IR 05000249/1991041

Enforcement Conference Rept 50-249/91-41 on 911121.Major Areas Discussed:Circumstances Surrounding 911011 Unplanned Exposure of Two Workers During Inservice Insp

ML17174B045
Person / Time
Site:	Dresden
Issue date:	12/06/1991
From:	Schumacher M NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
To:
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ML17174B044	List: IR 05000249/1991041 ML17174B043
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50-249-91-41-EC, NUDOCS 9112160296
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I NUCLEAR REGULATORY COMMISSIO~

REGION III

Report No. 50-249/91041(DRSS)

Docket No. 50-249 License No. DPR-25

.Enforcement Action No.91-152 Licensee:

Commonwealth Edison Company Facility fliame: *Dresden Nuclear Power Station - Unit 3 *

Enfcircement Conference At:

Region III Office, Gl~n Ellyn~ Illinois Enfortement Conference Conducted:

November 21, 1991 *

/I-A. l( ~-

Inspector:

M. A. Kunowsk Approved By:

__ ?ffo~~Jl~;f t:*~ik~~

M. C. Sch~~her, Chief

,

Radiological Controls and Chemistry Section 12-~*-11 Date Enforcement Confer~nce on N6vember No. 50-249/9104l(DRSS))

,

reas 1scusse :

e c1rcums ances surrcun 1ng e cto er 11, 1991, unplanned exposures of two workers during inservice inspection were discusse Included in the discussion were the *accuracy of Inspection Report No. 50;.249/91033, in which thi~.event is d~scribed in detail, root causes, and the short and long-term corrective action ~DR ADOCK 05000249 PDR

DETAILS Persons Present at the Enforcement Conference Commonwea 1th Edi son Company D. G*a11e, Vice President;.. BWR Operations K. Graesser, General Manager, BWRs T. Kovach, Nuclear Licensing Manager C. Schroeder, Station Manager

. P. Barnes, Compliance Supervisor D. Ambler, Health Physics Supervisor, Dresden F. Rescek, Nuclear Stations Radiation Protection Director D. Saccomando, Compliance Engineer R. Flessner, Administrative Engineer S. Trubatch, Counselor R. Krohn, Radiation Protection Supervisor, Dresden D. Hieggelke, Health Physics Supervisor, LaSalle A. Lewis, Health Physics ~upervisor, Quad Cities K. Peterman, Regulatory Assurance Supervisor, Dresden R. Geier, Mechanical Maintenance _Master, Dresde H6rbac~ewski, Inservice Inspection/Inservice Testing Group Leader R. Aker, Radiation Protection Assessment Administrator M. lesniak, Health Physics Supervisor, Corporat W. Morgan, BWR Nuclear Operations

.

.

K. Yates, Onsite Nuclear Safety Administrator, Dresden P. Piet, Nuclea~ Licensing Ad~inistrator, Dre~de U. S. Nuclear Regulatory Commission C. Norelius, Director, Division of Radiation Safety and Safeguards R. Greger, Chief, Reactor Programs Branch B. Berson, Regional Counsel M. Schumacher; Chief, Radiological Controls and Chemistry Section W. Troskoski, Acting Director, Enforcement and Investigation Coordination Staff P. Pelke, Enforcement Specialist R. Lerch, Project Engineer P. Louden, Radiation Specialist N. Shah, Radiation Specialist T. Kozak, Radiation Specialist R. Paul, Senior Radiation S~ecialist thforcement Conference An Enforcement Conference was held in the NRG Region III office on November 21, 199 The purpose of the conference was to discuss the circum~tances surrounding the October 11, 1991, unplanned exposure*of two workers who were conducting inservice inspection (ISi) on the compor.ents of the "B" recirculation pump discharge valve (valve 3-202-5B),

a 28 double-di~c gate valv The ISi was conducted as part of a critical path job to remove, repair, and re-install the valve component An

inspection was conducted from October 15-25, 1991, and the inspection findings were doctimented in Inspection Report No. 50-249/91033(DRSS),

transmitted to the licensee -0n November 8, 199 The c6nference agenda included (1) a discussion of the apparent violations; their causes and safety significance, the licensee's immediate and long-term corrective actiohs, and areas of concern, (2} ~determination i there were any escalating or mitigating circumstances, and (3) obtaining further information which would help determine the appropriate enforcement

• action. The licensee did not identify any inaccuracies or discrepancies in Inspection Report No. 50-249/91033(DRSS).

• *

_

.

lhe licensee described the events which led to the apparent violations,*

including the root causes, safety significance, and their corrective actions.* The licensee indicated that the ev*ent was an isolated problem involving a non-routine _inspection, with no potential for a regulatory overexposure. * One of the long-term cor~ective actions for this event would include the revision of station procedure OAP 12-09, 11ALARA A~tion Reviews, 11 to ensure that non-routine inspection activities were adequately evaluated ~nd workers assigned to those jobs were adequately briefed prior to the job. Other corrective actions are described in the attached copy of the licensee's handouts from the enforcement conferenc These actions will be reviewed during future inspecti-0n *

Also at the conference, the licensee acknowledged that the technician who covered the ISi *had worked four 14-'hour shifts ih the four days prior to the event, but stated that there was no indication that fatigue was a factor in his performanc Nonetheless, the licensee added that effective January 1, 1992, the overtime of all radiation protection personnel would be limited in accordance with NRC Generic Letter 82-1 Previously. the overtime of only one radiation protection technician per shift, the "duty" technician, was limited by the licensee in accordance with the generic lette Based on the change in the overtime policy,' Open Item N /88009-01; 249/88011-01; which was opened to review the appropriateness of the previous policy, is close The lice.nsee's implementation of the new-policy will be reviewed during future inspection At the conclusion of the conference, the licensee was informed that they would be notified in the near future of the final enforcement actio Attachment:

As stated

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...

'NOVEMBER 21, 1991.

DRESDEN ENFORCEMENT CONFERENCE UNPLANNED ADMINISTRATIVE OVEREXPOSURE.

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AGENDA

. INTRODUCTION EVENT CHRONOLOGY EVENT SIGNIFICANCE * :

CONCLUSIONS AND CORRECTIVE ACTIONS

.SUMMARY

/scl:l329:1

• K. GRAESSER D~AMBLER F.RESCEK C.SCHROEDER D.GALLE

INIBODUCTION The Radiation Work Control Program and the Radiation Work Permit Program are fundamentally soun The root cause of the event is the failure to include a non-routine inspection activity in the pre-job planning proces Worker dose could have been reduced had RP personnel been more assertiv *

Actions of the Rad Tech showed that overtime is not an issu * The root and contributing causes will be addressed by both specific and general corrective action Applicability to other CECo Stations will be addresse Doses could not realistically have exceeded regulatory limit The event does represent a departure from. management expectations regarding performanc Conclusions are based on the following analysis of the even. */scl:1329:2

EVOLUTIONS OF A* JOB JOB WO~ REQUESf SIGNED PREPARATION AlARA ACilON* REVIEW NO

... I. RWP INI1lATED *.1 REQUIRED

....,FOR WORK.IN RCA

.* YES

COMPLIITE JOB EXPOSURE YES I RWP MARKED AS I NO ESllMATE FORM

--

. I AAR REQUIRED. I

< 1 PERSON-REM YES

... I > 1 R/HR WORKING DOSERATE )

&;

....,

> ~.000 DPM/100 CM2

< 2 MPC - HOURS O.. /AIARA CONDUCT NO PREJOB MEE11NG

....

~

Wl'IH JOB SUP PREJOB CHECKLIST COMPLEI'ED 1 r STATION AI.ARA COMMITTEE REVIEWS WORK TO BE PERFORMED AND MAKES RECOMMENDATIONS JOB PERFORMANCE

~NO YES ~r NO

< s BUI' > 1 PERSON-REM I EXPOSURE ESilMATE

~YES AND RADIOLOGICAL PI.ANNING PRECAUilON INCLUDED ONRWP AND PROCEED NORMALLY COMPLIITE PREJOB CHECKLIST u

I NORMAL RWP ~

.

. PROCESSING

~

REVIEW * PREJOB

-

CHECKLIST I

CONDUCT PREJOB MEE11NG

..

CONDUCT PREJOB -

BRIEflNG

~

....

~

MONITOR EXPOSURE

. JOBS > 1

...

RE_CE_IVE_D*D*U*Rl""N*G*1HE-*J*O*B...

-P-E_RS_O_N __ -REM--al*. AI.ARA STAFF REVIEWS WORK IN PROGRES Wl'IH WORK GROUP SUPV. AND JOB REVIEW JOB COMPLEl'ED ie---~

NO MAKES RECOMMENDATIONS FOR IMPROVEMENT.

TOTAL JOB> 1 PERSON~REM f-------~ POST-JOB REVIEW MAY BE LIMITED TONORMAL RWP YES CLOSEOUI' AND

> S PERSON-REM 1-----~

YES POST - JOB MEE11NG AND REVIEW POST - JOB REVIEW BY STATION AI.ARA COMMITTEE POST - JOB REVIEW NO DOCUMENTATION POSf - JOB REVIEW REQUIRED NORMAL RWP CLOSEOUI'

AND DOCUMENTATION MAINTAINED INJOB 1-------~-----~

HISTORY FILES

-.

• JOB PLANNING Nuclear Work Request 090960 (02190)

Initiated to replace the valve stem and nut of the recirculation pump discharge valve, 3-202-58

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2. * Radiation Work Permit (RWP) Request (09/03/91)

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Maintenance submitted a RWP request form to Rad Protection which included:

A description of the work to be performed including:.

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Valve disassembly Clean and inspect

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Replace stem

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Reassemble valve

. *. The expected person hours to be expended for each job task..

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Rad Protection reviewed the RWP request and performed surveys as require **

The job exposure estimate, based on the surveys and previous work histories of similar valves, met the criteria for an ALARA Action Review (>1 person.:.rem). ALA RA Action Review (09/09/91)

/scl:l329:4 The extent of pre-planning and reviews is based on the job's estimated collective person-rem expenditur Work Request 090960 met the Action Level 3 criteria (>5 person-rem) requiring:

ALARA Action Review Pre-Job Checklist

ALARA Committee Review

• Job Specific RWP with basic rad practices identified

JOB PLANNING (Continued)

Pre-Job _Checklist Identifies-items to be considered in planning

• _ Process Planning Items such as:

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Job procedures RP hold points

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Special training requirements

• Job Setup and Preparation Items such as:

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Work_ area planned to reduce exposure

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Low dose staging area

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Remote monitoring equipment

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Protective equipment

Wc:>rker Preparation Items such as:

- _ Worker selection and worker numbers Job rehearsals and mockups

• * Additional Exposure Reduction Methods

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Other items considered based on previous ALARA experience ALARA Committee Review (ACR) (09/10/91)

/sci:1329:5 An ACR was initiated based on the job estimate of 2.88.

person:-rem and an expectation that the job might exceed 5 person-re The ACR reviews and evaluates jobs estimated to exceed 5 person-rem, ensuring effective dose reduction measures are applie *

....

The ACR reviewed the dose reduction recommendations and approved the wor **

JOB PLANNING (COntinued) * RWP PaCkage initiated (09/11191)

• A job specific RWP-was issued for the removal of the valve operator and stem, and replacement of the stem by complete*

disassembly of the valve at the bonnet Protective actions and special instructions were specified in the RWP to be implemented during performance of the job. This included:

Use of protective clothing

Use of respiratory protective equipment ** *

Application of ALARA

Use of dosimetry

• . Job coverage by RP personnel.*

Special RP survey and sampling requirements ALA RA Action Review (09/20/91)

The Pre-Job Checklist was enhanced based on previous Quad Cities experienc Analysis of f>rlb.Job Planning Despite the limited attention to inspection, the RWP, in conjunction with*

the pre-job briefing process, was adequate to control radiological aspects of the maintenance jo * * Use of the generic terms inspect or clean, without specific task details,

• does not allow for effective pre-job planning from an ALARA perspectiv.

VT-1 Inspection attributes were not reviewed/evaluated adequately

. because they were not delineated in the job task analysis.

/scl:l329:6

.. :.**

JOB BRIEFING (8 a.m. 10/11191) Maintenance Briefing (MEMO 300.12)

Provides guidance to Maintenance Supervisors on the conduct of

• a pre-job briefing with assigned crew members. The briefing

. covers the scope of work* to be accomplished that shift. The depth

• of the briefing is based on the experience of the worker on the jo As applicable, items for discussion include:

Personnel safety

Scope of work

.

Procedure adherence

RWP/ALARA requirements

• Special tools required and their use

• QC, NQP or other hold or witness points

• VERANTSO (self check program)

Analysis Of Maintenance Briefing

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.*

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.. The briefing*for the*valve disassembly was very thorough including drawings and sketche$. The timely, accurate completion of the valve's disassembly indicates an effective pre-job briefing for this phase of the.

jo.

VT-1 Inspection attributes were not covered during the briefing.

/scl: 1349: 7

JOB BRIEFING (Continued)

-- ALARA Briefing (OAP 12*9)

The pre-job briefing for Work Request 090960 was to include all work groups involved in the job for that shif *

The ALARA Pre-Job Briefing Checklist is to be completed by each.

Job Supervisor for each work crew on the job. The workers

. *

acknowledge attendance by signing the Checklis Checklist briefing includes items such.as: -

Work area description, job layout, task assignments, routes

Working dose rates, hot spots, low dose_ rate areas

Requirements forprotective clothing

Work practices to minimize time and potential contaminations

Guidelines for work in high dose rate gradients or localized hot spot areas

Analysis of ALARA_ Briefing The ALARA briefing was based on the pre-job planning per1ormed. It's focus for this shift's briefing was the valve's disassembly; The need for

• the VT-1 inspection was discussed in general term.

Personnel not present - Rad Tech #2, ISi engineer, Maintenance General Foreman Rad Tech #2 knew from the beginning* of his shift that he was to cover the 58 job on the second part of the shif iSI engineer did not know until mid-morning that he would be per1orming the VT-1 inspection..

Maintenance General Foreman, late in the morning,. volunteered to conduct the maintenance aspects of the inspection rather than the Maintenance Supervisor who conducted the pre-job briefing. This was done because the General Foreman had less accumulated exposur Copies of the "Guidelines for Work in High Dose Rate Gradients or Localized Hot Spot,A.reas" were not provided to the workers involved in the job. However, the basic information contained in the guideline was conveyed to the workers during the pre-job briefing:

Non-attendance by these individuals is contrary to procedures and

• unacceptable. However, each worker did participate in field briefings for their specific job scope..

/scl:l329:8

. JOB PERFORMANCE Valve Disassembly

• Disassembly of the valve went smoothly... Overall completion of *

this task was efficient and effective from both a maintenance and ALA RA perspectiv *. Post Disassembly Surveys Adequate surveys were taken based upon completion of.the disassembly tas *

Results of the survey were not immediately documented onto a*

one-line survey or survey ma. * Inspection Activities

/scl:1329.:9

. The General Foreman and ISi engineer arriv~d at the job site.

separately.

. Dose extensions to 300 mrem were authorized for the two worker the General Foreman received a field briefing by the Job Supervisor, including a review of the work area at the video *

monito Rad Tech #1 provided an ALARA briefing with respect to current radiological conditions, dosimetry placement and advised.the worker on areas to stay away fro The *1s1 engineer received a field briefing by the Job Superviso The specific inspection process was not discussed. The adequacy of the inspection. mirror was addresse Rad Tech #1 provided an ALARA briefing with respect to current radiological conditions, dosimetry placement and advised the worker on areas to stay away from. The ISi engineer indicated

• that penetration of the valve body plane would be necessary to perform the inspection. The Rad Tech reiterated to stay out of the valve body. No follow through was made on this point of *

difference between the two worker As the workers entered the work area Rad Tech #2 arrived to relieve Rad Tech #1 on the job. The turnover included a discussion of the inspection, current radiological conditions, and *

time-keeping for the worker Continuous air sampies were being taken in the work area.

The. seat* and dis.c inspections were carried out by the worker *

JOB PERFORMANCE (Continued)

Analysis of F1eld Pre-Job Briefings 1. * The field briefings were not effective in that: *

i

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The maintenance and ALARA briefings were conducted separately. *

The details of the inspection process were not fully discussed by any of the worker *

• *, *

Communications*between the Rad Tech and ISi engineer were not adequat *

• • The Rad Tech did not reach resolution with the ISi engineer when it was indicated that he would break the valve body plan.

The process for field briefings is not formalize Analysis of Inspection Activities

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. There was no discussion of the disc separation during any p_hase of the job planning/briefing. Appropriate surveys were not performed upon disassembly of the valve.disc to ensure.radiological conditions were as expected. *

2.. The workers were over-zealous with respect to completing their assigned task without evaluating/performing the task in a radiologically

• conservative manne *

. The RP personnel were not sufficiently aggressive in admonishing the workers to comply with their directions. Neither the Rad Tech nor the ALA RA Coordinator stopped the job to better evaluate radiological.

conditions and dosimetry placemen * Results of a 1210 air sample indicated 3.3E-8 uc/cc in the tent. This information was not made available to RP personnel in the bullpe This should have prompted additional RP action..

/scJ,.:i329:10

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APPARENT.CAUSES/CONTRIBUTORS

. Apparent Boot Cause The scope of inspection activities, including the separation of the disc *

for inspection, were not adequately discussed or communicated during the pre-job planning/briefing. Had this been properly considered, subsequent actions would have been appropriate to preclude an overexposure (i.e., dosimetry placement, enhanced worker knowledge, appropriate surveys).

Apparent Contnbuting Causes. Inadequate eoniniunications between the workers involved in the job including a lack of follow through when differences were identifie.

Failure of workers to implement radiologically conservative work practice.

Failure to fully implement station procedure Other Issues

• Corrective actions associatedwith the prior administrative over-exposure events in* 1989 and 1990 were evaluated. These action appeared to be appropriate to those events' root causes. However, job planning, and specifically inspection activities, was not fully evaluated as part of these action.

Rad Tech. #2 did work four 14 hour1.62037e-4 days <br />0.00389 hours <br />2.314815e-5 weeks <br />5.327e-6 months <br /> days preceding the day of the event. Based on a review of the event, and the performance of Rad Tech #2 during that period, it is not apparent that overtime worked*by the Rad Techs was a contributor to the even *

...

/scl:l329:11

.. EVENT SIGNIFICANCE.

. OVERVIEW Health and safety risks to the workers were minima * Worker exposures could not have exceeded regulatory limit * The event is significant in that the administrative dose limits were exceeded by a wide margi *

DOSE EQUIVALENTS RECEIVED BY THE WORKERS Dose assessment methodology provided a*realisticupper bOunding calculatio * Doses to be credited:

ISi Engineer

• Maintenance Foreman WBDOSE SKIN of WB. EXTREMITY 1175 mrem 1429 mrem 558 mrem 746 mrem 1683 mrem 846 mrein Post-event whole :body dose totals:

ISi Engineer. * *

• Maintenance Foreman

/scl:1329:12 4th OTA 1178 582

• YEAR 234.

• EVENT SIGNIFICANCE (Continued)

CONTRQLS/CONDmONS 1. * Work scope was limited.

. Valve body inspection took about 7.5 minute Disc inspection took about 12.1 minute.

• oose approvals were for 300 mre Electronic dosimetry alarm setting was 240 mre.

. Rad Tech was timekeeping based on 20 mrem/minute at the ankl.

Measured dose rate gradients for the disc inspection were not large enough fora portion of the whole body to exceed 3 rem before th electronic dosimeter alarmed.

. The workers were knowledgeable of their approved dose of 300 mrem and that the dose alarm was set at 240 mrem accumulated dos * Remote video monitoring and communication devices were available..

• Workers*received instructions to-back away from.the dis SUMMARY* Two individuals received unplanned dose equivalents above administrative limit.

Given the radiological conditions and scope of work,. the controls in place ensured that no worker could receive a dose equivalent in excess of regulatory limit /scl:l329:13

CONCLUSIONS Regulatory limits were not exceeded and a substantial potential for

. exceeding these limits was not eviden.

. The use of video equipment was a valuable tool in the identification and analysis of this even * The managerial and administrative systems of the radiation protection *

program provide multiple layers of control and* are essentially soun However, we need to enhance the process with respect to evaluation of inspection activities for certain challenging non~routine/high dose jobs.

[procedure content]. Contributing to this event were individual failures to.follow certain

• .elements of established procedures and conservative radiological work practices [procedure adherence].*

s:

This event represents a departure from management expectations regarding performance (communications/management expectations].*

/scl:l329:14

IMMEDIATE ACTIONS.COMPLETED Stopped work on job; informed upper station management and Corporate Radiation Protectio.

• Reviewed similar ongoin-gjobs (no similar problems found)~

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. Notified NRG Senior Resident Inspector of the event.*

4. *

Prohibited the two workers from entering the RCA pending evalu~tio.

. Counseled workers~ Investigation completed by team of station/corporate personne.

Lessons Learned Initial Notification report was issued on-10/15/91 to all CECo nuclear station *. The Station Manager and Vice President BWR Operations met with station supervisors on 10/24/91 to discuss recent performance problems and management expectations.. On 10/25/91, station supervisors met with station employees to discuss recent perlormance problems, including this event, and to convey corporate management's expectations regarding conduct of wor /scl:1329:15

,.

.SPECIFIC CORRECTIVE AQTIONS TO BE TAKE.

• The ALARA Action Review process, OAP 12:-09, will be revised by December 31, 1991 to correct deficiencies identified from the analysis of,this event including:

• Evaluation of non-routine inspection activities.

. Evaluation of the adequacy and detail of the job tasks identifie Methods to ensure that all workers are appropriately briefe * 2. * Senior station management Will communicate it's expectations to all personnel regarding their responsibilities for radiological safety, minimization of exposure and performance of work In a radiologically

. cons~rvative manner. This will be included in all station meetings which.

will be conducted by January 31, 1992. Also, 1992 performance appraisals Will include items regarding radiological performance of wor.

During ttie 1992 Rad Tech Continuing Training, a lessons learned session will be conducted to review the 1991 Unit 3 refuel outag Specific emphasis will be placed on:

Open discussion between the Rad Techs, RP Supervisors and

\\;.

• - Operations Health Physics personnel regarding outage problem *..

Barriers encountered during performance of work;*

• 4. * The station will develop lesson plans addressing conduct of

• radiologically challenging jobs to be used in departmental continuing training. The lesson plans will be focussed at three levels of radiation workers including: (1) RP Department personnel, (2) supervisors and planners, and (3) other personnel who routinely perform work In radiologically controlled areas. This will be accomplished by March 31, 199. Corporate Radiation Protection will direct the preparation of a Lessons Learned Report based on the evaluation of recent CECo unplanned *

exposure events. Appropriate recommendations will be made by

• .February 1992 to improve overall processe.

The station will incorporate application of good rad practices/ ALARA into the long term review action plan of planning, scheduling, work control activitie /scl:1329:16

CORRECTIVE ACTIONS IN RESPONSE TO

. RECENT STATION EVENTS Based on an overall review of recent Dresden events several short and long _term actions have been identified. This review and the actions to be taken were

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reviewed with senior NRC management during the November 12, 1991, NRC/CECo Management Meetin * * *

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SHORT TERM ACTIONS IMPLEMENTATION OF MANAGEMENT EXPECTATIONS *

Focused and frequent senior management presence In the plant *

Daily senior management meeting to review plant observations Personnel error interviews by senior managers Assistant Superintendent of Operating one-on-one expectations meetings Control room.overviews Shift crew visits to other stations Continue Maintenance 2nd line supervisor obser\\iations Implement corporate oversight meetings

• COMMUNICATIONS

• ..

Improve shift turnover process

• Continue Operations Improvement.Team.

Significant station event communications Continue and enhance HLA briefings *

Further implement 3-Level Down Meetings

• PROCEDURE ADHERENCE

• ...

Develop clear, concise statement of procedure adherence expectations

..

.,

..

Communicate the procedure adherence expectations to all personnel through multiple methods

Monitor implementation of adherence policy via the senior management plant observations

• PROCEDURE QUALITY

Assign overall procedure manager for the station

Implement the new work package expectations guideline ENGINEERING AND LICENSING SUPPORT

• ..

/scl:1329:17 Revise ENC Operability Review Procedure Additional resources for technical issues, equipment problems and acceleration of UFSAR rebaseline Increased licensing resources

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Address Dresden licensing priorities with NRR

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":**

• '

CORRECTIVE ACTIONS IN RESPONSE TO

.RECENT STATION EVENTS*.*

(Continued)

LONG TERM ACTIONS Dresden Situational Review Team

Chartered by VP BWR Operations and new Station Manager to identify issues that negatively impact station performance

.

Output is starting point for Dresden strategies Strategies will be developed

Improve definition and implementation of the station vision/missiori/strategy/expeetations

Improve the team Communications

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Empowerment and accountability

. -

Performance appraisal

Improve task management

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Prioritization and resource management Planning, scheduling and work control Procedures upgrade Commitment management

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Resolution of technical issues

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Other backlogs *

. Action plans

To be prepared for each strategy

• *

To be tracked/monitored like ZMAP 4.. Ongoing 6 month situational review

• *

To* refocus

Living process - self correcting ~ ongoing 5.. Additional resources are being applied

To address the issues

To overview imp.rovemen /scl:l329:18