Since 1996, operations performance has been cyclical. Looking back at this time period, several attempts to improve Operator Fundamentals have not resulted in sustainable performance improvement. Over the last two years the following events occurred due to weaknesses in operators fundamentals that were classified as significant by INPO: 1. March 19, 2015 - Single loop operation results in unplanned automatic scram due to OPRM upscale trip. 2. October 4, 2015 - Lifted shutdown cooling relief valve failed to reseat, and operators did not promptly recognize the loss of reactor coolant. 3. January 10, 2016 - Extended loss of shutdown cooling. 4. June 17, 2016 - Automatic reactor scram resulting from uncontrolled core pressure and power changes over an extended period of time. 5. October 1, 2016 - Automatic reactor trip and actuation of safety injection in response to closure of a main steam isolation valve (MSIV). IER 17-5, Line of Sight to the Reactor Core was issued in June 2017. It highlighted the following causes and contributors from the events described above. Ineffective operations leadership and crew teamwork. 1. Lack of self-criticality to recognize behavioral warning signs signaling performance decline. 2. Non-conservative operations decision-making. 3. Weaknesses in mitigating proficiency shortfalls. 4. Ineffective training to reinforce operator fundamental behaviors 5. Weaknesses in abnormal operating and alarm response procedure implementation. 6.Weakness in corporate oversight and engagement.
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