ML041260149

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2004 Quality Audit Emergency Preparedness Program
ML041260149
Person / Time
Site: Columbia Energy Northwest icon.png
Issue date: 04/26/2004
From: Coleman D
Energy Northwest
To:
Document Control Desk, Office of Nuclear Reactor Regulation
References
G02-04-081 AU-EP-04
Download: ML041260149 (13)
v • d • e


Text

ENERGY NORTH WEST PO. Box 968

  • Richland, Washington 99352-0968 April 26, 2004 G02-04-081 U.S. Nuclear Regulatory Commission ATTN: Document Control Desk Washington, D.C. 20555

Subject:

COLUMBIA GENERATING STATION, DOCKET NO. 50-397 2004 QUALITY AUDIT EMERGENCY PREPAREDNESS PROGRAM

Dear Sir or Madam:

Enclosed is a copy of the 2004 Columbia Generating Station, Emergency Preparedness Program Audit Report. This is transmitted to your organization as required by the Columbia Generating Station Emergency Plan, Section 8.3.

The audit did identify minor deficiencies, but none that diminish the program's capabilities in protecting the health and safety of the public in the event of an emergency.

If you have any questions regarding the audit, please contact CM Moore, Supervisor, Emergency Preparedness at (509) 377-4323.

Respectfully, DW Coleman Manager, Regulatory Programs Mail Drop PE20

Enclosure:

Quality Audit AU-EP-04 cc: A Klauss, WA EM J Scheer, Franklin County J Berky, WA DOH D Henry, Oregon State P Massey, FEMA W Macon, NRC NRR M Uphaus, WA EM B Calvert, Benton County M Mills, EFSEC NRC Resident Inspector - 988C B Mallett, NRC-RIV R Sherman, 1399 T Poindexter, Winston & Strawvn

z-ENERGY NORTHWEST People Vision Solutions QUALITY SERVICES AUDIT REPORT Emergency Preparedness Audit Report: AU-EP-04 Audit Entrance Date: 02/23/2004 Audit Exit Date: 03/18/2004 Team Members Alex Torres Lead Auditor Bill J. Hahn Auditor Steve J. Rejniak Auditor Mark P. Reis Auditor Sam A. Nappi Auditor Kevin J. Moles Technical Specialist Y56 /oy A To , LEAD AUDITOR DATE DA/TE0 MJ F VSgwOR, ALITY SERVICES DATE

'tV /v ID4 RH TORRES, MANAGER, QUALITY DXTE I

TABLE OF CONTENTS EXECUIVE

SUMMARY

.1..........................................

PURiPOSE AND SCOPIE ........................................... 2 REPORT DETAILS ..................................... .. .2 SECTION 1.0 - ORGANIZATION .......................................... 2 SECTION 2.0 - TRAINING ......................................... 3 SECTION 3.0 - READINESS TESTING ......................................... 3 SECTION 4.0 - FACILITIES AND EQUIPMENT .......................................... 3 SECTION 5.0 - PERFORMANCE INDICATORS ................... ....................... 4 NRC Performance Indicators .......................................... 4 Department Performance Indicators .......................................... 4 SECTION 6.0 - STATE AND LOCAL GOVERNMENT INTERFACES ............................... 5 SECTION 7.0 - PLANS AND PROCEDURES ............... ........................... 5 SECTION 8.0 - PROBLEM IDENTIFICATION AND RESOLUTION .................................. 5 Problem Evaluation Requests and Corrective Actions ...................................... 5 Self-Assessments ........................................... 6 ATTACHMENT A- PERSONNEL CONTACTED ATTACHMENT B -

SUMMARY

OF ISSUES

EXECUTIVE

SUMMARY

Emergency Preparedness (EP) is clearly on an improving trend. In comparison to the last audit period, EP has demonstrated a stronger sense of ownership and accountability as indicated by prioritization and timely execution of corrective actions, reduction of repeat issues, and timely incorporation of suggestions from emergency response personnel into procedures. Overall, EP and emergency response personnel can implement the Emergency Plan to protect the health and safety of the public.

Recent reorganizations were properly managed and had no impact on the Emergency Plan.

The Emergency Response Organization (ERO) staffing depth, knowledge, and qualifications are adequate to support implementation of emergency response actions.

Emergency drills and exercises have prepared the ERO to perform emergency response actions as delineated in the Emergency Plan and implementing procedures. Drill objectives were met and identified problems were entered in the corrective action process. The Institute of Nuclear Power Operations (INPO) recommendations for improving drill reports have been implemented.

Emergency facilities and equipment are maintained in a state of readiness to support emergency response operations. Equipment issues identified in the previous audit have been corrected and facility walkdowns indicated good material condition.

The Emergency Plan and implementing procedures contained the required regulatory elements and provide for effective emergency preparedness, response to emergency situations, and recovery actions. However, the Nuclear Regulatory Commission (NRC) identified that Revision 37 to the Emergency Plan contained a reduction in effectiveness that did not receive prior approval. The inspector stated that this would likely result in a Severity Level IV Non-Cited Violation. EP needs to improve their understanding of Emergency Plan changes concerning reductions in effectiveness.

The NRC EP performance indicators (PIs) were determined to correctly and accurately reflect EP performance. However, the team identified problems with a lower tier departmental PI.

The PI published on InsideEN did not reflect actual performance.

Effective lines of communication and good coordination between offsite agencies and Energy Northwest exist. This area continues to sustain good performance as indicated by past and current audit results.

Self-assessments are generally performed to address previously identified problems instead of reviewing performance to determine areas for improvements.

PURPOSE AND SCOPE This audit was conducted to satisfy the independent inspection requirement specified by Title 10 of the Code of Federal Regulations, Part 50.54(t), and the Operational Quality Assurance Program Description Appendix II, Section 2.2.8 (f). The audit scope included a review of the EP Program elements and an evaluation of adequacy of drills, exercises, procedures, capabilities, and interfaces with government agencies.

REPORT DETAILS Section 1.0 - Organization The team reviewed the impact of Energy Northwest's recent departmental reorganization on ERO staffing and response capabilities. These changes were adequately managed to ensure there were no adverse effect on Emergency Plan implementation. Responsibility is assigned for onsite and offsite radiological emergency response preparedness.

Improvements in the administration of EP were noted since the last audit period in the areas of ownership and accountability. During this audit period, a change in the supervision and an emergency planner position occurred. In addition, a position was added to EP. The team identified effective prioritization and timely execution of corrective actions, reduction of repeat issues, and timely incorporation of suggestions from ERO personnel into procedures. EP has taken steps to improve organizational effectiveness and accountability within the line organization by revising SWP-EPP-01, "Emergency Response Organization and Training," to identify responsible departments for each ERO position.

The reorganization of maintenance work teams resulted in a reduction in electrical and mechanical personnel on the back shift from two to none per position on three-out-of-seven days. The duties of one electrical and one mechanical position can be provided for by on shift personnel assigned other duties [i.e., equipment operators (EOs)] in accordance with the Emergency Plan. Call-in response personnel will staff the remaining two positions within 60 minutes. Based on interviews and a review of qualification lesson plans, the team determined that the EOs were adequately trained to perform maintenance craft duties, as described in SWP-EPP-01.

One potential weakness is that Maintenance craft personnel do not carry pagers and must be at home to receive the emergency call-in. Additionally, the response personnel are not assigned to teams; therefore, a select group of responders is not designated to be within one hour of the site and fit for duty. For the most limiting condition, two personnel out of a group of sixteen must be at home and fit for duty. Based on a successful call-in drill with the current organization and a benchmark of Wolf Creek, which indicated similar practices, the team concluded that the risk of not being able to activate the Operations Support Center (OSC) during an emergency is minimal.

2

Section 2.0 - Training Based on a review of the Personal Qualification Database (PQD) for twenty-one ERO positions and interviews with select response personnel, the team concluded that the ERO is qualified and adequately trained to perform their duties.

While improvements have occurred in the ability to verify and track ERO qualifications, diligence in ensuring accuracy of ERO personnel listings is needed. The team identified that the alphabetical roster of ERO personnel maintained on InsideEN and the Emergency Phone Directory did not include Maintenance craft personnel. The roster by emergency center included an OSC mechanic who had not been qualified for twelve months. Additionally, a 1999 revision of the Emergency Plan changed an ERO position title without a corresponding change to PQD or SWP-EPP-01. As a result, Condition Reports (CRs) 2-04-00404 and 2 00405 were initiated.

Section 3.0 - Readiness Testing Based on a review of drill and exercise reports, the team concluded that objectives were met and adequately documented, with problems entered in the corrective action process. Practices and procedures enable the ERO to recognize and classify emergencies correctly, assess consequences, notify emergency response personnel, and recommend appropriate protective actions to offsite agencies. EP has improved the drill reports by incorporating the INPO recommendation to clearly identify satisfactory performance of drill and exercise requirements.

Each drill objective has a descriptive narrative and a reference to the NUREG-0654 criteria with specific annotation as to the results.

During an observation of a computer simulation by the Scenario Development Committee (SDC) for the upcoming evaluated exercise, unanticipated results from several event programs occurred. The SDC demonstrated a good knowledge of plant operations, simulator programming, and emergency preparedness requirements by resolving each anomaly during the simulation. A review of past Problem Evaluation Requests (PERs) associated with the erroneous simulator data output indicated that they were isolated issues and no programmatic deficiency exists.

Section 4.0 - Facilities and Equipment Emergency facilities, equipment, and resources are maintained in a state of readiness and support emergency response operations. Equipment issues identified in the previous audit (e.g., field team vehicle accountability and emergency center computer problems) have been corrected. Facility walkdowns indicated a good material condition and acceptable cleanliness levels.

A review of the maintenance history for selected preventative maintenance (PM) items indicated that they were completed at the appropriate frequency within plus or minus 25 percent, which satisfies regulatory requirements. However, the current PM due date calculation settings in Passport allows EP related maintenance items to be performed outside 3

the scheduled month, quarter, or year as defined by the Emergency Plan. The Emergency Plan defines these frequencies as being "performed or executed any time within the calendar" month, quarter, or year. For example, a monthly PM can have a due late date that occurs outside the scheduled calendar month, but still be within periodicity. This is not consistent with the definition in the Emergency Plan. As a result, CR 2-04-00444 was intiated.

Model work orders (MWOs) generated to track EP periodic equipment testing and checks and administrative reviews are not consistently categorized. The appropriate classification for non-plant related tasks that are entered into Passport for tracking requires clarification. Nine MWOs are classified as "Essential" with the remaining 48 classified as "Other." PPM 1.5.13, "PM Optimization Living Program," states that PMs performed as a result of a commitment to an outside agency, such as the NRC, should be classified as "Essential." The potential for violating a regulatory commitment exist when performance of a PM is deferred. These deferrals require justification and approval regardless of classification. No occurrences of this type of problem were detected. As a result, CR 2-04-00443 was initiated.

Section 5.0 - Performance Indicators NRC Performance Indicators NRC EP PIs are being determined correctly and accurately reflect EP performance.

Columbia Generating Station (CGS) procedures provided adequate guidance and appropriately set more demanding thresholds for performance than required by regulatory guidance. The current NRC EP PIs are well within the acceptance range for both NRC and CGS's internally established limits. Trends are stable for Drill/Exercise Performance and Alert & Notification System Reliability and indicate improvement for key personnel participation. The source data was verified to be correct. Calculations were reviewed with no errors noted. The team identified an editorial deficiency in Revision 4 of PPM 1.10.10, "Consolidated Data Entry Process Description," for the formula for calculating EP Drill/Exercise Performance. As a result, CR 2-04-00224 was initiated.

Department Performance Indicators The ERO Staffing PI posted on InsideEN did not reflect the yellow conditions identified in the indicator worksheets for September through December 2003 and did not reflect the white condition for January 2004. Attentiveness is required to ensure accuracy of published reports. The PI was correctly determined on the indicator worksheet per EPI-24, "ERO Staffing Depth Performance Indicator," but the wrong information was being transcribed into the published report. EP was aware of yellow condition for ERO staffing, but did not realize the PI report posted on InsideEN was incorrect. As a result, CR 2-04-00536 was initiated.

4

Section 6.0 - State and Local Government Interfaces Based on interview results and a review of plans and procedures, the team concluded that effective lines of communication and coordination between offsite agencies and Energy Northwest remain strong. The technical specialist from Wolf Creek Nuclear Operating Corporation performed interviews and toured facilities to assess the adequacy of interfaces with State and local governments. The following organizations were assessed:

  • Radiation Health Physicist & Program Manager, State of Washington Department of Health
  • Washington Military Department, Emergency Management Division Section 7.0 - Plans and Procedures Overall, the Emergency Plan and implementing procedures contained the required regulatory elements and provide for effective emergency preparedness, response to emergency situations, and recovery actions. EP improved the review and tracking process of memorandums of understanding (MOUs) and plans by incorporating detailed procedures in the work management process for scheduled periodic reviews. EP revised the Emergency Plan and 30 implementing procedures to correct identified problems and include recommendations from the ERO, Quality, and INPO. These changes and the associated change management were adequate with the exception of a potential reduction in effectiveness, which did not receive prior NRC approval, for Revision 37 of the Emergency Plan. PER 204-0153 addresses this problem and the need for a better understanding of Emergency Plan changes concerning reductions in effectiveness. This issue will be corrected in next revision of the Emergency Plan and will most likely result in Severity Level IV Non-Cited Violation.

Section 8.0 - Problem Identification and Resolution Problem Evaluation Requests and Corrective Actions The corrective action process was effectively applied with regard to problem identification and resolution. A reduction in repeat issues, as compared to the previous audits, was noted and is indicative of effective use of the Corrective Action Program. A review of the corrective actions taken from the last EP audit, 2003 INPO Assist Visit, and 2002 USA Emergency Preparedness Program Assessment indicated that EP addressed each issue and implemented appropriate actions.

The team reviewed ten "Apparent Cause" PERs to assess the resolutions and effectiveness of corrective actions. The team determined that the resolutions were commensurate with the significance of the initiating event and its effect on the implementation of the Emergency Plan. The associated corrective actions were effective in preventing 5

recurrence based on the absence of repeat issues and a review of the program elements for similar problems.

Self-Assessments During the period from April 08, 2002, to the present, EP performed seven self-assessments with three completed within the last year. Review of the self-assessments indicated that they were conducted in accordance with procedure, but generally were performed to address previously identified problems instead of measuring performance to determine areas for improvement; specifically, assessments completed prior to May 2003.

Improvements were noted with the most recent self-assessment, which is a detailed evaluation of the effectiveness of corrective actions implemented to address the issues identified in the NRC Yellow Finding of EP. This self-assessment has a clearly stated purpose, scope, and objective with appropriate recommendations for improvement.

Based on validation of specific elements and conclusions addressed in the self-assessment, the team concurs with EP's assessment that the corrective actions were effective in adequately addressing the issues that led to the Yellow Finding. One corrective action remains open and is scheduled for completion in March 2004.

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I ATTACHMENT A- PERSONNEL CONTACTED Personnel Title PK Ankrum TSC Plant/NRC Liaison, Team C DK Atkinson Vice President, Technical Services

  • DL Beecher Auditor, Quality Services JE Bekhazi Manager, Maintenance J Berkey Radiation Health Physicist & Program Manager, State of Washington Department of Health BF Bond Support Supervisor, Construction & Maintenance Services B Calvert Manager, Benton County Emergency Preparedness P Campbell Technical Specialist III, Licensing AG Carlyle Technical Specialist, Regulatory Services DW Coleman Manager, Regulatory Programs MS Collins Auditor, Quality Services KM Engbarth Assistant to Plant General Manager AJ Fahnestock Acting Manager, Training DS Feldman Acting Plant General Manager MJ Ferry Quality Assurance Supervisor SR Goodwin EOF Site Support Manager, Team D RE Guthrie Manager, Operations Training BJ Hahn Auditor, Quality Services DB Holmes Emergency Planner, Emergency Preparedness
  • WA Kiel Supervisor, Regulatory Services F Klauss Washington Military Department, Emergency Management Division C Leon Emergency Planner, Emergency Preparedness TC Martens OSC HP Lead, Team A RD Madden Auditor, Quality Services DL Moon EOF PIO Technical Support, Team C CM Moore Supervisor, Emergency Preparedness SA Nappi Auditor, Quality Services LC Oakes Manager, Site One/HGP LS Peters Lead, Site One/HGP ND Price OSC Equipment Operator MS Quintana EOF Field Team Coordinator, Team B MP Reis Auditor, Quality Services SJ Rejniak Auditor, Quality Services

4 v CL Robinson Auditor, Quality Services WH Sawyer Emergency Planner, Emergency Preparedness SL Scammon Manager, Resource Protection J Scheer Director, Franklin County Emergency Preparedness A Torres Lead Auditor, Quality Services

  • RH Torres Manager, Quality RL Webring Vice President, Nuclear Generation
  • Audit Entrance Attendee
  1. Audit Exit Attendee

ATTACHMENT B -

SUMMARY

OF ISSUES FINDINGS None DEFICIENCIES CR 2-04-00224 Emergency preparedness drill/exercise performance indicator calculation in PPM 1.10.10 is different from the parent guideline of NEI 99-02 CR 2-04-00404 Administrative issues with ERO listings CR 2-04-00405 Unqualified OSC mechanic was listed in the ERO electronic database and in the ERO roster by center CR 2-04-00443 Coding of EP model work orders is inconsistent with PPM 1.5.13, "PM Optimization Living Program" CR 2-04-00444 PM due date calculation settings allows EP related PMS to be performed outside the scheduled period as defined by the Emergency Plan CR 2-04-00536 Departmental performance indicator for ERO staffing did not reflect actual yellow conditions from September to December 2003 RECOMENDATIONS None

4 -

DISTRIBUTION DK Atkinson (PE08)

JE Bekhazi (927S)

IM Borland (927R)

DW Coleman (PE20)

KM Engbarth (927M)

DS Feldman (9270)

JC Hanson (1028)

RW Hogue (909)

DB Holmes (PE30)

MC Humphreys (PE23)

PJ Inserra (909S)

JP Ittner (PE30)

RE Jorgensen (PE30)

CM King (927C)

WL Laframboise (PE24)

C Leon (PE30)

LL Long / CNSRB 18 copies (901A)

DS Mand (909)

CM McDonald (1028)

CM Moore (PE30)

WS Oxenford (927M)

JV Parrish (1023)

WH Sawyer (PE30)

SL Scammon (PE30)

PM Taylor (9171)

RL Webring (PE04)

GL Weimer (927P)

PT Ziemer (PE30)

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