Am 31. Januar 2013 Abends legte die BKW den Bericht der OSART Mission von Ende letztem Jahr auf Ihrer Homepage auf. Der Bericht zeigt Misstände im Management, im Anlagenbetrieb und der Überwachung. Wohl deshalb wurde er ohne Medienmitteilung auf der Homepage BKW Kernenergie aufgeschaltet.
Am Freitag Abend 1. Februar 2013 um 16:45h wurde der OSART Bericht auch auf der ENSI Seite ausfgeschaltet. Das ENSI fordert nun wieder “knalhart”: “Das Eidgenössische Nuklearsicherheitsinspektorat ENSI erwartet, dass das Kernkraftwerk Mühleberg die offenen Punkte angeht.” Nun ich frage mich wieso hat dass ENSI die Punkte der OSART Mission nicht zuvor selbst festgestellt?
Ende 2011 verliess der langjährige Leiter und Physiker Patrick Miazza des AKW Mühleberg seine Stelle und überliess die Führung des AKW fortan dem Elektrotechniker Hr. Martin Saxer. Der Weggang von Patrick Miazza überraschte die Ankündigung kam damals Anfang Dezember und bereits im Januar darauf war er ersetzt. Die Hintergründe wurden nicht bekannt. Sicherlich war das Fukushima-Jahr eine Stresssituation für den Kraftwerkleiter, Demonstrationen und Sitztsperren von AKW-Gegnern gleich vor dem Kraftwerk zeigten den Betreibern “Wir glauben nicht mehr an die Sicherheit des AKW”.
Nun in einem AKW gibt es viel Technik, die Ansprüche an das Kader sind hoch obwohl die Maschine Strom produziert ist es nicht alleine der Elektrotechniker der die Technik beherrscht, im AKW sind Chemiker, Physiker, Mechaniker, Strömungstechniker, Materialspezialisten, Servicetechniker aller Art, Klima- Lüftungs- Kältetechiker usw. tätig. Organisation ist das wichtigste, ist die Strucktur fehlerhaft werden falsche Entscheide gefällt oder Kommandos zeitlich verzögert. Und gerade dies stellte die IAEA fest!
Im Oktober 2012 besuchte eine Delegation der IAEA in einer OSART Mission das Kraftwerk Mühleberg, diese hatte die Organisation und den Betrieb des Kraftwerks zu beurteilen. Der nun vollständig veröffentlichte Bericht kritisiert das Management des AKW stark. Auch wenn dies die BKW in ihren Medienmitteilungen zu beschönigen versuchte.
Hier ein Auszug aus der OSART-Kritik:
Die Schichtübergabe erfolgt ohne Dokumentation des Anlagenzustandes!!
Validierprotokolle wurden nicht ausgefüllt
Das On the Job Training ist mangelhaft!!
Das Management ist zu wenig auf der Anlage!!
Das Management zitiert oftmals “unser Standard” dieser ist aber nicht dokumentiert
Lokale Instruktionsblätter werden zu wenig auf ihre Aktualität geprüft
Korrekturmassnahmen erfolgen nicht in rationeller Zeit!!
In 8 Schichten im Jahr 2012 war kein ausgebildeter Feuerwehrmann auf der Schicht!!
Das Industrielle Sicherheitsprogramm entspricht nicht dem guten Industrie Standard. “1.5(1) issue: The industrial safety programme is not in line with good industry standards.”
44 Modifikationen seit 2009 sind noch nicht abgeschlossen. “Forty-four modifications implemented since 2009 and turned over to Operations, have not been closed.”
Notsteuerzentrale SUSAN: Das SUSAN Gebäude kann nicht auf lange Zeit als Notstandsgebäude benutzt werden! “The SUSAN building is protected against external risks and is equipped with communication tools with the on and off site locations, but in its current state its long-term habitability by the emergency team is not ensured.”
Die Liste ist erschreckend!!!! Das Management das AKW Mühleberg ist Mangelhaft, die BKW muss sofort handeln! Das Management des AKW hat keine Qualität! Wäre das AKW Mühleberg ein Pharmabetrieb müsste er die Produktion einstellen! Im Statut der IAEA steht “zur Förderung der Atomenergienutzung” kein Wunder winkt diese Behörde das AKW trotz seiner Managementmängel durch!
http://www.iaea.org/About/statute.html#A1.1 ARTICLE II: Objectives: The Agency shall seek to accelerate and enlarge the contribution of atomic energy to peace, health and prosperity throughout the world.
Dieser Link führt zum Bericht der OSART: Innerhalb des Dokuments werden die Felherhaften Positionen unter “Recommendations” aufgelistet.
Auszug der kritischen Punkte aus dem Bericht:
1.5(1) issue: The industrial safety programme is not in line with good industry standards.
- However there is no independent, systematic review and reporting of the on-going safety performance from the plant manager to the utility CEO and review of these reports by Management Board of KKM.
- The KKM plant manager reports to the board relatively freely and at his own discretion. There is no specific structure or indicators to be evaluated.
- The function of the Management Board of KKM concerning the safety review of plant
operation on a continuing basis with formal reports resulting from this activity is not a
formally established requirement
Suggestion: The utility should consider improving its means for an independent nuclear
oversight with a continuous review of safety performance at the nuclear power plant.
- Managers do not spend enough time in the field to observe work places and plant status, to coach plant personnel and to communicate and enforce management expectations. However, there has been a decreasing trend in the use of this process between 2008 and 2011.
- The power plant management has a set of objectives including focus on nuclear safety and an overview of the management expectations is described in a document entitled “Our standards” (“Unsere Standards”). However, it is not common practice by management to explain what this means in concrete terms and to coach the individual.
- There are gaps in setting management standards and communicating them to the staff to report minor problems on equipment and near misses.
- Plant management has recognized that internal goals are not reached but has not yet been able to mitigate the situation.
Suggestion: The plant management should consider spending more time in the field to
observe work places and plant status, coach plant personnel and to communicate and enforce management expectations.
- Industrial safety near-miss reporting is low compared to accident statistics. During the outage 2012 there were one accident with lost work days, 29 instances where minor treatment was necessary but at the same time no nearmiss report was prepared. There is no evidence that line managers expect and enforce near-miss reporting.
- Cable drums not fixed
- In the decontamination area a hot bath with a mixture of water and “Ibel Ex”(a
caustic detergent) (da LAbel EX steht für Explosionsfähig, Anmerkung J. Joss) was not equipped with any warning signs.
Recommendation: The plant should improve the industrial safety programme to further decrease the industrial safety accident rate.
Suggestion: The plant should consider enhancing its training policies and programmes to
ensure appropriate training and qualification of OJT instructors. OJT-On The Job
The plant does very limited self-assessment of the fire prevention and protection programme. Performance indicators are not defined and systematically used to review status and effectiveness of the plant fire protection programme.
- The Shift Manual describes that the field operators have to use a checklist during their shift turnover. However, it was observed that this checklist is not always used during shift turnover.
- The Shift Manual asks that all local instructions in the plant are to be checked regularly to see if they are still valid. If valid, the documents receive a stamp with the check date. However, the validation is missing on some local documents.
Suggestion: The plant should consider clearly identifying and reinforcing its management expectations, its monitoring and assessment practices in operation to ensure that these expectations are well understood and applied correctly by operators at all times.
Two qualified fire-fighters may not be present on the shift at all times because
of age limitations. (Operators above 52 years are not qualified to perform
- In 8 out of 1045 shifts in 2012 two trained operators qualified to perform firemen duties were not available.
- Compensatory plant measures to call plant fire brigade staff do not ensure that they can arrive at the plant earlier than the external fire brigade. Test of mustering of the plant fire brigade in non-working hours has not been performed.
4.1(1) Issue: The plant maintenance staff does not always meet plant requirements and there are areas where expectations are not specified in enough detail.
- Status of maintenance discrepancy reports on safety-related equipment is not followed and acted upon in a timely manner properly by maintenance personnel (two maintenance discrepancy reports from 2011 were still open and not closed)
- Expired calibration period for some electrical instrumentation in electrical laboratory
as a recurring issue used for calibration of non-safety-related instrumentation
- Maintenance procedure of reactor pressure relief valve developed by OEM supplier not verifiably reviewed and approved by the plant
Recommendation: The plant should ensure that sufficiently detailed expectations are
provided and proper adherence to plant requirements is demonstrated in maintenance area by plant maintenance staff.
A backlog exists on closing modifications and there is no tracking indicator on
implemented modifications remaining open. Forty-four modifications implemented
since 2009 and turned over to Operations, have not been closed. Final closure requires affected documentation be updated.
Recommendation: The modifications process should be enhanced to ensure changes to the plant are identified and closed in a timely manner.
Corrective actions (CA): Closed corrective actions took on average of nearly 3 years to complete; At the time of the OSART review, the plant had a total of 19 overdue CA from deviation reports.
Recommendation: The plant should embrace and promote the operating experience program and methods throughout the plant, to ensure corrective actions are timely and OE is used throughout the plant in day-to-day activities.
6.2(1) Issue: Not all departments fully engage with identifying and reporting internal events and not all events that meet internal reporting criteria are reported in order to facilitate learning from events.
- For 2012, up until October 10th, the departments Services (DM) and Surveillance
(UM) wrote 68 and 59 low-level event reports, respectively. On the other hand, the
departments Operations (BM) (excl. the OE manager) and Mechanical Engineering
(MM) only participated with 19 and 11 deviation reports, respectively. Department
Electrical Engineering (EM) has not reported any deviation reports for 2012. Wir erinnern uns Hr. Martin Saxer der heutige Kraftwerksleiter war vorher Leiter dieser Abteilung bevor er zum Kraftwerksleiter wurde!!
- Quality Assurance audit reports, Operational Decision Making (ODM) reports and
information from pre- and post-job briefs are currently not put into any database
Suggestion: The plant should consider to encourage and reinforce reporting of identified
problems at all levels and all departments, inside and outside the organization, according to
well established criteria.
6.5(1) Issue: Analysis of events is not performed in a timely manner and with sufficient level of detail. Root causes, human factor and corrective actions are not always defined in a specific and measurable way.
The control, handling and labeling of chemicals in the plant is not always performed in a way that ensures safe and efficient application and the team has recommended changes.
- Appropriate written instructions are not provided to radiation workers to ensure their
- Events have occurred in the past when inappropriate actions were undertaken which have led to internal contamination events and spreads of contamination. Wissen das sie KKM Mitarbeiter?
- Without written radiological work controls (called a Radiation Work Permit), there is
a risk that inadequate controls will be in place for work which can lead to a spread of
contamination or unplanned exposure.
Recommendation: The plant should reinforce its work control and risk assessment system with the use of an RWP to ensure adequate, written radiological work controls are provided consistently at all times.
7.3(1) Issue: The controls in place at the plant for radiation hazards do not always fully minimise the radiation doses to workers.
Suggestion: The plant should consider enhancing controls for radiation hazards in place to ensure radiation doses to workers are always minimised.
Auch die Chemieabteilung hat Organistions-Probleme
- The chemical phenyl-xylyl-ethane (needed for analytical measurements –
“scintillator”) was valid only to 01.04.2012, but it was still in use.
- Of 800 safety data sheets only 200 valid were available, the other 600 safety data
sheets have been valid but an IT error made them invalid.
- Ether (high flammable) and hydroxide peroxide (fire-promoting) were stored in a domestic non Ex-protected fridge.
Recommendation: The plant should enhance its policy, programs and procedures to ensure
safe and effective application of chemicals.
9.2(1) Issue: KKM has several locations which can be used in emergency situations by the
emergency team. However, most of the facilities are not fully protected against all
emergency conditions (i.e. with protection against radioactive release, fire, flooding
and seismic event). The SUSAN building is protected against external risks and is equipped with communication tools with the on and off site locations, but in its current state its long-term habitability by the emergency team is not ensured.
Recommendation: The plant should provide all reasonable protection for the persons on the site in an emergency with radioactive release to avoid any unjustified health risks.
- The sludge tank 20 A45 is designed for a lifetime of 40 years. It is classified as
components of safety class 4. It has not been inspected since 1995. The plant has no
available data about the life-time of the internal coating. It has not been assessed for
the LTO period.
- The result of scoping is described only as a part of each specific AM report prepared
for safety systems. There is no overall list of SSCs in a scope for LTO in an
equipment master list.
- There is an ENSI requirement to revise AM Reports each 10 years at least.
One report has not been revised within the period specified.
Suggestion: The plant should consider to verify that the scope of SSCs is complete for LTO and properly documented, and that the ageing management review has been performed for all SSCs within the scope.
Suggestion: The plant should consider to review ageing management programmes to ensure that this programme contains all generic IAEA AMP attributes including evaluation against them.
11.3(1) Issue: Environmental qualification (EQ) of originally installed safety cables of class 1E is not completely revalidated for LTO.
- Several safety systems still have the originally installed class 1E cables and have their
original qualification documentation files. Qualified life-time of originally installed
class 1E cables has been defined for 380V power cables, but not yet for control
- ENSI-B01 guideline requires the plant to prepare AM (Ageing Management) reports
for all 1E class components. In some AM Reports for class 1E safety cables the
qualified life-time has not been defined.
- Qualification of original safety control cables was not revalidated for LTO.
Recommendation: The plant should take measures to revalidate environmental qualification for LTO.
Unfall- Accident Management
If multiple measures are described within one AMM strategy using different systems, often no prioritisation is given.
- Information is missing in the AMMs concerning the time needed or allowed to perform the individual action(s).
- The level of detail of instructions to the staff which must perform the action is coarse.
- No information is provided in the AMM check lists on how to proceed if one check fails; nor are any instructions written down to indicate, whether the check list has to be followed in hierarchical order or if parallel actions are allowed or recommended.
- Success criteria or information concerning which plant parameters are to be monitored and what to do, if one instrument fails, are limited.
- AMM(s) available in the current emergency documents folder to be used by plant
personnel in case of an accident, are not always linked to the symptom oriented flow
Suggestion: The plant should consider improving the descriptive details, priorities and
clearly written rules of usage of the guidance given in the procedures (AMM) and guidelines (SAMG). Particular consideration should be given to strategies that have both positive and negative impacts or those with multiple measures planned in order to provide a better basis for a decision about which strategy constitutes a proper response under a given plant damage condition.
- 14.2(1) Issue: The use of the containment venting system CDS under all expected conditions and the link to the use of the containment spray system DSFS is not clearly described in relevant documents: operating procedure, AMM and SAMG.
- The actions to be taken in case the rupture disc in the CDS system fails are not clearly described. A detailed estimation of the possible positive and negative consequences is missing.
- No clear guidance is provided for severe accident cases with possible enhanced leakages from the primary containment (hydrogen, aerosols, noble gases) into the secondary containment at high containment pressure.
Recommendation: The plant should clearly describe in the operating procedure, the AMM and the SAMG documents the use of the containment venting system CDS under all expected conditions for the strategies a) cooling of the torus by steam release through the CDS and b) use of CDS and DSFS under severe accident conditions to prevent containment failure and to minimize activity releases.