IR 05000461/1986004

Insp Rept 50-461/86-04 on 860121-24.No Violations or Deviations Noted.Major Areas Inspected:Review of Safeteam Major Program Elements,Verification of Implementation,Review of Corrective Actions & Sample Review of Program Results

ML20141N820
Person / Time
Site:	Clinton
Issue date:	03/10/1986
From:	Gwynn T, Schapker J, Weil C NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
To:
Shared Package
ML20141N817	List: IR 05000461/1986004 ML20141N816
References
50-461-86-04, 50-461-86-4, NUDOCS 8603180165
Download: ML20141N820 (13)

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U.S. REGULATORY COMISSION

REGION III

_ Report No.' 50-461/86004(DRP)

~ Docket No. 50-461- License No. CPPR-137 Licensee: Illinois Power Company 500 South 27th Street Decatur, IL 62525 Facility Name: Clinton Power Station Inspection At: Clinton Site, Clinton, IL Inspection Conducted: Janua 21- and February 24, 25, 1986 Team Members: C. H. Weil In estigation and M84/N Date C Specialist d

.F ch pker eactor Inspector RFLooudA W Team Leader: T. P. Gwynn, Chief, /C M M A 84 Projects Section 1B Date Inspection Summary Inspection on Janua y 21 throuch 24, 1986 (Report No. 50-461/86004(DRP))

Areas Inspected: This inspection was a special team inspection of the Clinton Power Station Safetcam (SAFETEAM). The SAFETEAM is a product of SYNDECO, an Illinois Power Company contractor, which provides interview and investigative services to the Clinton Power Station to address the concerns of site employee (Note: Investigative services are subcontracted to National Inspection Consultants (NIC).) The SAFETEAM concept provides a confidential way for current and terminated employees to raise concerns regarding the plant outside normal corrective action systems without fear of reprisal. The SAFETEAM concept also provides an investigation for resolution of employee concerns by persons who are independent of the site management organization. This inspection included a review of the major program elements; verification of program implementation, a review of corrective actions taken based on the results of a third party audit of the SAFETEAM; and a sample review of the program result The inspection involved 77 inspector-hours onsite by three NRC inspectors including 16 inspector-hours onsite during off-shift Results: This inspection confirmed that a number of SAFETEAM program weaknesses had been previously identified by an independent third party audit completed on August 15, 198 Several of those weaknesses, related to the SAFETEAM investigation unit, had not been correcte This resulted in the lack of fDR D G

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comprehensive treatment of some SAFETEAM identified employee concerns and the inadequate resolution of others. The specific weaknesses confirmed are discussed within the body of this report. The inspection team concluded that f' the acceptability of the SAFETEAM investigations is in question and corrective

? action is needed. The inspection team recommended that the SAFETEAM change its approach to the investigation of alleged wrongdoin L

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DETAILS Persons Contacted

. Illinois Power Company (IP)

• Bakunas, Director, Internal Auditing

• W.'Connell, Manager, QA ,

• C. Glenn, Director, SAFETEAM

• L. Haab, Senior Vice President F. Spangenberg, Manager, L&S i

SYNDECO ,.

B. Griffin, Interview Coordinator W. Northcutt, Interviewer D. Valentine, Interviewer NIC I

W. Ash, Lead Investigator T. Kubiak, Investigation Coordinator M. Mitchell, Lead Investigator L. Taylor, Investigator

• Denotes those personnel attending the exit meeting on January 24, 1986.

s Inspection Purpose and Scope (92701)

This special inspection team inspection of the Clinton Power Station (CPS) SAFETEAM was conducted to provide the NRC with a thorough understanding of the SAFETEAM program and to evaluate the effectiveness of the SAFETEAM in identifying and resolving safety-related employee

, concern There was no regulation, code, or national standard upon which to judge the adequacy of the program or its results; therefore, no basis existed for' direct regulatory enforcement action on the results of this inspection. The inspection team members based the conclusions of the inspection oni fegional guidance, experience, and judgemen The inspection consisted of a review of the SAFETEAM program / procedures; a question and answer briefing with SAFETEAM supervision; review of the classification e' SAFETEAM identified concerns; selective interviews with SAFETEAM interviewers, investigators, and their supervisors; interview of the IP Senior Vice President responsible for the SAFETEAM program; review of a third party audit report and the corrective action taken thereunder; interview of the SAFETEAN director; and review of a selective sample of typicalSAFETEAMinvestigqtionresult ,

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3. Documentation Reviewed IPQA/Safeteam Interface Agreement through Amendment 2 dated March 15, 1985 SYNDECO SAFETEAM Operational Manual, copyright dated 198 SAFETEAM Concern Classification Categories, (undated). .SAFETEAM Program Investigation Guidelines, (undated). SAFETEAM Interviewer Manual, dated January 198~ .SAFETEAM Interviewer Training, dated July 16 through July 18, 198 Advanced Interviewer Training Seminar Agenda, dated February 17, 198 SAFETEAM Interview Unit Office Practice Manual, dated August 198 . IPC Internal Audit Report, Results and Response To LRS Review of SAFETEAM, dated August 198 Memorandum C. D. Glenn to Stan Bakunas, Re: LRS Audit, dated January 16, 1986.~ Memorandum C. D. Glenn to S. F. Bakunas, SAFETEAM Management Reports, dated January 20, 198 . Fifty-four SAFETEAM concern investigation record . Program Overview The IP SAFETEAM consisted of an IP employed director and his administrative assistant; a SYNDECO employed interview unit consisting of an interview supervisor, one full-time and seven part-time interviewers; and a NIC employed investigation unit consisting of an investigation coordinator, four lead investigators, fourteen investigators, and two technical writers. This organization reported to the IP Internal Audit Department located in Decatur, Illinoi The internal audit department reported to the Chairman and President of IP through a Senior Vice President. This reporting chain was totally independent of the normal management organization for the Clinton Power Statio The SAFETEAM facilities were established in two parts; an appreciation center where the interview unit talks with site employees and solicits their concerns; and the investigation unit, separated by a road from the appreciation center, where the investigation staff offices are locate The interview unit conducts three types of interviews: scheduled ( interviews of site employees; drop-in (unscheduled) interviews for t concerned employees; and exit interviews for employees who are leaving their employment at CPS. In addition, concerns are also solicited

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through the mail via concern forms provided with postage paid, self-addressed envelopes; and through the use of a toll-free telephone

" hotline" which is reasonably well publicized onsite. The concerns are handled in such a way as to disassociate the concernee's name from his concern. The names are controlled but the concerns are forwarded to the investigation unit for review, investigation, and respons The investigation unit conducts a review of the concern, formulates an investigation plan, investigates the concern, and reports the result The results may include corrective actions taken or to be taken if the concern was substantiated. The results of the investigation are then reviewed for adequacy by the investigation coordinator, corrected by the

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technical writers, and submitted to a steering committee. The steering committee consists of an IP lawyer, an IPQA representative, and an IP public relations representative. Once the steering committee concurs in the accuracy and adequacy of the report, it is sent as a response to the concerned individual. The SAFETEAM program provides for followup of corrective actions and followup responses to the concerned individua . Program Strengths The inspection team observed several strengths in the SAFETEAM program and its implementatio Most of the strengths observed by the inspection team related to actions taken by senior management and the effectiveness of the interview unit. The following presents a summary of the strengths observed by the inspection team:

The IP Senior Vice President, with ultimate responsibility for this program, exhibited detailed knowledge of the program operation, its strengths, and its identified weaknesse In addition, he had been very involved in providing support and guidance to his subordinates, and in resolving conflicts between the SAFETEAM and the CPS line management organization while preserving the integrity and independence of the SAFETEAM organizatio The performance of an independent third party (LRS) audit of the SAFETEAM operation by a group of nationally recognized nuclear professionals with followup audit to verify certain corrective actions was considered to be a positive indicato However, as discussed in Paragraph 6, this audit was only marginally effective in bringing about needed corrective action Corrective actions taken by the interview coordinator in response to deficiencies' identified by the LRS audit addressed the identified deficiencies and resulted in an improved interview proces In addition to the above, the SAFETEAM program included several favorable program refinements not included in the SYNDECO progra The most obvious examples were: the SAFETEAM Interviewer Manual; a continuing interviewer evaluation and training program; commitment tracking and followup responses; and a prompt review for reporte.bility under 10 CFR 50.55(e). However, as discussed in Paragraph 6, implementation of these program refinements was not always effectiv . Program Weaknesses The inspection team observed a significant number of weaknesses in the SAFETEAM program and its implementation. Most of the weaknesses either directly or indirectly affected the adequacy of the SAFETEAM investigation process. Those weaknesses were identified by the inspection team through review of program documents, through interviews with personnel, and through detailed reviews of SAFETEAM investigation records selected at random from the total population of available record _ _ _ _ _ _ _ - - _ _ - _ _

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The inspection team selected 54 of the 1631 SAFETEAM quality concern investigation records for detailed review. The review was intended to assess the adequacy of implementation of the SAFETEAM program in providing resolution of employee identified concerns. The inspection team also selected two potentially hardware-affecting concerns for verification of the investigation result The inspection team identified weaknesses in 23 of the 54 investigation records reviewe The results of that review were categorized as follows:

NUMBERS OF RECORDS CATEGORY AFFECTED Investigation not independent 1 Investigation / investigation record did not address all employee identified Concerns 12 Followup responses not verified and mailed to the concernee 2 Investigative technique employed was inappropriate 3 Investigation record did not adequately support the response to the concernee 2 Investigation record did not include a copy of the interview report form 2 22"

• This number was different from the number of investigation records determined to contain weaknesses because some of the weaknesses involved multiple investigation records and some of the investigation records reviewed had multiple weaknesse Each of the above weaknesses affected the ability of the investigation record to provide evidence of plant qualit The team acknowledged that the investigation records were not intended to meet regulatory requirements for records or to provide evs ice of quality. The actual impact of the above weaknesses on plant h6rdware, if any, was not determined during the course of the inspectio Results of verification attempts made by the team for two potentially hardware-affecting investigation records selected are summarized below: Concern Number 12023 - C: This concern identified that an accident occurred during testing of one of the safety-related emergency diesel generators at the vendor's shop in Texas. The documentation available in the investigation record left a number of unanswered questions concerning the potential detrimental effects of excessive l

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generator currents and the fire that occurred as a result of the accident. It was not apparent from the investigation record if the emergency generator had been affected. There was no evidence of post-accident inspections, examinations, or tests having been performed by the vendor prior to shipment of the generator to the Clinton Power Station. The SAFETEAM response to the concern indicated that preoperational testing performed after delivery of the generator to the Clinton Power Station would be sufficient to ensure the integrity of the generato The inspection team requested that the SAFETEAM provide additional assurance that either the generator had not been affected by the accident or that corrective action had been taken to assure that the generator had not been degraded as a result of the acciden SAFETEAM was not able to provide the necessary information during the course of the inspection. The inspection team concluded that, as a minimum, the investigation record did not adequately support the response to the concernee -(weakness e. above).

b. Concern Number 10028 - A: This concern identified that certain bolts had been overtorqued during installation of safety-related cable trays due to inadequate work controls. The employee was concerned that the overtorqued bolts could fail during a seismic event and result in an unanalyzed common-mode failure of the Clinton Power Station cable tray system. The SAFETEAM response to this concern indicated that the SAFETEAM had contacted the concerned employee and discussed the matter; that the concerned employee was aware of a procedure change that recolved the problem with overtorquing bolts during installation (a torque wrench was required to be used); and that based on that procedure change, the employee was no longer concerned and no additional response was required from the SAFETEA The inspection team asked the SAFETEAM how they had addressed the overtorqued bolts which the concerned employee referred to as existing prior to the procedure change. The inspection team noted that the majority of cable tray installations had been completed prior to the procedure change being institute The SAFETEAM responded that the Baldwin Associates (BA) Quality Assurance (QA)

Program would automatically address potential hardware effects associated with installation procedure changes and that no additional investigation was required. The team requested that SAFETEAM provide documentation that would support the SAFETEAM contention that the BA QA program had addressed the concern (i.e., a I

nonconformance report, a corrective action request, etc.). The requested documentation was not provided during the course of the inspection. The inspection team concluded that, as a minimum, the investigation / investigation record did not address all employee identified concerns (weakness b. above).

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The above results indicate that there were some employee identified quality concerns for which the investigation record did not adequately address the identified concern. Since the investigation record did not adequately address the identified concern, there was some potential that hardware could be affected. The team did not establish the actual effect on plant hardware during the course of the inspectio Additional inspection will be required in order to verify that the SAFETEAM has adequately resolved the weaknesses identified above and similar weaknesses which may exist in other SAFETEAM investigation records. This is an open item (461/86004-01).

Review of the results of an independent third party (LRS) audit (see Paragraph 5 above) revcaled that every significant weakness identified by the inspection team had been previously identified by the LRS audi Corrective action statements had been prepared by the SAFETEAM to address each audit finding. Interview of the SAFETEAM investigation coordinator determined that he had not become aware of the LRS audit findings that affected his area of responsibility until December 1985, approximately four months after the audi The most significant overall weakness observed by the inspection team was the apparent failure of the SAFETEAM to correct the findings identified by the LRS audit relative to the functioning of the SAFETEAM investigation uni It must be noted that the inspection team did not-use the LRS audit in-the preparation and planning of this inspection, for the selection of samples, or for the interviews of SAFETEAM investigators and interviewers. Rather, the LRS audit results are documented here to show that corrective actions to previous audit findings were not effectively achieved. The following presents a sample of the LRS audit findings reviewed by the inspection team and the observations of the inspection team relative to each LRS finding: LRS Audit Finding Need for program definitions of " willful wrongdoing" and

" intimidation and harassment" for all SAFETEAM personne Inspection Team Observation The inspection team observed that, while *.he needed definitions had been obtained, supervision had failed to urovide the definitions to the investigators, LRS Audit Finding i

SAFETEAM responses don't always go to the root caus L

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Inspection Team Observation The inspection team observed that some SAFETEAM responses still failed to identify the root caus In addition, of fifty-four concern responses reviewed, independence of the investigation was not maintained in one case; the investigation / investigation record did not address all concerns in twelve concern responses reviewed; and follewup responses had not been verified and mailed to the concernee in two of the fifty-four concern responses reviewed, c. LRS Audit Finding Should have professional investigator under contract to SAFETEAM to investigate intimidation and harassment concern Inspection Team Observation The inspection team noted that the SYNDECO Safeteam program provided

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an appropriate mechanism for handling of alleged wrongdoing; that mechanism had never been used by SAFETEA In addition, in response to the LRS audit finding, S\FCTEAM had arranged for support from a professional investigator on an as needed basi That mechanism had never been used by SAFETEAM for the investigation of alleged wrongdoing. Rather, the SAFETEAM handled alleged wrongdoing in the same fashion as other concerns received by the SAFETEA The inspection team observed that the investigative techniques used by the SAFETEAM in investigating alleged wrongdoing were inappropriate to the circur. stances in three of the fifteen wrongdoing-related concern responses reviewed. In addition, the SAFETEAM investigators were not knowledgeable of the applicable laws governing the alleged wrongdoing and were not trained in rules of evidence, criminal investigative techniques, et The inspection team strongly recommended that the SAFETEAM change their approach to the investigation of alleged wrongdoin d. LRS Audit Finding Sometimes the concern file doesn't support written response to the concerne Inspection Team Observation The inspection team observed this weakness in two of the 54 concern responses reviewe e. LRS Audit Finding The investigation coordinator lacks supervisory skill __ _ .

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Inspection Team Observation The inspection team observed that the investigation coordinator had no methodology for evaluating the quality of performance of the investigators / senior investigators working for him other than to review written investigation reports and to track the productivity of the investigator There was no provision for direct performance evaluation such as accompanying investigators either by the investigation coordinator or the lead investigators; formal employee training was nonexistent; and there was no written job description for either the investigator or senior investigator position LRS Audit Finding Need training program for investigator Inspection Team Observation The inspection team observed that there was no evidence of any training being conducted in over a year. Each of the investigators interviewed stated that they had never been provided any training other than a brief SAFETEAM program indoctrination. Site specific training was not included in the indoctrinatio There was no training given related to interviewing techniques, investigation techniques, applicable laws, rules of evidence, minimum documentation requirements for a concern response file, investigative report writing, or other job-related activitie During an interview with the SAFETEAM director, he stated that some informal job-related training had been provided for each investigator. No records were maintained of the subject, length of training, names of attendees, or person (s) presenting the trainin The inspection team was not able to assess the scope or adequacy of the training provided. The inspection team noted that the investigators interviewed were not aware that they had been traine LRS Audit Finding Need job description for investigator Inspection Team Observation The inspection team observed that a true job description did not exist for the qualification requirements, duties, and respcnsibilities of either an investigator or senior investigato The SAFETEAM Investigation Guidelines Manual did include a brief statement of investigator responsibilities; however, neither of the investigators interviewed by the inspection team had ever seen the SAFETEAM Investigation Guidelines Manual before it was presented to them by the inspection tea s . . . . .

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h. LRS Audit Finding Investigators should listen to tapes of interviews before starting investigation of concer Inspection Team Observation The inspection team observed that only one of the two investigators interviewed routinely listened to interview tapes before planning an investigation even though this was a requirement of the SAFETEAM Investigation Guideline i. LRS Audit Finding Weak investigators need to be weeded ou Inspection Team Observation An interview with the investigation coordinator indicated that no one had left the SAFETEAM investigation unit since the date of the LRS audit. The investigation coordinator was not aware of any of the LRS audit findings until December 1985. Subsequent discussion with the SAFETEAM director indicated that two of the investigators working for the investigation coordinator had left the SAFETEAM after the LRS audi The inspection team noted that the entire interview unit staff had been replaced subsequent to the LRS audi j. LRS Audit Finding Need better file (1) Each file should have an inde (2) Each file should be more inclusive of all investigative informatio (3) It is not necessary to go back and retrofit old concern file Inspection Team Observation The inspection team observed that recent concern files were more complete than the earlier concern files; no indexes were observed in the file The inspection team did observe that two of the concern response files reviewed did not have the interview report form in the file and two others did not have documentation sufficient to support the investigation results. Many of the earlier concern response files were missing the investigation record which was the basis for the investigators' findings. None of the files reviewed had detailed investigative interview notes or signed statements from witnesse L

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l The above listed weaknesses were apparent in a total of twenty-three of the fifty-four concern response files reviewed by the inspection team.

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F The twenty-three concern response files affected represented work performed by the SAFETEAM investigation unit both before and af ter the date of the LRS audit and included the work of a cross section of I

SAFETEAM investigator . SAFETEAM Program Status Review of the management report identified in Paragraph 3.k. above provided the following information about the status of SAFETEAM concerns as of January 17, 1986:

DATA TYPE NUMBER I

Number of Individuals Processed Through the SAFETEAM Appreciation Center............. 6635 Number of Exit

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Interviews............................ 749 l

Number of Scheduled Interviews....................... 1629 Number of Drop-Ins................................... 197 Telephone Calls Received............................. 73

j Letters Received..................................... 197 Total Number of Interviews Conducted................. 2845 r

Total Number of Quality Concerns Received............ 1631 l Total Number of Quality Concerns 0 pen................ 45 l Total Number of Non-Quality Concerns Received........ 704 Total Number of Non-Quality Concerns Open. . . . . . . . . . . . 33 Total Number of Concerns Received.................... 2335 Total Number of Concerns 0 pen........................ 78 Total Number of SAFETEAM Substantiated Concerns Requiring SAFETEAM Initiated Corrective Action..... 48 The above status indicates that the SAFETEAM has processed a substantist number of employees; that a significant number of quality related

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concerns were received and investigated by the SAFETEAM; and that only a l minimal number of concerns were open at the time of this inspection. The l SAFETEAM director indicated that there was essentially no backlog of l concerns at the time of this inspection (i.e., each open concern was currently under investigation).

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8. Conclusion Based on the results documented above, the inspection team concluded that the SAFETEAM program, as originally estabitshed at Clinton Power Station, had several significant deficiencies that impacted the adequacy of both the interview process and the investigation process. Because of strong management action taken by the IP' Senior Vice President, those weaknesses were identified and corrective actions were determir.ed. In the case of the interview process, corrective actions taken appeared to have been generally effective. In the case of the investigation process, ,

corrective actions had not been taken or were ineffective. The

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inspection team concluded that the acceptability of the SAFETEAM investigations is in question and corrective action is neede .

9. Exit Interview (30703) 1 The inspection team met with Illinois Power Company representatives (denoted by asterisk in Paragraph 1) at the conclusion of the inspection on January 24, 198 The inspectors summarized the scope and results of the special inspection. The inspectors also discussed the likely informational content of the inspection report with regard to documents or processes reviewed during the inspection. Illinois Power Company did not identify any such documents / processes as proprietary. The inspection team reiterated their recommendation that SAFETEAM change their approach to the investigation of wrongdoing concerns. The results and conclusions of the inspection team were acknowledged by the IP Senior Vice Presiden Subsequent to the inspection, on February 24 and 25, 1986, results of the inspection was discussed by telephone with Mr. L. D. Haab, Illinois

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Power Company Senior Vice Presiden .

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