IR 05000289/1997004

Ack Receipt of Informing NRC of Steps Taken to Correct Violations Noted in Insp Rept 50-289/97-04 on 970627

ML20217Q027
Person / Time
Site:	Three Mile Island
Issue date:	08/14/1997
From:	Modes M NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:	Langenbach J GENERAL PUBLIC UTILITIES CORP.
References
50-289-97-04, 50-289-97-4, NUDOCS 9708290114
Download: ML20217Q027 (2)

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August 14, 1997 Mr. James Vice President and Director, TMI GPU Nuclear Corporation Three Mile Island Nuclear Station P. O. Box 480 Middletown, PA 17057-0191 SUBJECT: INSPECTION REPORT NO. 50-289/97 04

Dear Mr. Langenbach:

This letter refers to your July 24,1997 correspondence, in response to our June 27,1997 letter.

Thank you for informing us of the corrective and preventive actions documented in your letter.

These actions were examined during an inspection of your emergency preparedness program from August 4-8,1997. Detailed findings concerning these actions will be documented in an upcoming NRC inspection report, 50-289/97-08.

Your cooperation with us is appreciated.

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Sincerely, ORIGINAL SIGNED BY:

Michael C. Modes, Chief Emergency Preparedness, Safeguards Branch and incident Response Center Division of Reactor Safety Docket No. 50-289 cc:

J. C. Fornicola, Director, Licensing and Regulatory Affairs M. J. Ross, Director, Operations and Maintenance j D. Smith, PDMS Manager i J. S. Wetmore, Manager, TMl Licensing Department /

TMI-Alert (TMIA) l E. L. Blake, Shaw, Pittman, Potts and Trowbridge (Legal Counsel for GPUN)

Commonwealth of Pennsylvania

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Mr.--James ' 2 Distribution: -

Region 1 Docket Room (with concurrences)

Nuclear Safety information Center (NSlC) ,

PUBLIC NRC Resident inspector D. Screnci, PAO P. Eselgroth, DRP D. Haverkamp, DRP A. Keatley, DRP

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W. Dean, OEDO P. Milano, NRR, PDI 3 B. Buckley, PM, NRR, PDl 3 L. Thonus, NRR

. S. Weiss, NRR R. Correia, NRR inspection Program Branch, NRR (IPAS)

DOCUMENT NAME: G:\EP&SB\MAIER\TMl9704.RPL 2 To r.em . e.ev et w. e cum.nt. mac.t. m in. bon c - copy without att. chm.ntiencio.ur. e* - Copy with att.chment/.nclosu,. *N" = No copy OFFICE Rl/DRS C Rl/Op@ , l_

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DATE 8/t//97 8l/J97 "

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NUCLEAR Middletown, PA 17057 04 0 Tel 717 944 7621

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July 24,1997

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6710-97-2296

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U S. Nuclear Regulatory Commission Atta: Document Control Desk Washington, DC 20555 Subject: . nree Mile Island Nuclear Station, Unit I (TMI 1)

Operating License No. DPR 50 Docket No. 50-289 Reply to Notices of Violation 97-04 01,97-04 03, and 97-04-04

Dear Sirs:

Attached is the GPU Nuclear reply to the Notices of Violation,97 04-01,97 04-03, and 97 04-04, transmitted as an Enclosure in NRC Inspection Report No. 50-289/97-04.

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Sincerely, M O

- James W Langenbach 4 Vice President and Director, TMI

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cc: _ TMI-l Senior Resident inspector -

TMI l Senior Project Manager -

. NRC Regional Administrator, Region 1 .

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ATTACHMENT I :

6710-97 2296 +

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>< NOTICES OF VIOLATION . 97-04-01. 97-04-03. and 97-04-04

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During an NRC inspection conducted on May 12 through May 15,1997, violations of NRC requirements were identified. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement

,. i i Actions," NUREG 1600, the violations are listed below:

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A. 10 CFR 50.54(q) requires, in part, "A licensee authorized to possess and operate a n aclear power $

reactor shall follow and maintain in effect emergency plans whicli meet the standards in 50.47(b) ;

and the requirements in Appendix E of this part."

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10 CFR 50.47(b)(9) requires adequate methods for assessing actual or potential offsite j p

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- consequences of a radiological emergency condition as part of the licensee offsite emergency response plans, ne licensee's Technical Specifications, Section 6.8.1 states, in part " Written-procedures shall be established, implemented and maintamed covering the items referenced below -

, ...f. Emergency Plan implementation." t Contrary to the above, from April,1995 to May 15,1997, the licensee had no documentation for

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the continuous onJ.ne assessment and quick calculation computer codes used for dose projection

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calculations, nor written procedures to perform those calculations.

- This is a Severity lx.I IV violation,97-04 01 (Supplement Vill).

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B. 10 CFR 50.54(q) requires, in part, "A licensee authorized to possess and operate a nuclear

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power reactor shall follow and maintain in effect emergency plans which meet the

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standards in 50.47(b) and the requirements in Appendix E of this part."

E i- 10 CFR 50.47(b)(15) requires, in part, " Emergency response plans for nuclear power reactors must meet the following standard: Radiological emergency response training is pimided to those who may be called on to assist in an emergency "

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The licensee's Emergency Plan, Section 8.2.1, " Training," states "GPU Nuclear station and station support orgamzation personnel assigned to the emergency organization with specific Emergency Plan duties and responsibilities are required to attend specific EP

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assigned duties in accordance with the E-Plan and implementing Documents." It also 1 states " essential personnel reverify their assigned emergency preparedness trammg preferable every 12 months but at least every 15 months."

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- A'ITACHMENT I i 6710 97 2296 Page 2 of 9 ,

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- Procedure TEP ADM 1300.02, Emergency Preparedness Training," Section 4.0, Exhibit 1, states, s in part, "On Sh'ft Emergency Organiation, Initial Response Emergency Organiation and .

Emerge .,; Support Organiation must.. .._ satisfactorily complete and maintain EP training -

program requirements for the position assigned ....For personnel responding onsite... .must satisfactorily maintain respirator qualifications and General Employee Radiation Worker Training -

(Category 11) and must be active in the dosimetry system."

Contrary to the above, from about September 1994 to May 15,1997 the licensee

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. repeatedly had unqualified individuals listed on the response roster as part of their emergency response organiation. The licensec's audit reports indicated that in 1994 a number of ERO personnel on duty had allowed their qualifications to lapse; in 1995, nine personnel allowed their qualifications to lapse, of which four were on duty; and in 1996, .

10 personnel allowed their qualifications to lapse, of which three were on duty, Specifically, individuals did not complete required respirator training or whole body counts necessary to be active in the dosimetry system.

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his is a Severity Level IV violation,97-04-03 (Supplement Vill). .

_ C. 10 CFR 50.54(t) states, in part, a nuclear power reactor licensee "shall proside for a review of its emergency preparedness program at least every 12 months by persons who have no direct responsibility for implementation of the emergency preparedness program."

De licensee's Technical Specifications, Section 6.5.3.1.e, states that audits of the Emergency Plan and Implementing Procedures shall be performed in accordance with the

- TMI I Operational Quality Assurance Plan.

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ne GPU Nuclear Operational Quality Assurance Plan, section 9.1, states in part, "a comprehensive and documented audit system shall be established, implemented and maintained to ensure that...... corrective action systems and management reviews provide for timely completion of i - requisite action for identified deficiencies....and effective identification and prevention of recurrent j and/or significant program nonconformances." Section 2.4.3. states, "for audits, the program requirements of ANSI N45.2.12 shall be satisfied." ANSI /ASME N45.2.12-1977 Standard,

- Section 4.3.2.4, states "when a nonconformance or quality assurance program deficiency is identified as~a result of an audit, further investigation shall be conducted by the audited orgammtion in an effoit to identify the cause and effect and to determine the extent of the corrective action required."

A quality deficiency is defined in Procedure 1000-ADM-7215.02, "GPUN Quality Deficiency Reports" as "a deficiency in characteristic, documentation, or procedure which -

renders the qualify of an activity unacceptable or indetermmate" and a quality deficiency is --

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documented in a quality. deficiency report. Section 4.4.2 of said procedure, states, in part, 1: "the corrective action response shall address the following areas: The cause(s) and extent of the deficient condition (s); actions that will be taken to correct the deficient condition; and action which will prevent the deficient condition from recurring."~ Section 4.5 states

"upon receipt of the corrective action response, NS A shall review the response to ensure

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ATTACHMENT I 6710 97 2296

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. that theioot cause of the problem has been determined and appropriate actions to correct '

and prevent recurrence of the problem have been established." -

. Contrary to the above, from September,1994 to September 13,1996 the licensee did not: 1)

provide effective prevention of the recurring lapses in ERO qualifications identified during the 1994,1995 and 19% audits; 2) trend deficiencies to be able to monitor recurrence, such as

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outdated procedures or E-Plan changes found in the emergency facilities during the 1995 and 1996  ;

audits; 3) perform a resiew in order to determine the adequacy of the corrective actions.

Additionally, the characterization of findings was negotiated with the EP staff, obviating the .

i%c of the findings; JI5is is a Severity Level IV violation,97 04-04 (Supplenwnt Vill). 3 i ,

GPU NUCLEAR RESPONSE TO NOV 97-04-01

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Reason for the Violation

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The violation as stated was caused by poor implementation practices rtlative to development of the continuous on line and manual emergency preparedness dose assessment codes used at TMI. In short, computer soRware changes were made by Emergency Preparedness personnel without appropriately

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documenting the changes in approved station procedure 6610-PLN 4200.02, "The TMI Emergency Dose Calculation Manual (EDCM)". As stated in this procedure, the contents of the EDCM shall be used as the

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basis for the computations performed in the Emergency Plan RAC computer programs. Additionally, the

- soRware user's manual last updated in 1996 was not updated to reflect recent changes. As a result, the documentation associated with the TMI emergency dose assessment codes was found to be less than j adequate.

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Corrective Steos Taken and Results Achieved Several short term corrective steps have been taken to correct the deficiency noted. On 5/29/97, Quality

, Deficiency Report (QDR #972025) was issued relative to this deficiency as a means to assure that

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corrective actions are tracked through completion. Radiological Engineering has prepared a listing of the

, iodine reduction factors used by the dose assessment codes but not currently documented in the EDCM.

This information has been provided to the dose assessment code users as an interim step until the EDCM is

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appropriately updated. The dose assessment performance by the TMI staff demonstrated in the May 13,

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- 1997 Remedial Exercise and the Unusual Event declared on June 21,1997 provide evidance that the formal training provided to the dose assessment code users in conjunction with the interim step ,aken are .

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ATTACilMENT I 6710-97 2296 Page 4 of 9 Corrective Steos to be Taken to Avoid Further Violations As addressed in QDR #972025, a comparison is underway between the EDCM and the dose assessment codes. His comparison will provide the necessary detail to support a complete update of the EDCM.

Additionally, as part of this comparison, a formal verification of the dose assessment codes will be performed and documented. These actions will be complete by 1/1/98. To support training of users in the future, the dose assessment user's manual will be revised by 3/31/98. This will support the next training cycle for the dose assessment personnel.

A dose assessment committee headed by the Manager Radiological Engineering has been established to provide a formal means of approving all future changes to the dose assessment codes. His process will prevent modification of this software without the formal documentation and testing of the changes as required by station procedures.

Date when Full Comoliance will be Achieved

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Full compliance will be achieved by 3/31/98.

GPU NUCLEAR RESPONSE TO NOV 97-04-03 Harkeround GPUN agrecs that the information contained in this notice of violation is accurate; however, the yiolation as wTitten does not completely document the conditions related to the violation. Quality Deficiency Report (QDR) 942005 was issued on 7-6-94 to document failure to ensure ERO personnel maintained their required qualifications. (Qualifications expired for five individuals on duty in a four month timeframe.) A QDR is a GPU Nuclear approved 10CFR50 Appendix B, Criterion 16 corrective action mechanism. This QDR remained open until 2-6-96 to track long term corrective actions, and to ensure interim co.rrective actions n:mained in place until the long term actions were completed. Since the implementation of the corrective actions specified in the response to QDR 942005 (2-6-96), only two personnel have been on ERO duty with an expired qualification. He first individual was identified in the second quarter 1996, :ind he served in an ERO position for two days prior to requalifying. The second individual was identified in April 1997 and he served in a position on the ERO for six hours prior to requalifying, The corrective actions associated with QDR 942005 have been dete-;.Med to be effective in correcting the 1994 identified adverse trend of failing to maintain ERO qualifica*.ons foi ,n duty personnel. This determination of acceptability is based on the less than one percer . failure .ite obse:Ted after the close-out of the QDR, and the expeditious correction of the two occurrenc s of pers.innel with expired qualifications. The referenced audits acknowledged the existence and status .,c (5R y .2005 but did not repeat actions or oversight already tracked by the QDR.

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ATTACllMENT 1

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6710 97 2296 Page 5 of 9 Reason for the Violation As stated in QDR 942005, the cause of the deficiency was a lack of an adequate management tracking system and lac!t of knowledge in the use of the existing tracking system were the prime contributors.

Corrective Stens that Have Been Taken and Results Achieved As stated in QDR 942005, a qualification tracking system was verified to be operational on February 6, 1996. E Mail messages are being automatically sent to selected clerks and administrators notifying them of personnel qualifications coming due. Implementation of this tracking system was supplemented by the continued use of a previous tracking system, and a monthly check by the Emergency Preparedness department. Since February 6,1996 only two personnel have been on ERO duty with an expired qualification, Therefore, the corrective actions of QDR 942005 have been effective, in that a recurrence of

' the programmati c breakdown in maintaining ERO qualifications has not recurred.

Date when Full C==+ee will be Achieved Full compliance was achieved on February 6,1996. GPUN plans no further action on this siolation.

GPU NUCLEAR RESPONSE TO NOV 97-04-04 Basis for Diso=*i== the Violation

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GPUN disputes the violation in that the information presented in inspection report 97-04 is not complete.

Regarding item (1), the inspection report states:

"He licensee's Emergency Plan, Section 8.2.1, required essential personnel to reverify their assigned EP training every 12 to 15 months to maintain current quahfications A QDR, number 942005 wm issued to the EP Department as a result of a 1994 EP program audit for a number ofindividuals on the ERO duty roster with incomplete training. As a result of this deficiency, the EP stafrimplemented a computerized EP qualification tracking system in late 1994 to monitor training qualification records. However, during the 1995 EP program audit, nine individuals were identified with expired qualifications, four of which were on duty. De audit report indicated that an additional computerized tracking sptem was being implemented

, and scheduled for completion by September 1,1995 and QDR 942005 remained oten.

In February 19%, the QDR was closed by memorandum from the EP Manager to the Director. Radiation Health and Safety, stating that the EP Degurtment continued to monitor EP qualifications and a new tracking sptem was in place. Ilowever, dunng the 19% EP program audit, an EP staff member stated tint over a six month period, ten FRO personnel had their qualifications lapse, three of which were on duty. The report stated, "since the actual error rate for expired qualifications while on duty is very low it will be considered a minor deficiency?

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The NSA Audit Program Procedure !I 10-ADM-7218.10 defines a minor deficiency as one not being .

programmatic, not generic, does not compromise quality, is not potentially reportable, and/or corective action would not be extensive. The independent safety rev.wcr who evaluated the 1996 audit stated that

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] 'no significa . @j conditions were identined, all undings were poperly characterited as QDRs or minor

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deficiergte a.v u tadetected trends were identined by Otis teview? De mspector disagreed with the .

I . demion e dvngre is the QDR to a minor deficiency and tl.e determination that no trends were identined . i

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quahn.'PO ations hadquailNation g.Slems lapsed as recently had been as March.1997). De auditidentified in 4the team leader stat that past Gwee audits the IT staff (one individu

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ident:0ed ths .ndividuals and removed them from the !*O upon discovery. Sini. .ae EP staff was

! addressma the 120 quahlication poblem, NSA decided that a QDR was not necessary. Also, tlw estx stated that NMA did not do an independent assessment during the 1996 sudit to vmfy that all memkmf i the 120 w re quahfied at that time," t

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Initially, our findings were considered to be significant conditions adverse to quality Accordingly. [

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L a Quality Denciency Report was issued and corrective actions were taken to address the cause and

, program weaknesses identified. Subsequent to the completion of those corrective actions to the .

program, lapses in qualifications were identified; however, those lapses, we believe, are not  !

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indications of a fundamental program problem.

Ben was an appaent misun.lerstanding between the NRC Inspector and the NSA Audit Team

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Leader, De NSA Audit Team lander did not have the information or the involve.nent with all the  :

, issues discussed in this inspection and Notice of Violation. A specific, detailed bistory follows. j Quality Deficiency Report (QDR) 932')l0 was issued on 5 13 93 to document the failure to ensure personnel assigned to the ERO maintamed their qualifications current. The corrective action to this QDR was the creation and implementation of a computer based qualification tracking system.  ;

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The QDR was closed on 128 94 when the QDR initiator verified all corrective actions had been

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completed. On 7 6 94 QDR 942005 was issued to document the continued failure to ensure personnel on the ERO maintained their qualifications current. His QDR identified the trend of failed ERO quali6 cations and the long term ineffectiveness of the corrective actions associated with QDR 9320 Re corrective action response to QDR 942005 identified and offered a >

l solution to a we6 t identified in the corrective action to QDR 932010. De qualification tracking system c, mi to resolve QDR 932010 provided access to indhiduals to their  ;

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- qualification duc dates. De proposed system upgrade in response to QDR 942005 would allow plant managers and their administrators to access the qualification tracking database _for all of their

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personnel. De new system would also send computer generated reminders, two months in i

advance, to personnel whose qualificatims were coming due.  ;

e Neither QDR 932010 nor QDR 942005 were written as a result of an Emergency Preparedness ,

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Audit. Dese QDR's are issued as a result of oversight personnel external to the audit teams

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trending deficiencies related to maintaining ERO qualifications.- Both QDR's were closed aRet the. 1 i

initiator verified all corrective actions were completed. his verification included observir.g the - ,

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operation of the tracking database systems, Neither QDR was closed based on the initiation of a <

memorandum. As discussed in response to NOV 97-04 03, QDR 942005 remained open until 2 6-96 Since the closing of that QDR only two personnel have been assigned duty on the ERO when .:

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thdt qualifications had expired. One individual was expired for two days. and the other individual was expired for six hours;

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f ATTACllMENT 1 6710 97 2296 Page 7 of 9 The 1996 Emergency Preparedness Audit, S Thti 96-08, correctly classified the failure to maintain ERO qualifications as a minor deficiency. The audit referenced the number ofindniduals who allowed their qualifications to expire in a six month time pstiod, hiost of thor: deficiencies occurred while QDR 942005 was still open. Since an approved corrective action mechanism was tracking and correcting those deficiencies an additional QDR was not wntten. As discussed in response to NOV 97 04-03, the corrective actions of QDR 94200$ have been found to be effective in resolving this deficiency, Issuing another QDk as a result of the 1996 Emergency Preparedness Audit would have been repetitious, and would not have resulted in a correcHve action different from the corrective actions of QDR 942005. NSA did not perform an independent asseument of ERO qualification status during the 1996 Emergency Preparniness Audit since the interim corrective action for QDR 942005 was for Emergency Preparedness personnel to perform a monthly self assessment of those individuals whose qualifications were coming due each month.

'the Emergency Preparedness staff calls all indhiduals who have not requalified by tbr hst few days of the month to ensure these personnel are aware of their need to requalify. This ..ction continues, since it has been effective in ensuring ERO personnel maintain their qualifications.

.Regarding item (2), the Inspection report states:

"thscussions with the IT Manager alcut this matter indicated that the problem was not only poor tracking systems tml also the lad of management expectations regardmg 130 persormel mamtaining their quahtications cunent, and the consequences for not doing so.

While reviewing the audit reports, the inspector noted other * minor deficiencies * that were similar in nature in the 1995 and 19% reports l'or example, copes of EPIPs, the thergency Plan, and operating procedures and drawmgs located in various ill's were found to be out of date.

In 1996 it was identified that the equipment Lits were insu!!icient and Lit inventories uere not being properly conducted Smce these inwes were corrected during the audit, the licensee included them as undir.gs, but did not assess them as d ficienctet 11e NSA did not trend these similar findmgs and therefore had no historical referetxe of the EP Ikpartmerts performance m this area for identifying recurring inues in 1995 it was identined that lancaster County officials were concemed ateut the handimg of false stren soundmts lhe LP statt informed the auditors that only a few sirens had teen inadvertently activated and a system upgrade was expensne. The IT stalTcommitted to evaluate the stren system lhe 1996 audit stated 'there is aldi a problem with false siren soundings' and that EP is gettmg contract bids for installatmn of a system to identify faulty strens and gne feedback directly to the counties Although this was a repeat item, it was not made a deficiency in the 1996 audit leport.1he QA team kader stated that smce the Ep statihad been reviewing this concern for the past two years, and was in the process of making additional corrective action decisions, the issue did not warrant a deficiency.1he licenice appeared to tharmetenze the repeat audit findmg as insignificant due to the EP stafTs' commitment to continue to review the issue. The NSA was noncone'ative in its characterization of finAng as conditions adverse to quality,"

The following are responses to item (2) in the order of the issues raised.

Personal accountability for the maintaining of current qualifications has been addressed in QDR 972029, issued 616 97. This QDR documented an adverse trend in maintaining a number of qualifications.

Although not specifically written to solely address ERO qualifications, these qualifications will be addressed in this QDR. The QDR has been issued to the Director Thil, ar'd his proposed conective actions include the formulation, documentation, and issuance of a directive to all Thil personnel concerning

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ATTACilMENT 1 6710 97 2296 Page8of9 his management espectations for the maintaining of current qualifications. This directive will include the consequences of failing to maintain qualifications, including ERO qualifications, current. TMl is also creating a qualification tracking database which track all qualifications held by all personnel at TMI.

Minor deficiencies relating to out of date procedures and documents were identified in the 1995 and 1996 Emergency Preparedness Audits. He recurrence of these minor deficiencies has been trended by the Nuclear Safety Assessment (NSA) Department. A Quahty Assurance Morutoring Report (QAMR) was condu ~.d and issued in December,1996. This QAMR,9600053, was specifically conducted to review the current status of procedures and documents at the Emergency Offsite Facility (EOF) to determine if a significant condition adverse to quality existed. He QAMR identified one procedure which required updating. .Because the error rate was judged to be very small, NSA concluded that the issue should continue to be trended, but a significant condition adverse to quality does not exist. The referenced audit reports and QAMR have been distributed to management to ensure they are cognizant of the status of this trending.

Contrary to the inspection report, the Audit did assess the Emergency Equipment Kits / lockers not being propcily stocked and maintained as a deficiency. Ilased on a review ofinventory records and NS A Auditor observations of the kit / locker contents, a trend was identified and detennined to be a significant condition adverse to quality. QDR 962013, issued 816 96, documents this deficiency, We believe that how occasional siren false alarms are handled, as discussed in the Ep audits, is not considered to be a condition adverse to quality, Frequent siren false alarms or instances of sirens failing to alarm would be considered conditions adverse to quality, ne audit team documented their discussions with counties, including the suggestions for enhancement of the siren system. He suggested improvements to the siren system are properly documented as possible enhancements in th audit report. The enhancement of the siren system that the EP staff was pursuing was completed in January 1997.

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Regarding item (3), the inspection report states:

"c. Conclurlons lhe inspector determined that the audits covered many areas of resiew but that they appeared to te narrowly focused on complisnce rather than substance. The short tenn corrective actions taken by the EP staff that wete ident 0ed during the audit were considered acceptable even though an in-depth review for detennining the adequacy of the corrective actions was not perfonned. Characterization of audit findings appeared to be negotiated with the EP staff and minor deficiencies were not trended for detennination of recurrence Overall, the inspector assessed the NSA audit of the EP program to be perfunctory.

The licensee's Technical Specifications, Section 6.5.31, states, m part, ' audits r, hall te performed in accordance with the lhil 1 Operational Quality Assurance Plan * 1he Operational Quality Assurance Plan requues that the audit sy stem proside for corrective actwn systems and managernent resiews for timely correctmn of identified dc0ciencies and prevention of recurrent nonconfonnances.1he licensee did not 1

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provide effective prevention of recurtmg deficiencies not review corrective actions for denciencies to detennine their adeouacy. This is a violation (VIO 50-289.%0441)"

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ATTACllMENT I 6710 97 2296 Page 9 of 9 We consider auditing for compliance to our procedures and regulations to be a fundarnental aspect of the audit program. An audit matrix, which delineates the r quired and recommended areas of audit oversight has been developed based on regulatory requirement < and Emergency Plan and implementing Procedure requirements. The audits strive to be compliance and performance based Arcas ofimprovement or enhancement are frequently identified and documented in audits as Performance issues. These documented Performance issues offer sumsted um ofimprovement for management consideration. Repeated or significant Performance iss' . ! have been escalated to QDR's for correction. Corrective Actions associated with deficiencies are verified a observed to have been completed prior to the close out of the deficiency.

All deficiencies closed since the performance of the last audit in a functional area are reviewed for the effectiveness of the corrective actions in the current audit.

He procedure which administratively controls the QDR process,1000 ADM.7215.02, states in part in section 4 3.3 that the NSA Manager " ..shall have a conference (either in person or via phone) to obtain concurrence of the action party regarding the nature of the deficiency and the need for corrective action" nis is not to be interpreted as NS A negotiating a deficiency with a corrective action party. His process of discussion prior to issuance cf the deficiency is to allow the perspective corrective action party to supply information which the auditor or assessor may not have had asailable when the deficiency was drafted. If the corrective action party cannot supply information which contradicts the deficiency, but still refuses to accept the deficiency, a proceduralized process of escalation is pursued. This escalation process prosides access to increasing levels of management from first line management to the Office of the President.

As esidenced by the issuance of QDR's 932010,942005, and 962013, which were written against identified trends determined to be significant conditions adverse to quality, trending is and will continue to be utilized by the NSA audit staff.

As discussed throughout this response to the Notice of Violation, deficiencies were identified and documented as required. QDR 942005 documented the ineffective corrective actions of QDR 932010.

NSA performed an effectiveness review six months after the implementation of the corrective actions associated with QDR 932010, and found the actions were not effective in preventing significant recurrence of this deficiency. As a result of this effectiveness review, QDR 942005 was issued to document the inefTective corrective action. Rese QDR's are the highest tier 10CFR50, Appendix B, Criterion 16 corrective action mechanisms utilized at TMI. He corrective actions of QDR 942005 have been effective, in that a recurrence of the programmatic breakdown in naintaining ERO qualifications has not been observed. his is evident by a failure rate of significantly less than one percent which has been identified since the close out of QDR 942005.

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