulatory framework, the General Design Criteria (GDC) in 10CFR 50 are the cornerstones that establish the basic design requirements that must be met by nuclear power facilities in the United States. GDC #4 states in part that the NSSS piping systems must exhibit an "extremely low probability of rupture."

                                  Within the PWR fleet, specific compliance challenges with this requirement were addressed through an approach that has come to be known simply as Leak Before Break (LBB). LBB was not applied to the BWR fleet because of a key condition placed on the use of LBB that no known active degradation mechanisms threaten the integrity of the subject piping system and IGSCC had already been identified as a concern to BWRs.

                                  The identification of PWSCC in PWRs subsequent to LBB approval raises questions that now must be resolved. The prescribed LBB analytical methodology is a deterministic approach to address a fundamentally probabilistic design requirement.  Although the LBB technical basis is sound, the linkage between the deterministic analytical methodology and the probabilistic design criteria is not sufficiently robust to allow incorporation of rigorous analytical treatment of active degradation mechanism effects. MRP and NRC Research have therefore initiated a collaborative effort to take advantage of advances in analytical methods and computational capabilities to develop a new, more robust technical basis and analytical methodology to demonstrate compliance with the "extremely low probability of rupture" standard.

                                  MRP is presently funding a process mapping effort to define the new analytical framework. Small teams of industry and NRC experts will then be responsible for adding greater detail to the various elements of this process map such as initial conditions, crack initiation and growth, critical flaw calculation, inspection, etc.

                                  In order to explicitly address the existence of active degradation mechanisms, periodic inspection is expected to be an integral part of the xLPR methodology. Consequently, a parallel related effort is also under way to extract relevant POD information from the PDI database for use in these evaluations.



                                   
                                  On Sun, Oct 5, 2008 at 4:34 PM, T. Herrmann (Yahoo) <tjhsbh79@...> wrote:

                                  Here's a link to an explanation of LBB for those who are interested.
                                   
                                   
                                  Terry Herrmann


                                  --- On Sun, 10/5/08, JTTH <xcelnuclearguy@...> wrote:
                                  From: JTTH <xcelnuclearguy@...>
                                  Subject: Re: [Root_Cause_State_of_the_Practice] "leak-before-break" (LBB)?Date: Sunday, October 5, 2008, 2:05 PM


                                  Actually many plants have RCS piping and RCS branch lines licensed for leak-before- break, with sound reasoning.  I can provide (later) an excerpt from a recent EPRI update which provides a good nuclear layperson summary of LBB.
                                   
                                  If someone wants to dig further, they're on their own...it's outside my field of expertise, so I hesitate to comment any further on any other aspects of your reply.
                                   
                                  I've never heard of it being licensed for anything but piping.  I doubt if anyone was actually considering this at DB, although someone may have been rationalizing the logic.
                                   
                                  JTTH
                                  On Sun, Oct 5, 2008 at 2:04 PM, <Oldnuke640@aol. com> wrote:
                                  I am not an expert in this area so I would defer to someone who is... but here goes my best explanation as I understand it.  I am sure someone who is familiar with this area can explain it more accurately. 
                                   
                                  The use of the "leak before break" approach is allowable for low pressure piping systems - class 3 piping etc.  If a low pressure pipe has developed a flaw (an "indication" or a pit that has not yet coroded through the pipe wall) it is allowable to characterize the flaw using NDT (determine the flaw size and orientation) , analyze the flaw using a pipe analysis method (figure out whether it is susceptible to rapid failure) and show that if the flaw were to propogate further, a small leak would occur prior to a full blow pipe rupture.  If this can be shown (there are various AMSE code cases that apply here) then it will be allowable to continue to operate the pipe with the flaw until it begins to leak - when it must be taken out of service and repaired.  "Leak before break" makes sense because the pressure inside the pipe is low.  Once the leak begins, the leaking stream of fluid will neither cause impingment concerns (HLEB), nor cause the leak to increase in size rapidly due to errosion.  This approach allows a low pressure piping system to continue to operate until the next outage when it can be properly repaired without shutting down the reactor in the middle of a run. 
                                   
                                  For high pressure or high temperature applications, AMSE does not allow the use of "leak before break" because the high energy in the line will cause impingement damage or rapid errosion of the leak site.  LLB can never be applied to the pressure boundary of the RCS.  Yet some folks in the late 1990s believed that it should apply.  This was one of the reasons (although not the only or best reason) why the NRC and industry tried to modify 10CFR50.46 - the LOCA rule.  The LOCA rule states that the plant has to be designed for a double-ended guillotine break of the largest pipe - which for a Westinghouse PWRs is the RCS pipe cold leg.  Having never seen a pipe of this size rupture before, there were some who wanted to reduce this design requirement to a smaller pipe size.  Had this rule change been successful, it would have allowed smaller sized containments, smaller capacity ECCS systems and would not have required utilities to "take credit" for containment accident over pressure for ECCS NPSH for large power uprates. 
                                   
                                  The LOCA rule change has not been approved.  The "experts" could not agree that this was the right or safe thing to do.  I think the effort died (or at least stopped) when Chairman Diaz left the NRC.  He was hoping to get it approved before he left office. 
                                   
                                   
                                   
                                   




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                                • Salot, William
                                  All, To me, this is an interesting thread. I was a young feller when leak before break (LBB) began appearing in mechanical design literature. The original
                                  Message 16 of 27 , Oct 6, 2008
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                                    All,

                                     

                                    To me, this is an interesting thread.

                                     

                                    I was a young feller when “leak before break” (LBB) began appearing in mechanical design literature.  

                                     

                                    The original concept, as intended then, was reasonably simple.  It created a legitimate and welcome sense of “safety”, not “complacency”.  Later “refinements” then led to your “complacency” questions.

                                     

                                    I believe research on LBB was triggered by the catastrophic fragmentation of a high-pressure vessel in the UK during its initial hydrotest.  See the attached picture.  A heavy fragment went through the roof.  The research was also influenced by brittle fractures of large oil storage tanks during cold weather.

                                     

                                    The point is that the LLB concept was intended to address catastrophic “brittle fracture” emanating from an unknown, hidden, critical-size defect, and occurring during the first fatigue cycle of critical-magnitude.  Let’s agree that we are a whole lot better off when undetected cracks in pressurized equipment manifest themselves by leakage rather than fragmentation.  “Brittle fracture” does not happen as much as it once did.   

                                     

                                    The objective of LBB is effectively accomplished by controlling materials, maximum localized stresses at assumed through-wall cracks, and corresponding minimum metal temperatures, all during the design stage.  Leaking cracks in CRDM nozzles are examples of successful LBB design.  None of those nozzles went into orbit.

                                     

                                    The 1) timely detection of a leak and 2) timely correction of the leak are really separate issues.  If an LBB designed component eventually fails catastrophically, issues 1) and 2) are deeply involved.  The LBB designer does not have much control over the critical size and location of a leak, particularly if the leak is in a small component and the component has to be internal (e.g., the CRDM nozzles).  Please do not fault the LBB concept when the timeliness of detection and correction are the significant issues.

                                     

                                    I mentioned subsequent questionable LBB refinements that do invite “complacency”.  They are based on the optimistic belief that the growth rate of a leaking crack can be reasonably estimated from the time it is detected until the time it reaches critical size.  Based on such estimates, some folks apparently have the confidence to postpone correction of leaking cracks.  But most of us are not that sophisticated.  We see a leaking crack that could grow and become dangerous.  We declare it unfit for service.  We even interpret our NB and API Inspection Codes as requiring such action.

                                     

                                    Here is one last point: Bill C, in an “earlier incarnation” was shown “a section of pipe that had clearly broken before leaking”.  Evidently he had not yet developed his current inquiring mind.  I assume the broken section had completely separated from an adjacent section. 

                                    • Most likely the pipe was vibrating and broke off after a fatigue crack progressed to critical size (around much of the circumference), in which case the break had to be preceded by leakage.  If so, the pipe satisfied LBB, and the questions then become, “Was the leak detected before the break?” and “If not, why not?”
                                    • To simulate a pipe break without it leaking first, one would have to lower its temperature below its ductile-to-brittle transition temperature, make sure that there is a discontinuity of critical size for that temperature, and then apply sufficient energy to exceed its notch toughness at that temperature.  Such conditions violate LBB criteria, and would have been prohibited in an LBB design.

                                     

                                    Bill Salot   

                                         

                                     


                                    From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto: Root_Cause_State_of_the_Practice@yahoogroups.com ] On Behalf Of DR WILLIAM CORCORAN
                                    Sent: Sunday, October 05, 2008 5:00 AM
                                    To: Root_Cause_State_of_the_Practice@yahoogroups.com
                                    Subject: Re: [Root_Cause_State_of_the_Practice] "leak-before-break" (LBB)?

                                     

                                    JT,

                                     

                                    Thanks.

                                     

                                    Can you send us a link to a discussion of "leak-before- break" (LBB)?

                                     

                                    It sounds like one of those ideas used to support a false "sense of complacency. "

                                     

                                    In one of my earlier incarnations I argued LBB in a meeting with Harold Denton and others. After the meeting he took me into his office, presumably just to discuss the next meeting. While we were talking he fiddled with a section of pipe that had clearly broken before leaking. He did not need to make his point. I dropped the LBB argument for a hardware change.

                                    Take care,
                                     
                                    Bill Corcoran



                                    --- On Fri, 10/3/08, JTTH <xcelnuclearguy@ gmail.com> wrote:

                                    From: JTTH <xcelnuclearguy@ gmail.com>
                                    Subject: Re: [Root_Cause_ State_of_ the_Practice] Extent
                                    To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                                    Date: Friday, October 3, 2008, 10:33 AM

                                    In Licensing Space, LBB cannot be applied to material with an active degradation mechanism (boric acid).  As you note, that doesn't prevent the misapplication of the concept by someone who is trying to rationalize their behavior/decision- making.  Most such persons operate by their opinion and other opinions they choose to hear (screen out the dissention and factual information that should be considered), which I believe is your point.

                                     

                                    JTTH

                                     

                                    On Fri, Oct 3, 2008 at 4:24 AM, DR WILLIAM CORCORAN <williamcorcoran@ sbcglobal. net> wrote:

                                    Tedd,

                                     

                                    The type of thinking you describe is often called making a facilitative assumption. A facilitative assumption is one that facilitates doing or continuing to do that which was desired.

                                     

                                    See the attached reflective analysis.

                                     

                                    Hindsight should be used to refine foresight. (You can quote me.)

                                     

                                    Take care,
                                     
                                    Bill Corcoran

                                     



                                    --- On Thu, 10/2/08, Oldnuke640@aol. com <Oldnuke640@aol. com> wrote:

                                    From: Oldnuke640@aol. com <Oldnuke640@aol. com>
                                    Subject: Re: [Root_Cause_ State_of_ the_Practice] Extent
                                    To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                                    Date: Thursday, October 2, 2008, 9:26 PM

                                    I think that the management at Davis-Besse believed in the "leak-before- break" scenario.  They figured that - if the CRDM nozzle had a crack (as the NRC had said it probably did - the leak rate would slowly increase until tech spec UNIDENTIFIED LEAKAGE limits were exceeded.  Then, they could shut down without penalty or criticism from First Energy.  They would be prudent. 

                                     

                                    I doubt that leak-before- break would have happened based on the characterization of the site.  But nobody (not NRC, industry, NEI etc) thought that a football sized hole could develop on the RPV head without a major increase in the leak rate.  20x20 hindsight is so wonderful... we can be SOOO smart. 

                                     

                                     




                                     

                                    _,_.___

                                  • Salot, William
                                    All, This is an interesting thread. I was a young feller when leak before break began appearing in mechanical design literature. The original concept, as
                                    Message 17 of 27 , Oct 6, 2008
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                                      All,

                                       

                                      This is an interesting thread.

                                       

                                      I was a young feller when “leak before break” began appearing in mechanical design literature.  

                                       

                                      The original concept, as intended, was reasonably simple and created a legitimate and welcome sense of “safety”, not “complacency”.  It is the later “refinements” that led to the questions you raised.

                                       

                                      I believe research on “leak before break” was triggered by the catastrophic fragmentation of a high-pressure vessel in the UK during hydrotest.   

                                       


                                      From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto: Root_Cause_State_of_the_Practice@yahoogroups.com ] On Behalf Of DR WILLIAM CORCORAN
                                      Sent: Sunday, October 05, 2008 5:00 AM
                                      To: Root_Cause_State_of_the_Practice@yahoogroups.com
                                      Subject: Re: [Root_Cause_State_of_the_Practice] "leak-before-break" (LBB)?

                                       

                                      JT,

                                       

                                      Thanks.

                                       

                                      Can you send us a link to a discussion of "leak-before- break" (LBB)?

                                       

                                      It sounds like one of those ideas used to support a false "sense of complacency. "

                                       

                                      In one of my earlier incarnations I argued LBB in a meeting with Harold Denton and others. After the meeting he took me into his office, presumably just to discuss the next meeting. While we were talking he fiddled with a section of pipe that had clearly broken before leaking. He did not need to make his point. I dropped the LBB argument for a hardware change.

                                      Take care,
                                       
                                      Bill Corcoran
                                      Mission : Saving lives, pain, assets, and careers through thoughtful inquiry.
                                      Motto: If you want safety, peace, or justice, then work for competency, integrity, and transparency.
                                       
                                      W. R. Corcoran, Ph.D., P.E.
                                      NSRC Corporation
                                      21 Broadleaf Circle
                                      Windsor , CT 06095-1634
                                      Voice and voice mail: 860-285-8779

                                       

                                      Subscribe to "The Firebird Forum" by sending an e-mail to TheFirebirdForum- subscribe@ yahoogroups. com

                                       



                                      --- On Fri, 10/3/08, JTTH <xcelnuclearguy@ gmail.com> wrote:

                                      From: JTTH <xcelnuclearguy@ gmail.com>
                                      Subject: Re: [Root_Cause_ State_of_ the_Practice] Extent
                                      To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                                      Date: Friday, October 3, 2008, 10:33 AM

                                      In Licensing Space, LBB cannot be applied to material with an active degradation mechanism (boric acid).  As you note, that doesn't prevent the misapplication of the concept by someone who is trying to rationalize their behavior/decision- making.  Most such persons operate by their opinion and other opinions they choose to hear (screen out the disention and factual information that should be considered), which I believe is your point.

                                       

                                      JTTH

                                      On Fri, Oct 3, 2008 at 4:24 AM, DR WILLIAM CORCORAN <williamcorcoran@ sbcglobal. net> wrote:

                                      Tedd,

                                       

                                      The type of thinking you describe is often called making a facilitative assumption. A facilitative assumption is one that facilitates doing or continuing to do that which was desired.

                                       

                                      See the attached reflective analysis.

                                       

                                      Hindsight should be used to refine foresight. (You can quote me.)

                                       



                                       

                                      Take care,
                                       
                                      Bill Corcoran
                                      Mission : Saving lives, pain, assets, and careers through thoughtful inquiry.
                                      Motto: If you want safety, peace, or justice, then work for competency, integrity, and transparency.
                                       
                                      W. R. Corcoran, Ph.D., P.E.
                                      NSRC Corporation
                                      21 Broadleaf Circle
                                      Windsor , CT 06095-1634
                                      Voice and voice mail: 860-285-8779

                                       

                                      Subscribe to "The Firebird Forum" by sending an e-mail to TheFirebirdForum- subscribe@ yahoogroups. com

                                       



                                      --- On Thu, 10/2/08, Oldnuke640@aol. com <Oldnuke640@aol. com> wrote:

                                      From: Oldnuke640@aol. com <Oldnuke640@aol. com>
                                      Subject: Re: [Root_Cause_ State_of_ the_Practice] Extent
                                      To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                                      Date: Thursday, October 2, 2008, 9:26 PM

                                      I think that the management at Davis-Besse believed in the "leak-before- break" scenario.  They figured that - if the CRDM nozzle had a crack (as the NRC had said it probably did - the leak rate would slowly increase until tech spec UNIDENTIFIED LEAKAGE limits were exceeded.  Then, they could shut down without penalty or criticism from First Energy.  They would be prudent. 

                                       

                                      I doubt that leak-before- break would have happened based on the characterization of the site.  But nobody (not NRC, industry, NEI etc) thought that a football sized hole could develop on the RPV head without a major increase in the leak rate.  20x20 hindsight is so wonderful... we can be SOOO smart. 

                                       

                                       




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                                    • Oldnuke640@aol.com
                                      In a message dated 10/5/2008 9:03:36 P.M. Eastern Daylight Time, williamcorcoran@sbcglobal.net writes: Perhaps a member will comment. Take care, Bill Corcoran
                                      Message 18 of 27 , Oct 7, 2008
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                                        In a message dated 10/5/2008 9:03:36 P.M. Eastern Daylight Time, williamcorcoran@... writes:
                                        Perhaps a member will comment.

                                        Take care,
                                         
                                        Bill Corcoran
                                        OK Dr. Bill, I started it - so I will try.   
                                         
                                        I am glad that I started my posting with a disclaimer that I was not an expert in this (LBB) area.  Your replies have indeed been enlightening for this Old Nuke.  I guess I did not realize that we were using fracture mechanics to justify licensing RCS piping to reduce the amount of seismic and HELB restraints.  Guess it is OK if it works.  This is beyond me...but it was never my original point.
                                         
                                        I did not mean to imply that the senior managers at Davis-Besse thought that leak-before-break methodology was appropriately applied to the CRDM nozzle boundary.  I am sure they knew that this was not appropriate.  Rather, I was trying to say that they used the concept that any leak in the CRDM nozzles would, in all likelihood, progress to exceed tech spec limits before a break would happen (and a rod ejection would occur) as the rationalization for why they did not need to shutdown to look at the CRDM nozzle area.  This rationalization was never intended to be a defense based on the appropriate use of the LBB methodology (which I apparently never understood anyway). 
                                         
                                        Putting 2 and 2 together, I suspect that it was a management decision (by 2 or maybe 3 people) to run the plant until the unidentified leak rate reached the tech spec limit.  As long as the leakage remained officially classified as unidentified leakage, they could run at 100% power until it exceeded 5 gpm.  If it had ever been officially classified as pressure boundary leakage, they would have to bring the plant to cold shutdown.  The only way to classify it as pressure boundary leakage was to visually observe it leaking from a pressure boundary (a non-mechanical joint).  I think they chose not to look. 
                                         
                                        But they never thought in their wildest dreams that a football-sized hole could develop in the reactor vessel head before the RCS leak rate would exceed the tech spec limit - nor did the consensus opinion in industry and NRC.  They may have been technically violating their tech specs for pressure boundary leakage, but their perceptions may have been that the consequences of prematurely shutting down due to (suspected) pressure boundary leakage would be worse than continuing to operate until the leakage would exceed the tech spec limits - at which time they would then have to shutdown.  Maybe the strategy would last long enough until the new RPV head was ready.  Certainly it would last until the next outage.  If it did not last, nobody in Akron could fault them for shutting down when they exceeded the tech spec unidentified leakage LCO.  The risk appeared to be worth it. 
                                         
                                        In the final analysis, people screw up for only 3 reasons (and here's a HUGE oversimplification for Dr. Bill - I expect a major rebuttal). 
                                         
                                        We are ignorant (we lack knowledge of the facts),
                                        we are stupid (we have the knowledge but reach the wrong judgments) or
                                        we are deceptive (we have the knowledge, we know better but we decide to see if we can get away with it).
                                         
                                        All our root cause analysis methods - factor trees - staircases - streaming analysis - barriers - timelines - ECFs - MORT - etc etc etc take these broad-bush categories and slice and dice them into more meaningful and specific causes - especially the first 2 categories.  We rarely want to think about or analyze the third category - but human nature continues to confound us. 




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                                      • Mike
                                        The corrosive effects of boric acid leakage were well known in the industry prior to the Davis Besse event. Its difficult for me to conclude ignorant, stupid
                                        Message 19 of 27 , Oct 7, 2008
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                                          The corrosive effects of boric acid leakage were well known in the industry prior to the Davis Besse event. Its difficult for me to conclude ignorant, stupid or deceptive in that case. Perhaps negligent could be a fourth category.
                                          ----- Original Message -----
                                          Sent: Tuesday, October 07, 2008 8:41 PM
                                          Subject: Re: [Root_Cause_State_of_the_Practice] "leak-before-break" (LBB)?

                                          In a message dated 10/5/2008 9:03:36 P.M. Eastern Daylight Time, williamcorcoran@ sbcglobal. net writes:
                                          Perhaps a member will comment.

                                          Take care,
                                           
                                          Bill Corcoran
                                          OK Dr. Bill, I started it - so I will try.   
                                           
                                          I am glad that I started my posting with a disclaimer that I was not an expert in this (LBB) area.  Your replies have indeed been enlightening for this Old Nuke.  I guess I did not realize that we were using fracture mechanics to justify licensing RCS piping to reduce the amount of seismic and HELB restraints.  Guess it is OK if it works.  This is beyond me...but it was never my original point.
                                           
                                          I did not mean to imply that the senior managers at Davis-Besse thought that leak-before- break methodology was appropriately applied to the CRDM nozzle boundary.  I am sure they knew that this was not appropriate.  Rather, I was trying to say that they used the concept that any leak in the CRDM nozzles would, in all likelihood, progress to exceed tech spec limits before a break would happen (and a rod ejection would occur) as the rationalization for why they did not need to shutdown to look at the CRDM nozzle area.  This rationalization was never intended to be a defense based on the appropriate use of the LBB methodology (which I apparently never understood anyway). 
                                           
                                          Putting 2 and 2 together, I suspect that it was a management decision (by 2 or maybe 3 people) to run the plant until the unidentified leak rate reached the tech spec limit.  As long as the leakage remained officially classified as unidentified leakage, they could run at 100% power until it exceeded 5 gpm.  If it had ever been officially classified as pressure boundary leakage, they would have to bring the plant to cold shutdown.  The only way to classify it as pressure boundary leakage was to visually observe it leaking from a pressure boundary (a non-mechanical joint).  I think they chose not to look. 
                                           
                                          But they never thought in their wildest dreams that a football-sized hole could develop in the reactor vessel head before the RCS leak rate would exceed the tech spec limit - nor did the consensus opinion in industry and NRC.  They may have been technically violating their tech specs for pressure boundary leakage, but their perceptions may have been that the consequences of prematurely shutting down due to (suspected) pressure boundary leakage would be worse than continuing to operate until the leakage would exceed the tech spec limits - at which time they would then have to shutdown.  Maybe the strategy would last long enough until the new RPV head was ready.  Certainly it would last until the next outage.  If it did not last, nobody in Akron could fault them for shutting down when they exceeded the tech spec unidentified leakage LCO.  The risk appeared to be worth it. 
                                           
                                          In the final analysis, people screw up for only 3 reasons (and here's a HUGE oversimplification for Dr. Bill - I expect a major rebuttal). 
                                           
                                          We are ignorant (we lack knowledge of the facts),
                                          we are stupid (we have the knowledge but reach the wrong judgments) or
                                          we are deceptive (we have the knowledge, we know better but we decide to see if we can get away with it).
                                           
                                          All our root cause analysis methods - factor trees - staircases - streaming analysis - barriers - timelines - ECFs - MORT - etc etc etc take these broad-bush categories and slice and dice them into more meaningful and specific causes - especially the first 2 categories.  We rarely want to think about or analyze the third category - but human nature continues to confound us. 




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