IR 05000245/1996004

Ack Receipt of Revised Commitmments Described in Re Surveillance Program Violation from Insp Repts 50-245/96-04,50-336/96-04 & 50-423/96-04

ML20138H803
Person / Time
Site:	Millstone
Issue date:	12/30/1996
From:	Durr J NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:	Harpster T, Kenyon B NORTHEAST NUCLEAR ENERGY CO.
References
NUDOCS 9701060244
Download: ML20138H803 (3)

Text

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December 30, 1996 i ! , Mr. Bruce , President and Chief Executive Officer l Northeast Nuclear Energy Company l c/o Terry Harpster P. O. Box 128 - Waterford, Connecticut 06385-0128 l l SUBJECT: SURVEILLANCE PROGRAM VIOLATION 50-245/336/423/96-04

Dear Mr. Kenyon:

i The purpose of this letter is to acknowledge the receipt of your revised commitments , described in your letter, dated August 2,1996 (B15799). We note that you are continuing I your efforts to establish effective surveillance tracking systems for all three units. These efforts will be inspected as part of the restart programs for each of the units. Your l cooperation in this matter is appreciated.

Sincerely, l ORIGINAL SIGNED BY: Jacque P. Durr, Chief l Special Projects Office i Office of Nuclear Reactor Regulation Docket Nos. 50-245 50-336 50-423 cc w/o cv of Licensee's Response: T. C. Feigenbaum, Executive Vice President - Chief Nuclear Officer J. McElwain, Unit 1 Recovery Officer M. Bowling, Jr., Unit 2 Recovery Officer J. Cowan, Unit 3 Recovery Officer D. M. Goebel, Vice President, Nuclear Oversight , J. K. Thayer, Recovery Officer, Nuclear Engineering and Support P. D. Hinnenkamp, Director, Unit Operations g H. F. Haynes, Director, Nuclear Training \ P. M. Richardson, Nuclear Unit Director, Unit 2 \ M. H. Brothers, Nuclear Unit Director, Unit 3 , J. F. Smith, Manager, Operator Training l F. C. Rothen, Vice President, Work Services- 'n-j@p'

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i Mr. Bruce ! i I cc w/cv of Licensee's Response:

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L. M. Cuoco, Esquire i J. R, Egan, Esquire l V. Julieno, Waterford Library .! J. Buck ngham, Department of Public Utility Control  ! S. B. Comley, We The People l State of Connecticut SLO Designee  !;

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Distnuution w/cv of Licensee's Response: l { j Region 1 Docket Room (with concurrences) l j M. Kalamon, SPO, RI  ;

; NRC Resident inspector        !

i Nuclear Safety Information Center (NSIC)  : < PUBLIC l D. Screnci, PAO l .; , , 4 1 i  ! i

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DOCUMENT NAME: G:\ BRANCH 6\REPLYLTR\96-04.RPY , j ' To' receive e sepy of thle document. Indicate in the box: "C" = Copy without ettechment/ enclosure "E" = Copy with ettechenent/ enclosure i 4- 'N' = No copy ) > , , OFFICE Rl/DRP l l ! l NAME Durr Q  !

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. Northeast   107 seidea street. Berlin, cT 06037
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*' f b k 88 N   Northeast Utilities Service Company l     P.O. Box 270

Hartford, CT 06141-0270

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AE 2 1996 Docket Nos 50-245 50-336 50-423 B15799

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U.S. Nuclear Regulatory Commission Attention: Document Control Desk Washington, DC 20555 Millstone Nuclear Power Station, Unit Nos.1,2 and 3 45-Day Response to NRC Combined Inspection 50-245/96-04; 50-336/96-04: 50-423/96-04 in a letter dated June 6,1996,W the NRC Staff transmitted NRC Inspection Report Nos.

50-245/96-04; 50-336/96-04; and 50-423/96-04. The report discusses the results of the safety inspection conducted during the seven week period ending May 6,1996, at Millstone Station. Based on the results of the inspection, the Staff requested that Northeast Nuclear Energy Company (NNECO) respond within 45 days of receipt of the June 6,1996 letter, to provide additional information regarding the adequacy of corrective actions for violations 336/95-38-01 and 423/95-38-01. These violations were cited for untimely corrective actions to address weaknesses in the surveillance tracking program. Attachment 1 to this letter provides NNECO's reply to the NRC Staff's request, on behalf of Millstone Unit Nos.1,2, and 3.

The June 6,1996, inspection report also documents NRC Staff review of the corrective actions for violation 245/95-07-02, regarding a missed Local Power Range Monitor calibration at Millstone Unit No.1. The inspection report states that although the corrective actions were adequate, they were not complete and were not clearly described in the response to the violation. Attachment 2 to this letter clarifies and updates the corrective actions for violation 245/95-07-02. The information requested M J. P. Durr letter to T. C. Feigenbaum, "NRC Combined Inspection 50-245/96-04; 50-336/96-04; 50-423/96-04 and Notice of Violation," dated June 6,1996.

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U.S. Nuclear Regulatory Commission B15799\Page 2

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by the June 6,1996, inspection report, regarding the Millstone Unit No. 3 containment basemat, has been submitted under separate cover, by letter dated August 1,1996.A NNECO recognizes that the information provided herein is specific to the issue of missed su veillances. We acknowledge the need to address the broader issues surrounding the corrective action program and are doing so via the Nuclear Excellence Plan.

The following are NNECO's commitments made within this letter. All other statements are for information only.

B15799-01 The Unit Directors will emphasize their expectations regarding the i department managers' responsibilities and reinforce accountability for ! managing the various elements of the surveillance program.

B15799-02 The Millstone Unit No.1 LPRM calibration procedure (RE-1003) will be l added to the Production Maintenance Management System (PMMS) so that it will be schedu'..d, tracked and controlled in a manner similar to Technical Specification Surveillances. This action will be completed by September 1,1996.

If you have any questions regarding information contained herein, please contact Mr.

W. J. Temple at (860) 437-5904.

Very truly yours NORTHEAST NUCLEAR ENERGY COMPANY FOR: T. C. Feigenbaum Executive Vice President and Chief Nuclear Officer BY: h OR - 8.E.Scac6 Vice President - Nuclear cc: See Page 3

* S. E. Scace letter to U.S. Nuclear Regulatory Commission, " Millstone Nuclear Power Station, Unit No. 3, Additional Information Related to the issue of Cement from the Millstone Unit No. 3 Containment Mat," dated August 1,1996.

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U.S. Nuclear Regulatory Commission B15799\Page 3 i ! cc: T. T. Martin, Region i Administrator J. W. Andersen, NRC Project Manager, Millstone Unit No.1

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T. A. Eastick, Senior Resident inspector, Millstone Unit No.1 l D. G. Mcdonald, Jr, NRC Project Manager, Millstone Unit No. 2

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P. D. Swetland, Senior Resident inspector, Millstone Unit No. 2

V. L. Rooney, NRC Project Manager, Millstone Unit No. 3 A. C. Cerne, Senior Resident inspector, Millstone Unit No. 3

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Docket No. 50-245 50-336 50-423 B15799 Attachment 1 Millstone Nuclear Power Station, Unit Nos.1,2, and 3 45-Day Response NRC Combined inspection 50-245/96-04; 50-336/96-04; 50-423/96-04

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i I l i U.S. Nuclear Regulatory Commission j B15799\ Attachment 1\Page 1 Corrective Action Status for Violations 336/95-38-01 and 423/95-38-01. Missed  ; Technical Specification Surveillances i Violations 336/95-38-01 and 423/95-38-01 were cited against 10 CFR 50, Appendix B, { Criterion XVI, " Corrective Action," for failure to take effective corrective actions to l

prevent recurrent instances of missed technical specification surveillances at Millstone l Unit Nos. 2 and 3. In the violation response dated February 15,1996,M Northeast '

i Nuclear Energy Company (NNECO) identified corrective actions applicable to all three i Millstone units.  !

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NRC Inspection Report 50-245/96-04; 50-336/96-04 and 50-423/96-04, dated June 6, l 1996, characterizes the corrective actions for these violations as ineffective and ; untimely, and requested NNECO to provide a response clearly describing any changes l in the commitments. A current status of each of the commitments made in response to the Notices of Violation (NOVs), followed by a general assessment of their adequacy, is provided below.

B15529-01 Provide action plan for standardized Station Surveillance Program by ! June 30,1996.

i NNECO letter, davd June 28, 1996,M provided a description of the standardized surveillance prog am in accordance with this commitment. The program was  ! developed based on a review of License Event Reports (LERs) involving surveillance testing at the five Northeast Utilities (NU) units since 1993, independent Safety i Engineering Group (ISEG) report dated October 27, 1995, and the root cause ' evaluation for violations 336/95-38-01 and 423/95-38-01.

The standardized station surveillance program will result in the Work Planning and i Outage Management (WP&OM) department at each Millstone unit using the Production

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Maintenanr.e Management System (PMMS) as the primary scheduling tool for periodic Technical Specification and Technical Requirements Manual surveillances with an interval greater than 24 hours. Each responsible implementing department will use a Microsoft Access database as an independent tracking tool.

M F. R. Dacimo letter to U.S. Nuclear Regulatory Commission, " Millstone Nuclear Power Station, Unit Nos.1,2, and 3, Reply to Notice of Violation, inspection 50-245/95-38; 50-336/95-38; 50-423/95-38," dated February 15,1996 m T. C. Feigenbaum letter to U.S. Nuclear Regulatory Commission, " Millstone Nuclear Power Station Unit Nos.1,2, and 3, Standardized Surveillance Program Plan" dated June 28,1996. j l l

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. . i U.S Nuclear Regulatory Commission B15799\ Attachment 1\Page 2 Millstone Unit No. 3 is currently using PMMS and Microsoft Access consistent with the standardized surveillance program. Units 1 and 2 are in transition and will achieve full implementation by September 1,1996.

B15529-02 Utilize an independent tracking method to verify surveillance schedule. Work Planning Surveillance Planner will monitor performance of surveillances and provide early warning of approaching due dates. Due date is March 29,1996 for Millstone Unit No. 3 and April 30,1996 for Millstone Unit Nos.1 and 2.

Millstone Unit No.1 Implementation of Millstone Station Procedure WC-9, " Station Surveillance Program," Revision 1, on April 30, 1996, established a procedural requirement for a backup tracking method for each responsible implementing department. Recognizing that the backup methods were not formalized and varied among the implementing departments, consistent use of the Microsoft Access database as the backup method will be fully implemented by September 1,1996 as part of the standardized surveillance program.

The WP&OM department assigned a Surveillance Planner in February 1996. WC-9, Revision 1, effective April 30, 1996, requires the Surveillance Planner to schedule periodic surveillances with an interval greater than 24 hours and periodically review the schedule to identify surveillances past their scheduled start date or approaching the overdue date (drop dead date).

Millstone Unit No. 2 Implementation of WC-9, Revision 1 on April 30, 1996 established a procedural requirement for a backup tracking method for each responsible implementing department. For Operations Department surveillances, an independent surveillance tracking method was implemented on March 29,1996, via issuance of Revision 5 to Operations Department Instruction 2-OPS-9.03, " Scheduling, Tracking, and Review of Technical Specification Surveillances." As in the case of Millstone Unit No.1, cc sistent use of the Microsoft Access database as the backup method is scheduled for September 1,1996. A WP&OM Surveillance Planner was assigned in December ^ 1995, and assumed the responsibilities delineated in WC-9, Revision 1 on April 30, > 1996.

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U.S. Nuclear Regulatory Commission B15799\ Attachment 'i\Page 3 l ! Millstone Unit No. 3 , j implementation of WC-9, Revision 1 on March 29, 1996 established a procedural j requirement for a backup tracking method for each responsible implementing j department. By April 15,1996, transition to consistent use of the Microsoft Access J database as the backup program was achieved. A WP&OM Surveillance Planner was j assigned in December 1995, and assumed the responsibilities delineated in WC-9,

Revision 1 on March 29,1996.

i h B15529-03 Operations instructions will require the Shift Manager to make log j l entries for condition-based surveillances, noting next expiration time, and utilize 1 l a timer alarm for surveillances that are not addressed by procedural controls, by i March 29,1996.

! l Millstone Unit No.1 ! ! A change to surveillance procedure SP 696.1, " Control Operators Log," effective March i' 29, 1996, added Technical Specification and Technical Requirements Manual , surveillances that were not already covered by another surveillance procedure. The  ! control operators' log is used to identify any required conditional surveillances, the next expiration time and the time of completion. The Shift Manager is notified when the j surveillance is completed. Conditional surveillance requirements are logged on the l shift turnover section of the control operator logs.

! !- LER 245/96-042-00, dated July 10,1996,* documents a conditional stack gas sample j flow surveillance which was missed on June 10, 1996. The cause of this missed j surveillance was failure to effectively implement the corrective actions for violations . 336/95-38-01 and 423/95-38-01. The conditional surveillance was not properly logged

in the shift turnover sheet, nor was the Shift Manager notified of the completion of the

! surveillance. Corrective actions taken in response to this event include the required ) use of an audible timer alarm for conditional surveillances to ensure coriipWion of the

surveillance within the specified interval. Additional requirements regaroing log entries j were added to SP 696.1. The source of the conditional surveillance requirement, the

data required and performance frequency will be recorded, and a licensed operator is

! required to document successful completion of the surveillance. The LER also includes } a corrective action to complete briefings of the licensed operators on surveillance j tracking by August 30,1996. , a

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i i A W. J. Riffer letter to U.S. Nuclear Regulatory Commission, Licensee Event l j Report 245/96-042-00, " Stack Gas Sample Flow Surveillance Missed by 90 Minutes," dated July 10,1996.

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. . O e U.S. Nuclear Regulatory Commission B15799%ttachment 1\Page 4 MillNne Unit No. 2 On March 29,1996, Millstone Unit No. 2 issued Revision 5 to Operations Department Instruction 2-OPS-9.03, " Scheduling, Tracking, and Review of Technical Specification Surveillances." This revision included a new section that instructed Shift Managers to track surveillances required as a result of entry into a Technical Specification Action Statement by noting when the next surveillance is due on the Shift Tumover Report, and use of an audible timer alarm to ensure completion of the surveillance within the specified interval.

In addition to the specific items in this commitment, Millstone Unit No. 2 developed a $ table for procedure 2-OPS-9.03, which lists condition-based surveillances that are ; triggered by entry into Technical Specification Action Statements. This table was i included as an aid to the operating crew and was included in Revision 6 to 2-OPS-9.03, ; which was issued April 29,1996. In order to further improve the surveillance trackir:g l process, Millstone Unit No. 2 is currently administering non-Technical Specifice'.lon surveillances using the same program as Technical Specification surveillances. ;

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By March 29,1996, Millstone Unit No. 3 Operations revised Department Instruction 3- 1 OPS-10.2 to require shift turnover log entries for Limiting Conditions of Operation l (LCO) Action Statements which are in effect at the end of the shift, including -{ identification of the time the associated actions are due. This change ensures j conditional surveillances are identified on the tumover logs. Millstone Unit No. 3 also 1 I proceduralized the pre-existing practice of using audible timer alarms and temporary logs to track conditional surveillances whose frequencies are not procedurally l controlled.

B15529-04 The Operator Training Requalification Program will be updated to include scenarios that will evaluate the operator's ability to apply Technical Specifications in various operational situations (i.e., potential distractions from surveillance requirements). l By June 4, b96, simulator exercises were developed for each of the three Millstone units, to determine the operators' ability to comply with conditional surveillances during a simulated plant transient.

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U.S. Nuclear Regulatory Commission B15799\ Attachment 1\Page 5 B15529-05 Implement enhancements to Adverse Condition Resolution (ACR) process by June 1,1996.

Revision 2 of Millstone Station Procedure RP-4, " Adverse Condition Resolution Program," was effective on June 1,1996. Key improvements to the ACR process include 1. Increased control of ACRs through the implementation of unit-specific sequential numbering of ACRs.

2. Increased ACR initiator involvement in the clear understanding of the issue by the evaluator and in the development of corrective action plans.

3. The Management Review Team (MRT) has been initiated at all three nuclear units to perform initial and final review of ACR packages.

4. Simplification and electronic availability of all forms used in the process.

5. Review of all ACRs by the Shift Manager.

6. MRT review of investigation results and the corrective action plan for significance level A, B and C ACRs (levels A and B require a root cause evaluation and corrective action plan; level C requires a causal factors evaluation and corrective action plan).

7. Corrective action effectiveness requirements for significance level A/B ACRs.

8. Personal error trend code broken down into INPO subsets (omission, transposition, etc.). Over8 Adeauacy of Corrective Actions Millstone Unit No.1 The missed surveillance described in LER 245/96-042-00 was the result of ineffective implementation of the corrective actions taken for conditional surveillances per commitment B15529-03. Had the operator logs and shift turnover sheets been used in accordance with the revised procedure, the surveillance would not have been missed.

Although the procedure changes were considered adequate to prevent recurrence, additional procedural requirements and use of the timer alarm were deemed prudent

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( - i ! I' U.S. Nuclear Regulatory Commission B15799\ Attachment 1\Page 6 based on a missed conditional surveillance subsequent to initial implementation of corrective actions.  ; i Millstone Unit No. 2 ,

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NNECO's response to the original NOV's was contained in a letter dated February 15, 1996. The first commitment implementation date for corrective action to prevent recurrence was March 29,1996. In the interim, on March 11,1996 (ref: LER 96-014-00), * weekly surveillances were missed. Prior implementation of the corrective l actions would have prevented the March 11,1996 event.

Millstone Unit No. 3 On May 5,1996, it was discovered that a new precedure section created for auxiliary feedwater valve testing was not captured in PMMS. The procedure section was created to separate periodic valve surveillances from those that have a periodicity as well as conditional (cold shutdown) requirements. A root cause analysis was performed in June 1996. The root cause was consistent with that of the original 95-38 1

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violation, in that it identified lack of standardization of the surveillance tracking systems as a process deficiency. The root cause report also identified a split in oversight responsibility for periodic surveillances and conditional surveillances as a causal factor.

. Conclusions j I With respect to the timeliness of the corrective actions, it is important to consider the magnitude of the changes involved. To use Millstone Unit No. 2 as an example, more than 650 new PMMS ids were created and approximately 2300 Automated Work

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Orders (AWOs) are being generated. The start dates and frequencies of the new AWOs require validation prior to use. Reports have been developed to assist in  !

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tracking c 7eillances and identifying any that are overdue, implementing departments require faniiliarization with the use of the Microsoft Access database as a backup ; tracking method. These activities are labor intensive, and also affected the timeliness ! with which the Surveillance Planner was able to fully assume the surveillance j monitoring responsibilities per'WC-9, Revision 1.

l M P. M. Richardson letter to U.S. Nuclear Regulatory Commission, Licensee Event l Report 336/96-014-00, " Weekly Technical Specification Surveillance Missed 1 Due to Scheduling Error," dated April 10,1996, i A

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e U.S. Nuclear Regulatory Commission B15799%ttachment 1\Page 7 The events at Millstone Unit Nos.1 and 3 described above emphasize the need for effective implementation of planned corrective actions and continued improvement in the area of conditional surveillances. Responsibility for successful performance of conditional surveillances is shared among the various implementing departments, the Operations department and WP&OM. The Unit Directors will emphasize their expectations regarding the department managers' responsibilities and reinforce accountability for managing the various elements of the surveillance program.

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i i Docket Nos. 50-245 , 50-336 50-423 B15799

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Attachment 2 Millstone Nuclear Power Station, Unit Nos.1,2 and 3 45-Day Response NRC Combined Inspection 50-245/96-04; 50-336/96-04; 50-423/96-04 l

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i l U. S. Nuclear Regulatory Commission B15799%ttachment 2tPage 1 , Corrective Actions for Violation 245/95-07-02. Test Control for Local Power Ranoe Monitor Calibration i Millstone Unit No.1 Violation 245/95-07-02 was cited against 10CFR50 Appendix B, Test Control, for failure to establish a procedural requirement to specify Local Power Range Monitor June 12,1995,0(LPRM) and stated thecalibration frequency.

following in inspection NRC Report reviewed 96-04: S NNECO's respon'

"Although the corrective actions were adequate, they were not complete and were not clearly described in the licensee's response to the violation. Therefore, this violation remains open for further licensee corrective action."

The inspector's remarks are concerned with two aspects of the violation response: (1) the means by which the LPRM calibration is tracked and scheduled; (2) the Reactor Engineering enhancement program.

LPRM Calibration Trackina and Schedulina ' The LPRM Calibration procedure (RE-1003) has been revised to incorporate a surveillance frequency of 2000 Effective Full Power Hours (EFPH) which is consistent with General Electric (GE) recommendations. Since this parameter is not readily measured nor tracked, core burnup (MWD /ST), which is calculated by the plant process computer, is used to determine the aciual surveillance schedule. The conversion between EFPH and M 'IST is cycle-dependent since the constant depends on core weight. For the 81 core, 2 LOO EFPH corresponds to a time interval of approximately 2.7 calendar m, ths when the plant is operated at full power.

To ensure that this requirement was met, the frequency of performance was scheduled every 2 calendar months. This practice provided additional time (2-3 weeks) to coordinate the calibration with other department activities and plant conditions (i.e., equilibrium xenon, etc.). ' The LPRM calibration was scheduled and tracked using a computerized database and manually tracked by Reactor Engineering. Since this procedure is not a Technical Specification surveillance, it is not part of the Millstone Station Procedure WC-9,

") D. B. Miller, Jr. letter to U.S. Nuclear Regulatory Commission, " Millstone Nuclear Power Station, Unit Nos.1,2, and 3, Reply to a Notice of Violation, inspection Nos. 50-245/95-07,50-336/95-07, and 50-423/95-07," dated June 12,1995.

• J. P. Durr letter to T. C. Feigenbaum, "NRC Combined Inspection 50-245/96-04; 50-336/96-04; 50-423/96-04 and Notice of Violation," dated June 6,1996.

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i U. S. Nuclear Regulatory Commission B15799\ Attachment 2\Page 2

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" Station Surveillance Program" at this time. Although the corrective actions taken were adequate, as noted in the NRC's inspection report, additional enhancements can and should be made.

' Specifically, a standardized program is being implemented to track surveillances, which will use the Production Maintenance Management System (PMMS) as the primary

scheduling tool. Upon completion of a surveillance, PMMS automatically prompts the planner to generate a work order for the next scheduled performance. A backup departmental computerized database is also being used to ensure proper scheduling ,

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and tracking of these surveillances.

' ! As part of the inclusion of selected non-Technical Specification surveillances into the 1 i standardized surveillance program, the LPRM calibration procedure (RE-1003) will be I added to PMMS so that it will be scheduled, tracked and controlled in a manner similar I to Technical Specification surveillances. This action will be completed by September 1, 1996. The LPRM calibration will not ried to be performed until the plant returns to power. Thus, this enhancement will be implemented prior to the next required performance of the LPRM calibration.

Reactor Enaineerina Enhancement Proaram The original violation response of June 12,1995 included a corrective action to review all similar Reactor Engineering procedures as part of the Reactor Engineering enhancement program. The June 6,1996 inspection report noted that the program is not formalized since there is no governing upper tier Millstone Unit No.1 or Millstone site document, and therefore represented a weakness. In response, the following summary of the enhancement program is provided.

A formal assessment of the Reactor Engineering department was performed in October,1993 with the issuance of 6 recommended improvement actions. These recommendations were formally documented in NE-93-F-452 dated October 26,1993.

These actions were undertaken within the department, and a second, more rigorous assessment of the interface between the Reactor Engineering department and Operations was conducted in November 1994, with the issuance of a formal report on i November 30,1994. This latter self-assessment was conducted in accordance with the Millstone Self-Assessment Manual, and contained 14 recommended corrective actions, mostly long term in nature.

Examples of these Reactor Engineering enhancements include: development of a Reactivity Management Program (ongoing); Reactor Engineering Staff Augmentation

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U. S. Nuclear Regulatory Commission B15799\ Attachment 2\Page 3 (completed); development of a Conduct of Reactor Engineering procedure (ongoing); irnprovement in the transfer of Reactor Engineering information to Operations (completed); and development and improvement in stand-alone Reactor Engineering procedures (ongoing). Specific efforts to improve Reactor Engineering department procedures are covered as part of this last action item. All of these corrective actions are formally tracked in the Action item Tracking and Trending System and a periodic written progress report is provided to the Technical Support Department Manager.

Other activities currently underway include a more rigorous inter-department review of procedures which includes technical, independent reviews and procedural validation.

These more rigorous reviews are currently required by the procedure DC-1,

" Administration of Millstone Procedures and Forms," which was not in place when the

, " subject procedural discrepancy was overlooked. Selected procedures are also i reviewed by the entire Reactor Engineering group during Table Tcp sessions, as a training function and to ensure consistent understanding of procedural requirements.

Procedural compliance and management expectations are also enforced by the performance of routine work observations.

, it should be noted that the Reactor Engineering improvement is an ongoing process, rather than a stand-alone activity with a specific completion date. As additional self assessments and evaluations are performed any identified corrective actions are dispositioned and tracked to completion. The most recent self-assessment was : completed earlier this year, focusing on work culture issues and performance ! improvements. Recommendations of the most recently completed self-assessment are being reviewed and scheduled for implementation.  !

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