IR 05000155/1986015

Insp Rept 50-155/86-15 on 861208-12.Violations Noted: Emergency Preparedness Program Audits Not Submitted to State Govt as Required by 10CFR50.54

ML20207J464
Person / Time
Site:	Big Rock Point File:Consumers Energy icon.png
Issue date:	12/30/1986
From:	Foster J, Patterson J, Hironori Peterson, Snell W NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
To:
Shared Package
ML20207J411	List: IR 05000155/1986015 ML20207J409 ML20207J441
References
50-155-86-15, NUDOCS 8701080466
Download: ML20207J464 (10)

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U.S. NUCLEAR REGULATORY COMMISSION

REGION III

Report No. 50-155/86015(DRSS)

Docket No. 50-155 License No. DPR-6 Licensee: Consumers Power Company 212 West Madison Avenue Jackson, MI 49201 Facility Name: Big Rock Point Plant Inspection At: Big Rock Point Site, Charlevoix, Michigan Inspection Conducted: December 8-12, 1986

,h. fah4D Inspectors: J. PMterson /7- 30/[

Lead Inspector Date ' '

LO.GA h J. Foster / ,zAe/sc Date bo.$)/h H. Peterson Approved By:

(A). Y W. Snell, Chief n ho/34 Emergency Preparedness Date Section Inspection Summary:

Inspection on December 8-12, 1986 (Report No. 50-155/86015(DRSS))

Areas Inspected: Routine unannounced inspection of the following areas of the Emergency Preparedness Program: Changes to the Emergency Preparedness Program; review of emergency facilities / equipment, and required drills; organization and management control; training, including interviews with key emergency response personnel; examination of independent reviews / audits of Emergency Preparedness Program; activations of the emergency plan; and licensee actions on previously identified items. The inspection involved observations on site by three NRC inspector Results: One violation was identified as a result of this inspection which relates to 10 CFR Part 50.54(t); requirements for an independent 12 month review of the Emergency Preparedness Progra PDR ADOCK 05000155 g PDR .

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DETAILS Persons Contacted

• D. Hoffman, Plant Superintendent

• L. Monshor, Quality Assurance Superintendent

• J. Beer, Cnemistry and Health Physics Superintendent

• M. Hobe, Emergency Planning Coordinator (EPC)

• P. Loomis, Corporate Emergency Planning Administrator D. Staton, Shift Supervisor L. Darrah, Shift Supervisor R. May, Shift Supervisor

• R. Buckner, Nuclear Training Administrator

• R. Alexander, Technical Engineer R. Burdette, Senior Health Physicist T. Hancock, Associate Engineer M. Bourassa, Engineering Analyst E. Evans, Engineer

• J. Werner, Chemistry and Health Physics Supervisor-Planning Department L. Schuster, Corporate Quality Assurance Supervisor

• Indicates those who attended the exit meeting on December 12, 1986.

2. Licensee Action on Prsviously Identified Open Items Related to Emergency Preparedness (Closed) Open Item No. 155/84014-03. The type of communication equipment being tested and the correct frequency, shall be specified in the Site Emergency Plan (SEP). Section 9.8.1.2 has been revised for the next revision of the SEP to specify both the type of equipment and the testing frequency, including monthly communication tests with the NRC Headquarter This. item is close (Clo' sed) Open Item No. 155/86002-01. This item relates to the conduct of shift augmentation drills for both 30 minute and 60 minute response capabilities. This inspectors confirmed that such a shift augmentation drill was conducted in May 1986, and another is scheduled for the week of December 15, 1986. Also the EPC has included a statement in a revised EPIP 6I to specify that these drills will be conducted semiannually to demonstrate this capability. This item is close (Clesed) Open Item No. 155/86002-02. The Emergency Preparedness Implementing Procedures (EPIPs) have been amended to provide the proper titles and tabs to correspond with the procedure behind the tab. This should eliminate some of the difficulties encountered by the Shift Supervisors (SSs) in efficiently using these EPIPs, as noted previously in walkthroughs during the January 1986 inspection. This item is close . Emergency Plan Activations Documentation related to activations of the SEP were reviewe Since the previous routine inspection in Janua y 1986, only one activation of the SEP occurred, a Notice of Unusual Event (NUE) occurring on February 11, 1986. The inspector's evaluation concluded that the proper Emergency i

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Action Level (EAL) was used and notifications to the State, Counties, and the NRC were made within the required times and in proper sequence. In addition, several Licensee Event Reports (LERs) issued since the previous inspection of January 1986 (Report No. 50-155/86002) were reviewed by the inspector for possible emergency event classification. None were determined to include any operating conditions which could lead to an EAL for possible emergency classificatio . Operational Status of the Emergency Preparedness Program (82701) Emergency Plan and Implementing Procedures A major and thorough revision of the SEP has been completed and is scheduled for implementation by February 1,1987. A draft copy of the SEP revision was reviewed by the inspector and found to be satisfactor Changes made could not be construed as downgrading the effectiveness of the emergency plan. This major revision is primarily the effort of the EPC, and it should improve the overall quality and specificity of the SEP. Several changes in the EPIPs have also been made which include among others, new organizational titles of individuals who have responsible emergency director positions, elimination of some duplicating procedures, and also a major revision of the Protection Action Recommendations (PARS) chart which is part of the implementing procedures. The latter includes changes more site specific to Big Rock Point, including a security event and PARS level to reduce exposure as recommended by the State of Michigan, all on a single two page foldou A review of the current SEP and selected EPIPs confirmed that they were received and approved by the Plant Review Committee (PRC) and Plant Superintendent as required. Changes to the EPIPs have been submitted to the NRC within 30 days after being issued as verified by independent selection of eight EPIPs, which were revised and distributed since January 198 Document Control at the plant issues an annual verification sheet for off-site recipients requesting that the recipient list which portion of the SEP or implementing procedures they are missing. Also, each is requested to check whether or not that individual wishes to continue receiving either or both documents. This is another mechanism at the plant to assure better document control.

i Based on the above findings, this portion of the licensee's program is adequate.

' Emergency Facilities, Equipment, Instrumentation and Supplies The main change in emergency equipment is the addition of a computerized dose assessment program with related hardware which has been adapted specifically for the Big Rock Point reactor with its more limited reactor parameters and five mile Emergency Planning Zone (EPZ). This computerized dose assessment program as displayed

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on the terminal, included a printout which contained the licensee's notification form and was utilized in two walk-throughs by the inspector. The equipment performed very satisfactorily and the data produced was relevant to the subject matte Communication equipment has not changed; however, the inspector reported that the NRC Emergency Notification System (ENS) telephone line had erratic reception. This E0F telephone has been reported to the NRC several times over the past year as being either out-of-order or erratic in reception. At this time no effective repairs have been mad There is only one ENS telephone at the E0F in Boyne City, Michiga The inspectors recommended that it be moved from the designated NRC office room to a position closer to the E0F Communicator. Both Health Physics Network (HPN) telephones were identified in the EOF. The second extension at the EOF Director's table should be moved to the HP work area where it could be used more advantageously. This information has already been forwarded to the Region III's Incident Response Coordinator to initiate these changes through NRC Headquarter An emergency kit in the Operational Support Center (OSC) was selected to be inventoried. It was found to contain all required emergency supplies, dosimeters, and monitoring equipment. An inventory list was included inside the kit. Ir.ventory records on the kit were adequat Based on the above findings, this portion of the licensee's program is. adequat c. Organization and Management Control A new Emergency Planning Coordinator (EPC), M. Hobe, has been appointed as of approximately September 1, 1986. She had been functioning on a part-time basis in this position for several months before the September 1986 appoini. Ten The new EPC, a former training instructor from the Midland site, also conducts all the EP Training for the emergency response positions at Big Rock Point. From an organizational standpoint the EPC reports to the Chemistry / Health Physics Superintendent, who, in turn, reports to the Plant Superintendent as identified in the emergency procedure This line of supervision for the EPC should be included in the Big Rock Point organization chart as listed in Section 9.5, Page 20, Figure 9.5.1, of the SEP where it is more visible than in the Administrative Procedures. Several management job titles have changed in the last six months. These new job titles will be listed in the next revision of the SEP, scheduled for implementation by February 1, 1987. Where applicable, these new management-level job titles will be included in the revised EPIPs as confirmed by the inspector. The qualifications of those assigned emergency response functions have not been downgraded to any extent as determined by the inspection team. With very few exceptions the emergency functions relate directly to the individuals normal job ,

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Based on the above findings, this portion of the licensee's program was acceptable; however, the following item should be considered for improvemen *

The plant organization chart in the SEP should be revised to include the position of Emergency Planning Coordinator and its line of reporting to the Plant Superintenden d. Training Walkthroughs and interviews were conducted with three Shift Supervisors (SSs), two On-Call Dose Assessors and two Dedicated Communicators to assess the quality of the training program, as well as to determine their proficiency and knowledge in implementing their assigned emergency response duties. All three SSs could use the EALs correctly, properly classify the event and perform their emergency functions well as initial Site Emergency Director However, one SS was not aware that all emergency response facilities (ERFs) were activated at the Alert level or that 15 minute updates to State and local agencies as well as the NRC were required every 15 minutes according to EPIP 4I. The initial SED should be cognizant of these basic requirements, even though he may not personally implement them. The two On-Call Dose Assessors and the two Dedicated Communicators demonstrated very good knowledge of their emergency assignments and utilized their emergency equipment in a proficient manner. The printout from the computer now includes dose assessment data and a few other parameters already typed in before the Dedicated Communicator completes this notification for Emergency Preparedness (EP) training for Big Rock Point was conducted by the licensee's Midland Training Center up to the present tim Currently, the new EPC conducts virtually all EP training at the sit This change should prove beneficial since suggested improvements or variations in the training courses car, be readily incorporated into the training program by the EPC/ Training Instructor to better improve the progra .

A systematic review of training records, training schedule, course outline / content, training matrix, procedures and drill / exercise records was conducted to assess the quality of this training program. The licensee has a computer controlled personnel training attendance record. A review of this attendance record was made for the EP positions of Site Emergency Director, Shift Supervisor, On-Call Technical Advisor, Technical Support Group Leader, Dose Assessor, and Chemistry / Radiation Protection Technicians. These records do not constitute official records. Therefore, the inspector requested several select personnel training records to verify the computer dat It took approximately one day to retrieve these records because the training records were microfilmed and stored at the Midland Training Center. Only Fax copies were reviewed. After the records were microfilmed the hard copies were destroyed. Upon review of the training records compared to the training matrix, two inconsistencies were foun . _ _ _ _ _

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(1) In accordance with the EPIP 4C, the On-Call Technical Advisor (OTA) should be able to assist the Site Emergency Director (SED) in the following areas:

(a) Core damage calculations and release rates to support emergency classifications, and (b) Support of off-site dose calculations and updates (EPIP 5A) if the Dose Assessor needs hel According to the Site Emergency Plan Matrix 5.06 of Administrative Procedure 1.7, Master Training Plan, the OTA's are not required to take the Core Damage or Dose Assessment training. The training records listed three out of six individuals designated as OTA's who had received such trainin These training modules should be consistent and administered to all designated OTA's. For consistency the SEP Matrix 5.06 should be changed to add these modules as requirements for OTA's. This will be tracked as part of open item 50-155/86015-0 (2) In accordance with SEP Matrix 5.06 of Administration Procedure 1.7, Master Training Plan, Dose Assessors are to receive the Post Accident Sampling System (PASS) training module. Two such individuals designated as Dose Assessors have not yet received PASS training. The EPC has stated that upon review of Dose Assessor duties; the EPC decided that the PASS training was unnecessary, and therefore, a change in the Administrative Procedure was implemented this year. The other individuals designated as Dose Assessors also have other responsibilities which requires them to take the PASS trainin The SEP Matrix 5.06 required the changes as described, be implemented to correctly reflect the training requirement This item will be tracked as part of open item 50-155/86015-0 Any pertinent changes to the SEP and EPIPs are documented and tracked for appropriate training on the changes, via SEP seminars and by the use of the QA-05A form The EPC keeps a projected 12 month training schedule for emergency preparedness training and tentative drills. This assists the EPC in ensuring appropriate training be conducted within prescribed time requirement The training modules and course outlines are fairly well organized; and as determined from interviews with operators, are also well presented. The training program incorporates a critique form at the end of the training session to receive comments and suggestions. These critique forms are reviewed by the EPC to determine how to use them to improve the training progra ,

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The EPC has implemented a periodic dose assessment problem pac This new method is being utilized for requalification of Dose Assessors to reduce the time in classroom training while still maintaining a high level of emergency preparedness. Those problems are to be completed by those who may be responsible for dose assessment; and their signature assures that the problems were completed without assistance from any other individuals. This program is a good method in establishing a refresher check. Although the SEP authorizes self-study as an adequate method for requalification, the classroom training and drills should still be the primary form of trainin The plant also conducted plant specific training for off-site support personnel. This training is annotated at Emergency >

Planning Meetings with State / Local governmental authoritie The required annual review of EALs with state and local agencies was conducted on December 10, 1986 by a staff member of the licensee's corporate EP group. The inspector reviewed the format and attendance list and concluded this meeting satisfactorily met the requirement of 10 CFR 50, Appendix E, Part I The drill program requires evaluation, documentation and critique The inspectors review concluded that communication drills, fire drills, semi-annual HP drills, annual radiological monitoring drills, annual emergency repair team drills, annual post accident sampling drill, and an annual emergency medical drill were being conducted as required by Section S.8.1.2 of the SEP. Documentation of these drills was somewhat difficult to obtain, particularly the monthly communication drills with the NRC and state and local counties. Hard copy of these tests were unavailable for several of the months. Microfiche records were retrieved by the licensee's staff with a great deal of effort. Documentation was poor on the annual participation of off-site fire and ambulance support agencies for the required annual fire drill. A security audit was found which established that a fire drill was conducted and also listed a timeline of two entries indicating that the local Fire Department had arrive Such secondary documentation of a required annual fire drill is less than adequate and marginally acceptable at best. The drills identified in the SEP as Emergency Repair Team, Radiological Monitoring, and part of the Health Physics drill were conducted as required, but all three were done as part of the annual emergency exercise. This practice is adequate, however, it should have corresponding documentation to annotate this course of action. One exception to inadequate documentation of drills was the shift augmentation drill conducted in May 198 Documentation indicated that the drill was satisfactor Suggestions for improvement were included by the EPC at that time, and action has been initiated in the suggestions. The next drill is scheduled for the week of December 15, 198 ,

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A previous inspection conducted on November 13-16, 1984 (Report No. 50-155/84-14 made a similar finding that the NRC preferred that drills be conducted following the guidance of NUREG-0654,Section II.N.2, and be conducted separately from the annual emergency exercis The plant adequately performs drills, and they utilize drill and exercise critiques to improve upon their training progra This is accomplished by the use of an AIR (Action Item Record)

form. The critique items are documented and tracked via the AIRS. The plant then follows up on these items, and once all the items are resolved, the results are recorded via a letter titled " Emergency Planning: Resolution of Exercise # Critique Items." Overall, the plant is adequately performing the training and drill requirements. However, throughout the inspection, pertinent records were not readily available, and in one instance the records were lost. There is definitely room for improvement in the organization and the maintenance of pertinent Emergency Preparedness related records and in increasing their retrieval capability to make a more efficient and organized EP program at Big Rock Poin Based on the above findings, one open item was identifie In addition, the following item should be considered for improvement:

The licensee should improve the administration and document maintenance related areas of the Emergency Preparedness Program to provide better continuity, retrieval, and efficiency for this aspect of the progra e. Independent Reviews / Audits The inspector reviewed the independent reviews of the Big Rock Point Emergency Preparedness Program performed by the Corporate Quality Assurance Support group and by Detroit Edison personnel from the Fermi Nuclear Plant. A mutual agreement with the licensee to meet the requirements of 10 CFR 50-54(t) was arranged between Consumers Power and Detroit Ediso Audit Report No. QT-86-2, dated May 13, 1986, was conducted from April 21-25, 1986. The main portion of the audit was Health Physics and Shipping and Packaging of Radwast Emergency Planning findings were interspersed with the other two audit areas. One procedural deficiency for EP was identified. This deficiency was an outdated and incorrect listing of emergency response personnel as listed in EPIP 6F, Emergency Notification. A deviation report was issued and action was initiated to update and correct the listings of these individuals, some who no longer worked at the site. The inspector confirmed that adequate corrective actions had been taken. One other statement was listed in the audit report as applicable to

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m P all three ' areas examined, including EP. This was'"the exercise 1 of administrative controls in the areas examined appeared to be :

marginally adequate." This statement was exemplified in the poor '

availability of certain training records as described.in '

Section 4.d of this_ repor l One observation in EP was made in that plant procedures require that the Plant EPC prepare a summary report of all emergency drills and exercises for PRC review. The EPC considered this unnecessary since there_were extensive reviews / overviews given these exercises and chose not to prepare the reports. The licensee auditors considered this a " Condition Adverse to Quality Requiring Response and Remedial Corrective Action." This observation is being tracked by AIRA-QG-86-25, the plant's action item tracking. syste Thus, the only two items relating to EP have been followed up and management was made aware of the status of the items. The audit plan did not include any specific references to 10 CFR 50.54(t) or Appendix E to 10 CFR Part 50. The audit was only marginally acceptable, lacked depth, and did not address most of the EP progra The other portion of the independent annual review was conducted by a separate, independent utility on May 20, 1986 in conjunction with the annual Big Rock Point exercise. This portion of the annual audit was not reported to the licensee until almost three months after it took place, specifically on August 6,1986. The letter contained

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observations and comments on the exercise performance in the TSC/ Control Room, E0F, and JPIC. Also_ included was a short section entitled " Organizational" with general programmatic .recommendatio_n No other documentation regarding the effort was available. It could not be determined that the adequacy of interfaces with State and local governments had been evaluated. A check list used in evaluating various portions of this audit was not included in the documentatio The inspectors learned from the licensee's Corporate Emergency Planning Administrator that a check list regarding audit findings was never received by the licensee from Detroit Ediso Discussion with licensee personnel indicated that neither the licensee conducted audit nor the one done by Detroit Edison had

- been made available to the State or local governmental agencie Both reviews / audits did contain areas which were relative to offsite support agencies. The licensee transmitted these two documents to the State of Michigan representatives after the inspector called it to their attention during the inspection. The licensee's EP representatives indicated that copies of the audit were not sent to the local counties, but, rather the counties would be provided with them for review by the State of Michigan. Discussion with State of Michigan personnel indicated that they were not aware of this arrangement. Therefore, these portions of the independent review

" involving the evaluation for adequacy of interface with State and

, local governments (which) shall be available to the appropriate. State and local governments" were not made available. This is contrary to 10 CFR Part 50.54(t) requirements. Post-inspection information

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determined that the review done by Detroit Edison did in fact include a 25 page check list which was never received by the license Since a Region III team observed this review during the May 1986 Big Rock Point exercise, the inspection team confirmed that the review was made. However, 10 CFR 50.54(t) requires that the results of the annual review, along with recommendations for improvements, shall be documented, reported to the licensee's corporate and plant management, and retained for a period of five year Failure to implement the 12 month 10 CFR 50.54(t) review as stated above, is a violation and will be tracked as open item 50-155/86015-0 Based on the above findings, one violation was identifie . Exit Meeting The inspectors met with licensee representatives (denoted in Section 1)

at the conclusion of the inspection on December 12, 1986. The inspectors summarized the scope and findings of the inspection. There was considerable discussion regarding a probable violation involving the required independent 12 month review of the licensee's Emergency Preparedness Program. The inspectors clarified what components should be included in the review. The licensee agreed to consider the items discussed and stated that none of the material discussed was proprietary in natur