IR 05000483/2003012
| ML033140253 | |
| Person / Time | |
|---|---|
| Site: | Callaway  |
| Issue date: | 11/07/2003 |
| From: | Chamberlain D Division of Reactor Safety IV |
| To: | Randolph G Union Electric Co |
| References | |
| EA-03-060 IR-03-008, IR-03-012 | |
| Download: ML033140253 (17) | |
Text
ber 7, 2003
SUBJECT:
CALLAWAY PLANT - NRC SUPPLEMENTAL INSPECTION REPORT 05000483/2003012
Dear Mr. Randolph:
On September 8 through 10, 2003, the NRC conducted an onsite supplemental inspection at your Callaway Plant, and completed an in-office inspection between October 27 and 30, 2003.
A preliminary exit meeting was held onsite on September 10, 2003, and a telephonic conference exit call was held with plant management on October 30, 2003. The enclosed report documents the inspection findings which were discussed with you and other members of your staff.
The NRC issued a White inspection finding and Notice of Violation in Inspection Report 50-483/03-08. This finding involved a failure to meet the requirements of planning standard 10 CFR 50.47(b)(5). The performance weakness associated with this finding involved a failure to establish a means to notify members of the public in the emergency planning zone of an emergency using tone alert radios in areas lacking effective siren coverage.
This supplemental inspection was conducted to provide assurance that the root and contributing causes of the White inspection finding were understood and to provide assurance that the corrective actions were sufficient to address the causes, and prevent recurrence of the problems. Detailed observations, assessments, and conclusions of the inspection are presented in the enclosed inspection report.
The inspection concluded that the root causes of the finding were appropriately evaluated and understood. The corrective actions implemented as a result of your evaluations addressed the root and contributing causes.
In accordance with 10 CFR 2.790 of the NRCs "Rules of Practice," a copy of this letter, its enclosure, and your response will be made available electronically for public inspection in the NRC Public Document Room or from the Publicly Available Records (PARS) component of NRCs document system (ADAMS). ADAMS is accessible from the NRC Web site at http://www.nrc.gov/reading-rm/adams.html (the Public Electronic Reading Room).
Union Electric Company -2-Should you have any questions concerning this inspection, we will be pleased to discuss them with you.
Sincerely,
/RA/
Dwight D. Chamberlain, Director Division of Reactor Safety Docket: 50-483 License: NPF-30 Enclosure:
NRC Inspection Report 05000483-2003012 Professional Nuclear Consulting, Inc.
19041 Raines Drive Derwood, MD 20855 John ONeill, Esq.
Shaw, Pittman, Potts & Trowbridge 2300 N. Street, N.W.
Washington, DC 20037 Mark A. Reidmeyer, Regional Regulatory Affairs Supervisor Regulatory Affairs AmerenUE P.O. Box 620 Fulton, MO 65251 Manager - Electric Department Missouri Public Service Commission 301 W. High P.O. Box 360 Jefferson City, MO 65102 Ronald A. Kucera, Deputy Director for Public Policy Department of Natural Resources P.O. Box 176 Jefferson City, MO 65102
Union Electric Company -3-Rick A. Muench, President and Chief Executive Officer Wolf Creek Nuclear Operating Corporation P.O. Box 411 Burlington, KS 66839 Dan I. Bolef, President Kay Drey, Representative Board of Directors Coalition for the Environment 6267 Delmar Boulevard University City, MO 63130 Chris R. Younie, Manager Quality Assurance AmerenUE P.O. Box 620 Fulton, MO 65251 Jerry Uhlmann, Director State Emergency Management Agency P.O. Box 116 Jefferson City, MO 65102-0116 Scott Clardy, Director Section for Environmental Public Health P.O. Box 570 Jefferson City, MO 65102-0570 Keith D. Young, Manager Regulatory Affairs AmerenUE P.O. Box 620 Fulton, MO 65251 David E. Shafer Superintendent, Licensing Regulatory Affairs AmerenUE P.O. Box 66149, MC 470 St. Louis, MO 63166-6149 Chief, Technological Services Branch National Preparedness Division Fema Region VII 2323 Grand Blvd., Suite 900 Kansas City, Missouri 64108-2670
Union Electric Company -4-Electronic distribution by RIV:
Regional Administrator (BSM1)
DRP Director (ATH)
DRS Director (DDC)
ORA/ACES (GFS)
OE (JLD)
OEDO RIV Coordinator (JAC),
Senior Resident Inspector (MSP)
Branch Chief, DRP/B (DNG)
Senior Project Engineer, DRP/B (RAK1)
Staff Chief, DRP/TSS (PHH)
RITS Coordinator (NBH)
Scott Morris (SAM1)
Site Secretary (DVY)
Dale Thatcher (DFT)
W. Maier (WAM)
NRR/DIPM/EPB/EPHP (REM2)
OEMAIL ADAMS: Yes * No Initials: ______
Publicly Available * Non-Publicly Available * Sensitive Non-Sensitive R:\_CW\2003\CW2003-12RP-PJE.wpd RIV:DRS/PSB C:PSB C:DRP/B D:DRS PJElkmann TWPruett DNGraves DDChamberlain
/RA/ /RA/ RKopriva for /RA/
11/03/03 11/03/03 11/05/03 11/07/03 OFFICIAL RECORD COPY T=Telephone E=E-mail F=Fax
ENCLOSURE U.S. NUCLEAR REGULATORY COMMISSION
REGION IV
Docket: 50-483 License: NPF-30 Report: 05000483/2003012 Licensee: Union Electric Company Facility: Callaway Plant Location: Junction Highway CC and Highway O Fulton, Missouri Dates: September 8 through 22, and October 27 through 30, 2003 Inspector: Paul J. Elkmann, Emergency Preparedness Inspector Approved: Dwight D. Chamberlain, Director, Division of Reactor Safety
SUMMARY OF FINDINGS
Callaway Plant
NRC Inspection Report 50-483/03-12 IR 05000483-2003012; 09/08-22/2003; Callaway Plant; Supplemental Inspection for one White finding in the emergency preparedness cornerstone.
The supplemental inspection was conducted by a region-based emergency preparedness inspector. The significance of most findings is indicated by their color (Green, White, Yellow, or Red) using Inspection Manual Chapter 0609, Significance Determination Process (SDP).
Findings for which the SDP does not apply are indicated by the severity level of the applicable violation. The NRCs program for overseeing the safe operation of commercial nuclear power reactors is described at its Reactor Oversight Process website at http://www.nrc.gov/NRR/OVERSIGHT/index.html.
A. Inspector Identified Findings
Cornerstone: Emergency Preparedness
The NRC performed this supplemental inspection to assess the licensees evaluation associated with the failure to meet requirements of 10 CFR 50.47(b)(5), in that the licensee did not establish a means to notify members of the public in the emergency planning zone of an emergency using tone alert radios in areas lacking effective siren coverage. This performance issue was previously characterized as having low to moderate risk significance (White) in NRC Inspection Report 50-483/03-08. During this supplemental inspection, performed in accordance with Inspection Procedure 95001, the inspector determined that the licensee performed a satisfactory evaluation of the White finding. The licensees evaluation identified the primary root causes of the performance issue to be: (1) situations that were not covered in procedures, (2) inadequate supervision of the Senior Nuclear Clerks, and (3) turn-over processes for the Senior Nuclear Clerks required improvement.
Given the licensees acceptable performance in addressing the issue, the White finding associated with this issue will only be considered in assessing plant performance for a total of four quarters in accordance with the guidance in Inspection Manual Chapter 0305, Operating Reactor Assessment Program. The issue was identified in the first quarter of 2003, therefore it will no longer be considered in assessing plant performance after the fourth quarter of 2003.
Report Details 01
INSPECTION SCOPE
The NRC performed this supplemental inspection to assess the licensees evaluation associated with the failure to establish a means to notify members of the public in the emergency planning zone of an emergency using tone alert radios in areas lacking effective siren coverage. This performance issue was previously characterized as having low to moderate risk significance (White) in NRC Inspection Report 50-483/03-08 and is related to the emergency preparedness cornerstone in the reactor safety strategic performance area. The licensees evaluation consisted of:
- Root Cause Analysis AUCA-03-006, Number of Residences in the EPZ Found to Not Have Tone Alert Radios
- Callaway Action Request System (CARS) 200208007, Number of Residences in the EPZ Found to Not Have Tone Alert Radios
- CARS 200300778, Request for Review of Outside Support of Regulatory Responsibilities
- CARS 200301479, Update Process to Identify the Hearing-Impaired in the EPZ
- CARS 200303795, Revise EPZ Information Brochure
- CARS 200304756, Consolidate Maps used to determine Eligibility for Tone Alert Radios
- CARS 200306307, Incomplete Action taken on Closure of Tone Alert Radio CARS 200208007"
- SEGR 03-08-003, Independent Technical Review Report on Tone Alert Radio Distribution 02 EVALUATION OF INSPECTION REQUIREMENTS 02.01 Problem Identification a. Determination of who (i.e., licensee, self-revealing, or NRC) identified the issue and under what conditions.
The licensee identified this issue as a result of a routine tone alert radio surveillance conducted November 2002. The surveillance revealed that an unexpectedly high number of new utility connections had been received (the licensee uses new utility connection information to identify households which are outside effective siren coverage).
Subsequent investigation by the licensee determined that customers had been transferred between electric service providers, that some existing connections had not been reported to the licensee, that the licensee had not adequately evaluated all new utility connections that had been received, and that tone alert radios had not been issued to some households in the emergency planning zone.
b. Determination of how long the issue existed, and prior opportunities for identification.
The licensee last validated their tone alert radio database in 1998 following a problem which also resulted in some households not receiving tone alert radios. As part of the investigation into the 2002 event, the licensee determined that the 1998 validation had been incomplete because one electric service provider was unable to supply customer data specific to the emergency planning zone. In 2002, the licensee attempted to validate its emergency planning zone data base using the original customer service requests and records rather than a computer-generated customer report. Because of incomplete or missing historical records kept by the same electric service provider, the licensee was unable to clearly determine when the electrical connection information needed to issue tone alert radios became inaccurate. Nevertheless, the inspector concluded that the licensee had performed a full validation of its tone alert database in 2002 and that tone alert radios had been appropriately issued to all households requiring them.
The licensee determined that there were no previous opportunities to identify that they were not being provided complete information about new utility connections in the emergency planning zone. Specifically, the scope of the licensees ongoing quality assurance audit, and self-assessment activities would not have extended to reviews of activities performed by the electric service providers. The inspector agreed with the licensees evaluation.
c. Determination of the plant-specific risk consequences (as applicable) and compliance concerns associated with the issue.
The licensee evaluated this issue as having only moderate safety significance because:
- (1) the likelihood of a large early release due to a steam generator tube rupture or loss of coolant accident is less than 1E-7 per year, and
- (2) best-estimate radiological calculations suggested that households requiring tone alert radios would not require dose-driven protective actions following a serious radiological accident. The inspector concluded that the licensees safety significance determination did not consider emergency preparedness as a defense-in-depth measure, or the NRCs planning basis for radiological accidents.
The inspector determined that compliance aspects of the failure to distribute tone alert radios within the emergency planning zone was addressed in CARS 200304665, Tone Alert Radio Notice of Violation and White Finding.
02.02 Root Cause and Extent of Condition Evaluation a. Evaluation of methods used to identify root causes and contributing causes.
The licensee used a combination of structured root cause analysis techniques to evaluate this issue including event and causal factors analysis, the Taproot method, and the Institute of Nuclear Power Operations Human Performance Enhancement System.
The inspector determined that the licensee followed its procedures for performing root cause analysis.
b. Level of detail of the root cause evaluation.
The licensees overall analysis was conducted to an acceptable level of detail. The inspector determined that all necessary analysis activities were captured in Callaway Action Requests (CARS, corrective action system entries) and that these documents, together with the root cause analysis report, identified and documented the root causes for this event.
The licensee determined that three causal factors were associated with this issue:
- Corrective actions from a previous event were inadequate to prevent recurrence
- Receipt of utility connection reports generated by the electric service providers were not addressed in procedures
- The Desk Top Instructions used by the Senior Nuclear Clerks did not contain an adequate level of detail to describe their tasks.
The licensee identified eight root causes associated with the causal factors, and two contributing causes:
- Situations that were not covered in procedures
- Inadequate supervision of the Senior Nuclear Clerks
- Turn-over processes for the Senior Nuclear Clerks required improvement
- Continuing training needs improvement
- Correction action needs improvement
- Tasks performed by the Senior Nuclear Clerks were not analyzed
- Communications with other work groups needs improvement
- Procedures or direction were confusing or incomplete
- The Annual Public Information Brochure distributed within the emergency planning zone does not give clear instructions on requesting a tone alert radio if the residence does not have one (contributing)
- Inadequate communication occurred between supervision and clerks, clerks and customers, and between the Callaway EP Department and AmerenUE Jefferson City offices (contributing)
The inspector evaluated the root cause analysis document against the requirements of the licensees procedure APA-ZZ-00500, Corrective Action Program, Revision 34, and determined that the root cause analysis contained all of the required elements.
The licensee identified inadequate corrective actions for Suggestion Occurrence Solution SOS-199803339 as a causal factor for the failure to distribute tone alert radios identified in 2002. The licensee determined that corrective actions in 1998 were inadequate or incomplete because all of the causal factors were not identified due to a lack of knowledge about root cause analysis methods. NRC Inspection Report 50-483/2003-08 noted that not all of the corrective actions identified for SOS-199803339 were completed, in that the tone alert database had not been corrected. The inspector concluded that the 1998 corrective actions were incomplete because corrective actions were not identified or implemented for one of the identified causes. Specifically, the licensee identified one root cause of the 1998 event as inadequate turnovers provided to successive Senior Nuclear Clerks, yet none of the corrective actions taken in 1998 addressed improving the turnover process.
c. Consideration of prior occurrences of the problem and knowledge of prior operating experience.
The licensee conducted a key-word search of their corrective action database and identified four previous events connected with tone alert radios. One of these events (CAR 199803339) was nearly identical to this event in that it also involved a failure to distribute tone alert radios due to inadequacies in the emergency preparedness database. The licensee determined that inadequate corrective actions from this prior event were a causal factor for this issue.
The licensee also performed a review of external operating experience using the Institute of Nuclear Power Operations database and was unable to identify any similar issues.
The inspector did not identify any contrary information.
d. Consideration of potential common cause(s) and extent of condition of the problem.
The inspector concluded that the licensees overall extent of condition review as documented by the corrective action process was acceptable. The inspector determined that the licensees extent of condition review involved:
- (1) identification of the number of households which had not been issued tone alert radios,
- (2) review of emergency preparedness programs to identify instances where databases critical to the EP function might be compromised, and
- (3) an assessment (CARS 20030778) to identify all cases where they relied on outside organizations to ensure compliance with regulatory responsibilities. The licensee concluded that no other program relied on activities or data provided by outside organizations. The inspector determined that the action items for CAR 20030778 were complete.
The failure to distribute tone alert radios constituted a non-compliance with the licensees Federal Emergency Management Agency Alert and Notification System Design Report.
The inspector determined that the licensee completed two reviews of the design report (Quality Assurance Audit report AP 02-016 and CARS 20025615) and determined that there were no additional concerns. The inspectors agreed with the licensees evaluation.
The NRC defines extent of cause as the extent to which the root causes of an identified problem have impacted other plant processes, equipment, or human performance. The inspector determined that the licensees root cause analysis process required that a generic implications review be performed to determine if the causes of the condition impacts other equipment, programs, procedures, or operations. The licensee completed the evaluation by performing a trend analysis of root cause codes and key words, and by interviewing personnel that may be affected by the root causes. The inspector determined that the licensees extent of cause review appropriately assessed the scope of the identified concerns.
02.03 Corrective Actions a. Appropriateness of corrective actions The licensee took extensive immediate corrective actions, which included:
1) Additional electric service provider data to validate the customer list in the tone alert radio database 2) Telephone calls to 108 households to determine whether they had been issued radios, and whether they were within siren coverage 3) Immediate delivery of additional tone alert radios from the vendor 4) Provisions for mobile route alerting in areas identified as lacking tone alert radios through the Callaway County Emergency Management Director 5) Delivery of approximately 90 new tone alert radios to households in the emergency planning zone approximately 20 days after initial identification of the problem The inspector determined that the immediate corrective actions addressed the safety concern of a failure to establish a means to notify members of the public in the emergency planning zone of an emergency using tone alert radios in areas lacking effective siren coverage. The inspector determined that compliance with planning standard 10 CFR 50.47(b)(5) had been restored approximately 20 days after discovery of the event and all immediate corrective actions had been completed in an acceptable time.
The licensees long-term corrective actions included:
1) Verification of the current service territories of each electric service provider doing business within the emergency planning zone 2) A task analysis of the duties of the Senior Nuclear Clerks with regard to distributing tone alert radios 3) Replacement of the previous Desk Top Instruction describing distribution of tone alert radios with procedure KSP-ZZ-00008, Tone Alert Radios, Revisions 0 and 4) Training to the Senior Nuclear Clerks responsible for distributing tone alert radios regarding procedure KSP-ZZ-00008, along with their supervisor; the licensee also designated a back-up Senior Clerk and provided similar training 5) Establishment of a Memorandum of Understanding with electric service providers to formalize the collection and reporting of customer hookup data to the licensee 6) Upgraded computer programs used by Ameren to replace field connection documents with a unified monthly computer-generated report 7) Revision of Surveillances ST-12055, ST-12100, ST-12101, and ST-2102, to provide better directions and standards for documenting the receipt of utility connection data and the distribution of tone alert radios 8) Revision of the annual tone alert data base surveillance to require that all electric service providers be audited in a rolling three year period 9) Revision of the text of the annual Emergency Planning Zone Brochure to provide additional information about requesting tone alert radios 10) Replacement of several outdated individual maps with a single set of large scale maps which included county roads, siren coverage zones and electric transformer locations. The licensee also assumed responsibility to update and maintain these maps as needed 11) Revision of the text of annual advertisements placed in local media by the licensee to provide additional information about requesting tone alert radios The licensee identified an inadequate turn-over process for Senior Nuclear Clerks as one of the causes of the 1998 event which resulted in inadequate distribution of tone alert radios. A need to improve turn-over processes for Senior Nuclear Clerks was also identified as a root cause of the 2002 failure to distribute tone alert radios. The inspector determined that corrective actions for the 1998 event were inadequate in part because no actions were taken to improve turn-over processes. One of the licensees long-term corrective actions for the 2002 event was to require the Supervisors of Senior Nuclear Clerks to become more knowledgeable about tone alert radio distribution, and for them to monitor or perform the turn-over. The inspector identified that the licensee had developed no additional training, checklists, or guidance to ensure consistency in performing turn-overs. The inspector concluded that the lack of standards for performing turn-overs could represent a future vulnerability. The licensee initiated CARS 200306726, Evaluate Formalizing the Tone Alert Radio Clerk Turnover Process to address this concern.
The inspector determined that the corrective actions were responsive to all of the root and contributing causes identified by the licensee.
b. Prioritization of corrective actions.
The inspector concluded that the corrective actions were properly prioritized. Actions of an immediate nature were given the highest priority and the provision of new tone alert radios was accomplished on an acceptable schedule. Actions to establish the reliability of future utility connection data were given the next priority, followed by actions to provide better guidance to the Senior Nuclear Clerks. A completion date and a responsible manager were assigned for each corrective action, and these were tracked through the corrective action system.
c. Establishment of a schedule for implementing and completing the corrective actions.
The inspector determined that the licensee had completed all corrective actions for the root cause analysis and for the associated Callaway Action Requests (CAR) 200208007, 200300778, 200301479, 200303795, 200304756, and 200306307, with the exception of a post-implementation effectiveness review. The inspector reviewed a sample of six corrective actions and concluded that they had been implemented successfully although in some cases formal documentation was lacking, such as completion of a task analysis of the tone alert distribution process to support procedure development. The inspector also determined that the thoroughness of some corrective actions, such as resolution of grey areas in the Desk Top Instructions, could not be evaluated because the root cause analysis and corrective actions did not identify the specific weaknesses which constituted grey areas.
d. Establishment of quantitative or qualitative measures of success for determining the effectiveness of the corrective actions to prevent recurrence.
The inspector determined that the root cause analysis included criteria for determining the future effectiveness of corrective actions: corrective actions will be evaluated as fully successful if less than or equal to five households in the emergency planning zone are found not to have received tone alert radios. The inspector concluded that the success criteria were acceptable. The licensee generated CAR 200300851 to track performance of the effectiveness review associated with the root cause analysis. This review is scheduled for the first quarter of 2004.
03 MANAGEMENT MEETINGS
Exit Meeting Summary
On September 10, 2003, the inspector presented the preliminary results of the supplemental emergency preparedness inspection conducted September 8-10, 2003, to Mr. G. Randolph, Senior Vice President and Chief Nuclear Officer, and other members of his staff. Mr. Randolph acknowledged the observations presented. The inspector confirmed that proprietary information was not provided or examined during the inspection.
On October 30, 2003, the Plant Support Branch Chief, NRC Region IV, conducted a telephonic meeting to discuss the NRCs assessment of the root cause evaluation with Mr. Keith Young, Manager Regulatory Affairs, and other members of the licensees staff.
04 Other Activities
4OA3 Event Followup
The Final Significance Determination for NRC Inspection Report 05000483/2003008 documented a violation that involved a failure to distribute tone alert radios to households in the emergency planning zone which required them. The inspector reviewed the licensees root cause determination and associated corrective action documents (Callaway Action Request System 200208007, 200300778, 200301479, 200303795, 200304665, 200304756, and 200306307) pertaining to the violation of the requirements of planning standard 10 CFR 50.47(b)(5). The licensees evaluation identified three primary root causes. The licensee identified 11 correction actions which taken together:
- (1) validated the current tone alert database,
- (2) procedurelized activities performed by the Senior Nuclear Clerks,
- (3) improved maps and other user aids, and
- (4) formalized program requirements and expectations between the licensee and the providers of information used to distribute tone alert radios.
The inspector concluded that the licensees corrective actions addressed the root causes.
ATTACHMENT PARTIAL LIST OF PERSONS CONTACTED Licensee K. Bruckerhoff, Supervisor, Emergency Preparedness S. Crawford, Emergency Response Coordinator, Emergency Preparedness G. Gilbert, Consulting Engineer, Corrective Actions L. Graessle, Superintendent, Protective Services J. Hiller, Engineer, Regulatory Affairs G. Randolph, Senior Vice President, Generation, and Chief Nuclear Officer M. Schnack, Supervising Engineering, Corrective Actions C. Younk, Manager, Quality Assurance NRC M. Peck, Senior Resident Inspector ITEMS OPENED, CLOSED, AND DISCUSSED Opened None.
Opened and Closed During this Inspection None.
Closed During this Inspection 50-483/0308-01 VIO Failure to meet the Alert Notification System design criteria due to programmatic deficiencies resulting in an inaccurate Tone Alert Radio database in apparent violation of 10 CFR 50.47(b)(5) (EA-03-060).
Previous Items Discussed None.
DOCUMENTS REVIEWED
APA-ZZ-00500, Corrective Action Program, Revision 34
KSP-ZZ-00007, Offsite Effectiveness of the Emergency Preparedness Program, Revision 1
KSP-ZZ-00007, Offsite Effectiveness of the Emergency Preparedness Program, Revision 2
KSP-ZZ-00008, Tone Alert Radios, Revision 1
KSP-ZZ-00008, Tone Alert Radios, Revision 2
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Callaway Plant Alert and Notification System Design Report, July 2001 Revision
Onsite Review Committee Scorecard for Root Cause Analysis AUCA 03-006
Pre-Job Brief Overview for Root Cause Analysis AUCA 03-006
Root Cause Analysis AUCA 03-006, Number of Residences in the EPZ found to not have Tone
Alert Radios
Root Cause Manual, Revision 1
Surveillance Task Sheet S71222563, Monthly Distribution of Tone Alert Radios
SEGR 03-08-003, Independent Technical Review Report on Tone Alert Radio Distribution
Callaway Action Request System 199803339, RMS Supervisor Investigating Delay in Issuance
of Tone Alert Radios to Residents of the Emergency Planning Zone discovered that no Tone
Alert Radios had been issued to New Residents in the Emergency Planning Zone since January
1998
Callaway Action Request System 200205505, Update Definitions of Generic Implications and
Extent of Condition
CARS 200304665, Tone Alert Radio Notice of Violation and White Finding
CARS 200306726, Evaluate Formalizing the Tone Alert Radio Clerk Turnover Process
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