ML18040B253
| ML18040B253 | |
| Person / Time | |
|---|---|
| Site: | Susquehanna  |
| Issue date: | 08/10/1989 |
| From: | Keiser H PENNSYLVANIA POWER & LIGHT CO. |
| To: | Bellamy R NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I) |
| References | |
| PLA-3238, NUDOCS 8908160195 | |
| Download: ML18040B253 (226) | |
Text
-kl'CEMRATED Dl!VKBUTION DEMONSTR TION SY~Eg REGULATO NFORMATION DISTRIBUTION TEM (RIDS)
ACCESSION NBR:.8908160195 DOC.DATE: 89/08/10 NOTARIZED: NO DOCKET FACIL:50-387 Susquehanna Steam Electric Station,.Unit 1, Pennsylva 05000387 50-388 Susquehanna Steam Electric Station, Unit 2, Pennsylva 05000388 AUTH. NAME AUTHOR AFFILIATION KEISER,H.W. Pennsylvania Power 6 Light Co.
RECIP.NAME RECIPIENT AFFILIATION BELLAMY,R.R. Region 1, Ofc of the Director
SUBJECT:
.Discusses insp of operational status of emergency preparedness program. ~9~
DISTRIBUTION CODE: IE35D COPIES RECEIVED:LTR ENCL f SIZE: (Dd TITLE: Emergency Preparedness-Appraisal/Confirmatory Action Ltr Exercise Rep C
NOTES:LPDR 1 cy Transcripts. 05000387 LPDR 1 cy Transcripts. 05000388 RECIPIENT COPIES RECIPIENT COPIES ID CODE/NAME LTTR ENCL ID CODE/NAME LTTR ENCL PDl-2 PD 1 1 THADANI,M 1 1 INTERNAL: AEOD/DOA/IRB 1 1 NRR/DREP/EPB 10 1 1 NRR/PMAS/ILRB12 1 1 NUDOC~BSTRACT 1 1 OC/LFMB 1 0 02 1 1 RGNl FILE 01 1 1 RGN2/DRSS/EPRPB 1 1 EXTERNAL: LPDR 1 1 NRC PDR 1 1 NSIC 1 1 NOTES: 2 2 NCTE 'ZO ALL 'KIDS" RECIPIENTS:
PZZASE HELP US ZO REDUCE RDCM Pl-37 (EXT. 20079) K)
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+'ennsylvania Power 8 Light Company Two North Ninth Street ~ Allentown, PA 18101 ~ 215/7705151 AUG 10 1989 Harold W. Keiser Senior Vice President. Nuclear 215i770 4194 Nr. Ronald R. Bellamy, Chief Facilities Radiological Safety and Safeguards Branch 'I Division of Radiation Safety and Safeguards U.S. Nuclear Regulatory Commission Region I 475 Allendale Road King of Prussia, PA 19406 SUSQUEHANNA STEAM ELECTRIC STATION INSPECTION OF THE OPERATIONAL STATUS OF EMERGENCY PREPAREDNESS - INSPECTION NOS. 89-23 AND 89-21 PLA-3238 FILES R41-1C, R41-2
Dear Nr. Bellamy:
The inspection of the operational status of the emergency preparedness program at SSES (Inspection Nos. 89-23 and 89-21) raised questions as to whether potential violations existed in two areas: 1) the adequacy of training for state personnel on Emergency Action Levels, and 2) the failure of independent audits and reviews to adequately address the interface existing between PP8L and state and local governments.
Trainin for State Personnel A listing of Susquehanna SES training offerings is provided to the state and state personnel are encouraged to attend training at the Susquehanna Training Center. This training includes instruction on Susquehanna SES Emergency Action Levels (EAL). Our training records indicate that in 1987 the principal engineer for SSES from Pennsylvania DER/BRP participated in EAL training.
This individual also participated in the 1988 Protective Action Recolmttendation training, but did not elect to take the EAL training offered later the same day. The subject training records are available for review.
PPEL also conducts annual training for offsite emergency planning support organizations, including local and state governmental agencies. The training given to the counties and municipalities includes an overview of the Susquehanna SES EALs; but, the training given to the state has not always covered EALs. In the future, we plan to take a more aggressive approach in this area by developing training tailored to satisfy the needs of state government personnel, which will include training on the Susquehanna SES EALs.
Bcyp8i 0 Scypsi&pi+> 85ppp387 ADO<~ p pgu G
- 2 - FILES R41-1C, R41-2 PLA-3238 Mr. R. R. Bellamy Inde endent Review of State and Local Interfaces Attached are copies of Susquehanna Review Committee 1987 and 1988 Emergency Plan Audit Reports (Audit Nos.87-085 and 88-107) along with other support documentation, These documents have been highlighted to identify audit coverage of interfaces between PPSL and state and local governments. Although in the past this level of coverage was considered adequate, NRC comments .
during the inspection have caused us to consider expanding a~dit coverage in this area. In the future, auditors will contact a sample of offsite emergency personnel to gather more information on the adequacy of the offsite interface.
Enclosed, as requested by Mr. Craig Gordon of your staff, are slides used in our meeting with your staff on May 31, 1989 on Susquehanna SES Emergency Planning. Mr. J. M. Minneman is available to discuss these slides with Mr. Gordon, should he desire to do so.
Very truly yours,
~r7 aq H. W. Keiser Attachment cc: NRC Document Control Desk (original)
NRC Region I Mr. G. S. Barber, NRC Sr. Resident Inspector Mr. M. C. Thadani, NRC Project Manager
~AENDA NRC/PP8L MEETING ON EMERGENCY PLANNIN INTRODUCTION AND PERSPECTIVE S, H ~ CAN TONE OFF-SITE SUPPORT J ~ M~ M I NNEMAN ENHANCEMENT INITiATIVES RE LE DOTY PLANT PERSPECTIVE AND
SUMMARY
R, G ~ BYRAM V
'908160195
ENERGENCY PLANNING NORE THAN RESPONDING TO ACCIDENTS
EMERGENCY PLANNING IS:
0 PREVENTING ACCIDENTS 0 CASUALTY CONTROL 0 INTEGRATED RESPONSE PLANS 0 MANAGEMENT COMMITMENT
PREVENTING ACCIDENTS A PROACTIVE APPROACH 0 OPERATING PHILOSOPHY DESIGN SAFETY FEATURES ONGOING MODIFICATIONS CONTROL OF PI ANT CONFIGURATION PEOPLE WHO PUT SAFETY FIRST 0 RISK ASSESSMENT IPE IDENTIFIES MAJOR RISK CONTRIBUTORS USED TO INITIATE MODIFICATIONS USED TO TRAIN OPERATORS USED TO IMPROVE PROCEDURES
ENERGENCY PLANNING IS:
(
0 PREVENTING ACCIDENTS 0 CASUALTY CONTROL 0 INTEGRATED RESPONSE PLANS 0 NANAGEMENT COMMITMENT
CASUALTY CONTROL PROMPT AND EFFECTIVE ACTION 0 PROCEDURES ALARM RESPONSE EMERGENCY OPERATING PROCEDURES EMERGENCY SUPPORT PROCEDURES EMERGENCY PLAN IMPLEMENTING PROCEDURES 0 DAMAGE CONTROL FAST AND EFFECTIVE TEAM DISPATCH PROFESSIONAL INVESTIGATION AND .REPAIR CLEAR AND CONCISE COMMUNICATIONS e
EMERGENCY PLANNING IS:
0 PREVENTING ACCIDENTS 0 CASUALTY CONTROL 0 INTEGRATED RESPONSE PLANS 0 MANAGEMENT COMMITMENT
INTEGRATED RESPONSE PLANS ...,
KEY TO PROTECTING PUBLIC HEALTH AND SAFETY PPaL PUBLIC HEALTH
" AND SAFETY FEDERAL STATE AND LOCAL GOVERNMENT GOVERNMENT
ENERGENCY PLANNING IS:
0 PREVENTING ACCIDENTS 0 CASUALTY CONTROL 0 INTEGRATED RESPONSE PLANS 0 MANAGEMENT COHHITNENT'
MANAGEMENT COMMITMENT ,...
WHAT MAKES IT ALL WORK 0 EMERGENCY PLANNING IS A LINE NANAGEMENT RESPONSIBILITY 0 PERFORMANCE DRIVEN BY EXCELLENCE i NOT REQUIREMENTS 0 OVER 500 PEOPLE CURRENTLY TRAINED 0 COMMITTED RESOURCES EXCEED REQUIREMENTS
EMERGENCY RESPONSE PLANNING 0 CLEAR GOALS 0 ACCURATE ASSESSMENT OF OUR CURRENT POSITION 0 RESPONSE TO DELTAS
GOALS 0 CAPABLE OF PEAK PERFORMANCE AT ALL TIMES 0 RECOGNIZED AS AN INDUSTRY LEADER 0 EXEMPLARY OFF-SITE EMERGENCY PLANNING
SELF ASSESSNENT 0 INPUTS FEEDBACK FROM EXERCISE PARTICIPANTS COMMENTS FROM EXERCISE REFEREES COMMENTS FROM THE NRC COMMENTS FROM INPO COMMUNICATION WITH OTHER UTILITIES COMPARISON TO FEDERAL/STATE GUIDANCE COMPAR I SON TO PUBL I SHED PROGRAM GUIDES COMPARISON WITH OUR GOALS 0 ASSESSMENT OFF-SITE PROGRAM VERY CLOSE TO GOAL ON-SITE PROGRAM FARTHER FROM GOAL INDUSTRY LEADERSHIP DEPENDS ON STRONG INTERNAL PROGRAMS
PLANNIN CYCLE OUTAGE WINDOWS OUTAGE CRITIQUE 4 SALP REPORT 4 lNPO REPORT 4 FULL SCALE DRILLS h CRITIQUES 4 4 Unannounced 4 Ingestion 4 Afl.er Pathway Hours 40n-Site 40n-Site Only On ly 4 municipal 4 l4unicipal Only Only 4 H.P. 4H.P. 4 H.P. 4 4H.P.
Drill Dri l I Drill H.P.'ri II Dri I l STRATEGIC PLANNINGO NEW INlTIATIYES WINDOWS
~ y 445fq I+a ~ ~ i q 44 5yq Qqg ~ ~ + 44(1> tq~ ~ho ~ +o 44 5eq 0++ a ~ its ~ c 44 eau+
44%QlY'tt 04% 1 1155 'h >4 0+4 l 5 1+0+y i% W4i Ve
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1989 1990 199't 1992 1995
CURRENT EMPHASIS 0 MAINTAIN STRONG OFF-S ITE RELATIONS 0 FOCUS ENHANCEMENT RESOURCES ON-SITE O PARTICIPATE IN INDUSTRY INITIATIVES 0 MONITOR RESULTS
INTEGRATED RESPONSE PL'ANS ...,
KEY TO PROTECTING PUBLIC HEALTH AND SAFETY PPRL PUBLIC HEALTH AND SAFETY FEDERAL STATE AND LOCAL GOVERNMENT GOVERNMENT
PENNSYLVANIA POWER AND LIGHT GNPANY CORPORATE PIISS ION TO MEET OUR CUSTOMERS'NGOING NEEDS FOR ECONOMICAL AND RELIABLE ELECTRIC SERVICE IN WAYS THAT l%RIT Tl% TRUST AND CONFIDENCE OF Tl% RSLICe
CORPORATE BUSINESS PHILOSOPHY 0 WE WILL MAINTAIN AN OPEN AND FUL DISCLOQRE. POLICY WITH CUSTOMERS > EMPLOYEES i INVESTORS I AND OTHER AFFECTED BY OUR BUSINESS, 0 ME WILL SEEK PUBLIC INPUT IN THE DEVELOPMENT AND IMPLEMENTATION OF PLANS TO MEET OUR COMMITMENT TO PROVIDE ECONOMICAL AND REL IABLE ELECTRIC SERVICE s WE WILL INFORM 'RK PUBLIC ABOUT OUR PROGRESS AND ABOUT PROBABLE EFFECTS OF OUR PLANS AND ACTIONS,
TO IYPLEYENT THE CORPORATE PHILOSOPHY OF BEING A GOOD NEIGHBOR, PAL HAS:
0 ESTABLISHED A SPECIAL OFFICE OF THE PRESIDENT IN BERWICK
~ FORMED A CITIZEN'S ADVISORY CORI ICE
~ INVITED PLANT NEIGHBORS FOR PLANT TOURS<
~ PUBLISHED A PERIODIC NEWSLETTER I INSIDE SUSQUEHANNA i
~ ENCOURAGED EMPLOYEES TO BECOME INVOLVED IN THE C(UNITY,
~ STRUCTURED THE OFFSITE EMERGENCY PLANNING PROGRAM TO BE A PUBLIC SERVICE,
FEDERAL INTERFACE
~ NRC PLAYED IN LAST EXERCISE
~ FIRST FULI SCALE PARTICIPATION 0 LESSONS LEARNED
~ FEN TIES WITH THE STATE ARE IMPROVING
~ NEED TO LEARN MORE ABOUT OTHER FEDERAL AGENCIES
%E (RSI'K PRG6RN IS NLTI-TIERED
-TRAINI%
-EXHKISES
STATE AND LOCAL PLANS AM) PROGZ)URES 0 SUPPORT ANNUAL UPDATES
~ SUPPORT UPGRADE FOR 10CFf650 APPROVAL POSITION SPECIFIC PROCEDURES 0 CONVERTED TO ALL HAZARDS FORMAT 1987
HARDWARE
~ INITIALLYPROVIDED REQUIRED HARDWARE
~ NOW FORMAL SUPPORT IS;
~ THROUGH ACT 147
~ ASSOCIATED AGREEMENTS
TRAINING 0 LAST YEAR TRAINED OVER 800 ATTENDEES
~ 27 MUNICIPALITIES i2 COUNTIES
~ 2 HOSPITALS
~ 5 AMBULANCE COMPANIES
~ 4 FIRE COMPANIES
~ AREA PHYSICIANS
~ RECORD TURNOUT
~ CONDUCTED SURVEYS TO DETERMINE FOCUS
Q4 EXERCISES
~ BIENNIAL EXERCISES OBSERVED BY FEN 8, PEN
~ ANNUAL DRILLS RUN AND OBSERVED BY PAL
PEOPLE
~ NONE OF THIS WORKS UNLESS THE PEOPLE DO)Is
~ ...AND T% PEOPLE DO e COMPLEMENTARY FEN CRITIQUE
~ THE PLANS HAVE BEEN USED AND THEY WORKED WELL 0 MUNICIPALITIES HAVE HELPED EACH OTHER
GOOD RELATIONSHIP WE HAVE A GOOD RELATIONSHIP WITH THE LOCAL C(Ã%NITY AND ARE WORKING TO MAINTAIN AND IMPROVE IT,
EMERGENCY PL'AN 0 BASIC APPROACH TO PREPAREDNESS 0 PART OF DYNAMIC PROCESS FOR ENHANCEMENT 0 BENEFICIARY OF ONGOING REVIEWS 0 CONTRIBUTOR TO VITALITY AND RELEVANCE
PROCEDURES 0 REFLECT BEST THINKING ON TASK PERFORMANCE 0 RECOGNIZE COMPLEXITY OF TASKS AND RISKS OF ERROR 0 SERVE AS BASIS FOR TRAINING 0 ARE USED WITH KNOWLEDGE AND OPEN MIND
PROCEDURAL COMPLIANCE 0 EXPECTATION 0 SUBJECT OF MANAGEMENT ATTENTION 0 SR. VICE PRESIDENT 0 SRC 0 Pl ANT SUPERINTENDENT 0 POSITIVE RESULTS
PROCEDURAL I N ITIATIYES 0 CONTINUOUSLY UPGRADED 0 INVOLVEMENT OF USER 0 EXPECTATION OF COMPLIANCE 0 REFLECTION OF PERSPECTIVE 0 ORGANIZED BY FUNCTION 0 INHERENT LIMITATION 0 BEING CHANGED TO POSITION-SPECIFIC FORMAT 0 INNOVATIVE 0 HUMAN FACTORED
HARDWARE 0 CONTINUING IMPROVEMENT IN TOOLS 0 MUlTIPLE EXAMPLES 0 IN PLACE 0 IN PROGRESS 0 IN PLANNING
HARDWARE I N ITIAT IVES FOCUS ON 0 COMMUNICATIONS 0 HUMAN ENVIRONMENT
TRAINING 0 CONTINUOUS EVALUATION OF EFFECTIVENESS 0 -
CHANGES TO REFLECT ENHANCED PROCEDURES AND HARDWARE 0 INTEGRATION 0 WITH EXERCISES 0 BY POSITION
TRAINING INITIATIVES 0 CHEMISTRY TECHNICIANS PASS USE 0 OPERATIONS S IMULATOR TRAINING 0 HANDS-ON FACILITY WALKTHROUGHS 0 COACHING IN PRACTICE DRILLS 0 TRAINING OF FACILITY MANAGERS
EXERCISES 0 DEVELOPING AND NAINTAINING SKILLS 0 IDENTIFYING AREAS FOR IMPROVBKNT 0 TESTING EFFECTIVENESS OF ENHANCPlENT ACTIONS
EXERCISES-REALITY 0 INITIATIVE: TO IMPROVE REALISM 0 PARTICIPANTS SEE "PIECES" OF INTEGRATED REALITY 0 SCENARIO DEVELOPMENT IS COMPLEX 0 PARTICIPANTS ARE REALLY TESTED 0 EXERCISE CRITIQUE IS COMPLEX
0 USE OF SIMULATOR AS CONTROL ROOM 0 ENHANCEMENT OF PERSPECTIVE 0 SCENARIOS BASED ON INDUSTRY EXPERIENCE AND SSES, DESIGN/OPERATIONS 0 USE OF IN-PlANT MOCK-UPS
FOCUS OF INITIATIVES 0 CONTINUALLY REEVALUATE 0 . REMENBER THE USER 0 CONUNI CATE 0 BE REAL
MEASURE OF SUCCESS RESPONSE CAPABILITY 0 DEMONSTRATED 0 ENHANCED
ENPHASES IN RESPONSE CAPABILITY 0 EFFECTIVE PERFORNNCE 0 ENHANCED PERFORNNCE 0 CONMUNICAT IONS II 0 REALISN
SUPERINTENDENT' PERSPECT I VE OF EMERGENCY MANAGEMENT
Ell FANCY NANAGENE'NT IS EXTENSION OF BASIC OPERATING PHILOSOPHIES 0 PEOPLE 0 AGGRESSIVE, QUALITY NANAGENENT 0 PARTNERSHIP MITH LOCAL, STATE AND FEDERAL 4-E--4 E 9 E R 8 A T I S F I E D
UR CAPABILITY TO SUCCESSFULLY MANAGE OFF-NORMAL S I TUAT I ONS HAS BEEN CLEARLY DEMONSTRATED.
REALISTIC ENERGENCY PREPAREDNESS EXERCISES ARE AN IMPORTANT CONPONENT
CURRENT FOCUS OF-PPRL EFFORTS
INPROVEMENT EFFORTS 0 ENHANCE PROVEN CAPABILITY 0 NEVER ENDING PROCESS THAT DOES TAKE T I Hf
S UNNh RY 0 E I ENCY PLANNING IS NORE THAN JUST-RESPOND I NG TO ACCIDENTS PROACT I VE OPERAT I NG PHILOSOPHY EFFECTIVE CASUALTY RESPONSE 8 CONTROL FULLY COORD I NATED ENDEAVOR BETMEEN PPCL, LOCAL, STATE AND FEDERAL COJlPREHENS I VE FUNCTION IN PLACE NANAGEllENT CONllITNENT TO STRIVE FOR EXCELLENCE
March 2, 1989 R. G. Byram SSES S. H. Cantone A2-4 SUSQUEHANNA STEAM ELECTRIC STATION SUSQUEHANNA REVIEW COMMITTEE AUDIT OF THE EMERGENCY PLAN AUDIT NO.88-107 CCN 740020 PLI- s91o3 FILES R12-1A R12-1C On behalf of the audit team, I wish to extend my thanks for the cooperation and support provided by members of your 'staffs. Attached for your review and action is the report of audit 88-107.
The audit resulted in one (1) finding and twenty-eight (28) observations/
recomendations. Finding 88-107-01 documents training deficiencies for personnel assigned emergency response duties. The audit team requests that Nuclear Services respond to this finding directly on the audit finding sheet within 30 days of receipt of this report. If corrective action cannot be achieved within 30 days, an interim response describing proposed actions and target dates for completion should be provided within 30 days.
Please direct any comments or questions relative to this audit to Kim Leone (ETN x7326).
. R. Sabol
Attachment:
Audft Report 88-107 cc: H. W. Kefser TW-16 J. R. Miltenberger A6-1 J. M. Mfnneman SSES W. R. Lfcht A6-1 J. V. Edwards SSES D. Castellano SSES R. A. Fedor SSES F. W. Sagl A2-4 A. A. Nargoskf SSES J. J. Graham SSES J. W. Folta SSES M. L. Grist SSES C. R. Whirl A2-2 NQA Audit File SSES SRMS Corresp. File A6-2
AUDIT OF THE EMERGENCY PLAN AUDIT NO. 88"107 DECEMBER 12 1988 TO JANUARY 30 1989 I. ~Pur ose This audit was conducted to satisfy SSES Technical Specification 6.5.2.e requirements to assess the effectiveness of the SSES Emergency Plan and its implementing procedures.'I.
~Sco e The audit included investigation of the following areas:
o Emergency on-call and communication systems.
Investigations into this area primarily consisted of evaluation of:
(I) equipment availability; (2) 1988 communication system and ANS test results; and (3) maintenance of emergency call-out rosters/staffing lists.
o Emergency drills and exercises conducted in 1988.
The audit team reviewed documentation generated as a result of 1988 drills/exercises to assure that (I) they were conducted at required intervals, and (2) any deficiencies identified in post-drill critiques were adequately resolved in a timely manner.
o Maintenance of procedures and manuals that prescribe emergency response activities.
The auditors focused on the development, review and revision processes for the Emergency Plan and the Emergency Plan Implementing Procedures (EPIP's).
o Selection; training and retraining of emergency response personnel (ERP).
Using various ERP eligibility lists, training records and the Personnel gualiffcation System (PgS), overall preparedness of individuals filling emergency positions was evaluated.
o Emergency equipment and supplies.
In order to assess the degree of preparedness of emergency facilities, the auditors conducted detailed inventories of the Control Room, Technical Support Center (TSC), HP Van, and EOF Decontamination Area. Additionally, Nuclear Emergency Planning (NEP) records and PMIS were utilized to ensure that periodic inventories were conducted in 1988 for other emergency facilities.
The scope also included three comments submitted by the SRC via PL I-57887:
o The audit should assess (quantify) the adequacy of responses to the emergency on-call program.
o The audit should include a review of previous audits to assess whether repeat items were found and required correction.
o NgA should verify by interview that the EP organization is aware of "ANI/NAELU Engineering Inspection Criteria for Nuclear Liability Insurance, Section 6.0, Emergency Planning" and that none of the criteria are inadvertently overlooked.
II I. ~Summa r The auditors observed overall improvement in the management of activities related to the Emergency Plan. This is evidenced by several initiatives taken in the last year'to improve previously identified weak performance areas, such as call-out response, procedure m'aintenance and control of equipment inventories. Further, the audit team noticed increased attention to detail and willingness to enhance the Emergency Plan program on the part of Nuclear Emergency Planning personnel.
Exceptions to this positive assessment include the one (I) finding and twenty-eight (28) observations/recomnendations identified in this report. Finding 88-107-01.identifies an individual assigned emergency response duties who failed to complete the required training associated with those duties. This and other examples provided in the finding are indicative of a potential breakdown of the administrative process that correlates training/qualifications of emergency response personnel and assignment of these individuals to duty positions.
Of the twenty-eight (28) observations/recommendations, the audit team considers the following to be significant and deserving of additional management consideration.
,o Observation f I documents NEP's failure to resolve emergency drill deficiencies in a timely manner. The program established to control drill deficiencies appears inadequate and as a result, has not been fully implemented. This is due in part to the lack of Plant Staff accountability to the requirements of a Nuclear Services Instructions (NSI).
o Observation k2 was generated following a review of the SSES response to 1988 call-out tests. Although the recent purchase of new pagers should eliminate many of the equipment-related non-responses, no action plan has been developed to resolve the people related aspect of SSES non-responsiveness.
o Observation 827 lists several criteria from "ANI/MAELU Engineering Inspection Criteria for Nuclear Liability Insurance, Section 6.0, Emergency Planning" that do not appear to be captured by the SSES Emergency Plan and/or its implementing procedures.
o Observation 828 was developed following an investigation of an NRC letter entitled "Emergency Communications Systems - Health Physics Network (HPN)." This letter suggests establishment of a dedicated HPN Communicator position within the Nuclear Emergency Response Organi'zation (NERO).
The remaining observations/recommendations listed in Section VI include isolated procedural noncompliances viewed by NgA as having no quality impact, as well as areas that could benefit from procedural enhancements.
IV. General Information Audit Team:
8*8. W. Folta Engineer - Level II 8~A. A. Nargoski Supv. gC Specialist
- K. R. Leone Engineer - Level II (Team Leader)
Controllin Documents 10CFR50, Appendix E Emergency Planning and Preparedness FSAR 18.1 Response to Requirements in NUREG 0737 SSES Technical Specifications NDI-2.1.5, Revision 5 Nuclear Dept. On-Call Duty Roster System NDI-6.6.1, Revision 4 SSES Nuclear Emergency Planning NDI-6.6.2, Revision 6 Selection, Training and Certification of Emergency Response Personnel NDI-gA-8.1.3, Revision 2 Document Review NDI-gA-10.3.1, Revision 7 Nuclear Department gualification and Training NSI-2.2.1, Revision 4 Coordination Organization and Management of Drills and Exercises NSI-2.2.2, Revision 3 Inventory, Inspection, Operational Testing and Calibration of Emergency Equipment and Supplies NSI-2.2.3, Revision 5 Surveillance Testing of Emergency Cooeu-nicatfons Equipment NSI-2.2.4, Revision I Review, Update, Control and Distribution of the SSES Emergency Plan and Implementing Pr'ocedures
NSI-2.2.5, Revision 1 Management of Uncontrolled Emergency Planning Documents AD-QA-OOO, Revision 5 Procedure Changes AD-QA-101, Revision 16 Procedure Program AD-QA-131, Revision 3 Plant Management Call-Out Procedure:,
NTP-QA-11.2 Training Matrices NTP-QA-52. 1, Revision 2 Emergency Plan Training Program NTP-QA-53.1, Revision 4 Susquehanna Fire Safety Training Program Station Policy Letter 1-84, Revision 2 - "Management Inspection of Facilities" NRC Letter, dated Dec. 15, 1988 - "Emergency Ceanunications Systems - Health Physics Network (HPN)"
ANI/MAELU Engineering Inspection Criteria for Nuclear Liability Insurance, Section 6.0, Revision 1, Emergency Planning SSES Emergency Plan, Revs. 10 and 11 Emergency Plan Implementation Procedures (EPIPs)
PLI-44352, dated 2/13/86 - Audit Report 85-119 PLI-49013, dated 2/ll/89 - Audit Report 86-088 PLI-54851, dated 3/14/88 - Audit Report 87-085 Personnel Contacted
¹ J. H. Lex Nuclear General Training Supv.
¹ A. J. Dominguez Sr. Results Engineer - OPS
¹~J. M. Minneman Supv.-Nuclear Emergency Planning
¹ H. L. Riley HP/Chemistry Supvs.
¹~J. V. Edwards Personnel 5 Admin. Supv.
¹ R. A. Beckley Supv.-QC 'eneral
¹ M. L. Crist Compliance Consultant
¹*R. G. Byram Supt. of Plant
- R. A. Fedor Supv.-DCC
- R. G. Sheranko Sr. Results Eng.
- P. E. Taylor Lead STA
- J. A. Blakeslee Asst. Supt. of Plant W. F. Tabor Analyst-Nuclear Support T. F. Harmon Steno/Clerk General E. Gorilla Central Div. Trouble Room C. F. Roszkowski Sr. Nuclear Emergency Planner E. J. Dreisbach Steno/Clerk General
G. J. Fernsler - Unit Supv.-SSES D. D. Sadvary - Shift Tech. Advisor R. T. Gribble - Asst. To Supv. Security D. A. Fassman - HP Tech - Level II R. T. Hock- - Health Physicist W. E. Morrissey - Rad Protection Supv.
P. F. Jaeger - Foreman - HP D. K. Shane - Asst. Fore - Health Physics T. R. Markowski - Shift Supv.-SSES H. J. Palmer - Supv. of Operations - SSES K. G. Hillman - Sr. Nuclear Plant Specialist W. J. Heske - Mgr.-Nuclear Administration C. L. Foreman - Supv.-Document Control Ctr. G.O.
P. S; Brown - Steno/Clerk General C. A. Burkhardt - Steno/Clerk General W. B. Dyer - Supv.-Nuclear Cme 5 Pers Systems R. Kushner - Tech/ Asst. - Transportation Specialist N. L. Lindenmuth - Steno/Clerk General R. H. Halm - Nuclear OPS Support Coord.
M. Morrissey - Steno/Clerk General C. T. Coddington - Sr. Proj. Eng. - Licensing J. N. Diacogiannis - Sr. Insurance Analyst F. G. Malek - Security Training Supv.-SSES C. D. Lopes - Sr. Security Shift Supv.-SSES
- Pro). Licensing Spec.
W. W. Williams E. W. Figard - IAC/Computers Supv.
B. J. Veazie - Sr. Results Eng.-SSES G. N. Dressier - Emergency Planner K. M. Roush - Supv. Nuclear Instruction E. A. Olshefski - Steno/Clerk General 0 - Attended entrance meeting on December 12, 1988.
- - Attended exit meeting on January 30, 1989.
~Findfn s A. Item Re uirin Action:
Contrary to NDI-6.6.2 requirements, individual's qualifications (or lack thereof) were not consistently reflected on the primary. contact and On-Call List. See Audit Finding 88-107-01 (attached to this report) for additional details.
ualit Im act Assessment - While the examples cited in the finding represent so ate nonconformances, they are indicative of a potential breakdown of the administrative process that correlates training/qualification of emergency response personnel and assignment of these individuals to duty positions .
B. Items Immediatel Corrected:
None.
C. Items In Com liance:
- 1. An auditor verified compliance with an NDI-2. 1.5 requirement that the On-Call List (weekly) be distributed to the EOF, TSC, Control Room, Security Group, and SSES Switchboard. No discrepancies were noted.
The On-Call List is now computerized on TOSS under the title "On Call Roster System". When a change is entered into the On-Call List, a new list prints at required locations. Distribution is instaneous rather than on a weekly frequency.
- 2. Pagers are of adequate supply. During the week of 12/19/88, there were thirty-seven (37) pagers in use. Investigations revealed that there were ten (10) spares, and four (4) additional spares that were still in their receipt packaging and had not been tested yet.
- 3. The SNEP develops an annual schedule, listing dates and times of all comounications drills to be conducted that year in accordance with NSI-2.2.3. This is based on a review of the drill schedules for 1988 and 1989
- 4. The auditors verified NEP's compliance with NSI-2.2.3 requirements to perform the following drills:
o Unannounced test of emergency responses call-out procedure.
o Cannunication drill to verify 2-way operation of CTN to off-site government agencies.
o Caanunication test to verify 2-way operation to TSC and EOF, ENS and HPN lines to KRC.
o Verification of 2-way operation of VHF console base, mobile, and portable radios.
o Verification of 2-way operation of VHF radios in TSC and EOF.
o Full scale test of Alert Notification System (ANS)
Verification was accomplished by review of completed NSI forms for drills performed in 1988. No discrepancies were noted.
- 5. An auditor verified compliance with NSI-2.2.2 requirements for the'quarterly inventory of emergency supplies. This was done by
a review of 1988 PMIS historical information. Except for -a single schedule slip where the TSC wasn't inventoried by the required date in the second quarter, no discrepancies were noted.
- 6. A walkdown was performed to verify that the TSC and the EOF Decontamination Area and HP Supplies contained equipment listed on forms NSI-2.2.2m and NSI-2.2.2L, respectively. No discrepancies were noted.
- 7. All EPIPs were found to be reviewed and approved by the Mgr.-
Nuclear Services and the Superintendent of Plant.
- 8. The Supt. of Plant has established an individual to coordinate all in-plant emergency planning activities.
- 9. All Emergency Plan 5 EPIP's were found to have been properly submitted to SRMS.
- 10. Deletions of EPIP's received the approval of the Supt. of Plant and the Mgr. Nuclear Services.
PORC properly received and approved the current Revision of the Emergency Pl'an and submitted a summary of changes to the SRC.
- 12. The current Revision of the Emergency Plan was properly distributed and stamped 'controlled'n accordance with the distribution list maintained by the SNEP.
- 13. With one exception (see Finding 88-107-01), all personnel were adequately trained and retrained in accordance with the training matrix.
PPEL made training for state 8 county agencies involved in SSES
'EP'fforts available on at least an annual basis.
D. Status of Findin s from Previous Audits:
One finding (f87-085-01) remains open from the 1987 Emergency Plan audit. It deals with distribution and document control discrepancies associated with the Emergency Plan manual.
An evaluation of NEP performance in this area for 1988 revealed that several steps have been taken to remedy Emergency Plan distribution problems. First, the SNEP purged the distribution list for Emergency Plan manuals by approximately two-thirds.
This list was established as a "controlled" list and forwarded to DCC and the Nuclear Department Librarian. Nuclear Emergency Planning then recalled all copies of Revision 10 of the Emergency Plan and distrrEuted Revision 11 in accordance with the distribution list. Emphasis was given to communicating the revamped distribution methodology to all manual holders.
The audit team verified that (1) Revision 11 of the Emergency Plan was stamped 'controlled'; (2) the HP copy of the Emergency Plan was deleted from the controlled list; (3) copies in the TSC and Shift Supervisor's office are were updated; (4) a sample of distributed manuals was consistent with the distribution list; and (5) the controlled distribution list was sent to DCC and to the Nuclear Department Librarian.
The audit team concludes that NEP's aggressive actions should minimize additional Emergency Plan manual distribution problems and recommends closure of finding 87-085-01. Closure correspon-dence will be processed separately from this report.
- 2. Audit Finding 87-044-03 documented discrepancies in the training/qualification of fire brigade personnel. Audit investigations had determined that a significant number of Operations personnel remained qualified as fire brigade members even though they had missed quarterly training sessions.
Subsequent discussions with Operations personnel revealed that this was due to disagreement between the Personnel gualification System (PgS) and Operation's fire brigade tracking system.
Representatives from NTG and Operations met to devise a corrective action plan responsive to this problem. The following actions were identified in a joint letter (PLIS-29986) from NTG and Plant Staff:
(1) 'Rezero'i.e. retrain in order to reassign) all Operations personnel with fire brigade responsibilities. (Attendance at F8002 provides new anniversary date for completion of quarterly training.)
(2) A new tracking number (FB016) should be used to satisfy previously missed quarterly training sessions.
(3) A new tracking number (FB001R) should be used to differentiate Harwood School hands-on retraining from initial training.
(4) No drill credit should be given for completion of Harwood hands-on training.
During conduct of the 1988 Emergency Plan audit, the team evaluated the qualifications of 10 fire brigade members from Operations. Each had been 'rezeroed'uring the first quarter of 1988; had completed quarterly training; and had participated in a minimum of two (2) fire brigade drills.
NgA's verification of the proper training and retraining of fire brigade personnel all'ows for the closure of audit finding 87-044-03. Closure correspondence will be processed separately from this report.
E. SRC Comments The following SRC Furnished comments were evaluated by the audit team with the identified results.
SRC Comment ¹1 "The audit should assess (quantify) the adequacy of responses to the emergency on-call program."
Results of Audit See Observation/Recommendation VI.2 of this report.
SRC Comment ¹2 "The audit should include a review of previous audits to assess whether repeat items were found and required correction."
Results of Audit ln response to this emanent, the audit team took two approaches:
(a) A review was conducted of 1985, 1986 and 1987 audit reports of the Emergency Plan. The results of each of these audits were compared with the results of this year's audit effort. This comparison enabled a categorization of audit findings and observations into seven 'Areas of Weakness'. Attachment A of this report tabulates NgA Emergency Plan Audit results over the last four years and illustrates areas where repeat items were found. Further, overall trends (in terms of improving, stagnant, or degraded) are provided. Trends include the following:
~0d 1 A Processing of drill deficiencies Last year (1987) N(A identified a concern with respect to the lack of timeliness in resolving drill deficiencies. At that time, nine (9) of twenty-two (22) co+vents remained unresolved.
This year, the auditors determined that all drill deficiencies remain open or unresolved from 1988 drills.
A (1) Maintenance and Distribution of Emergency Plan Staffing Lists
Updating and posting of the various staffing lists remains a problem, due in part to the division of responsibilities for maintaining these lists between Plant Staff, Nuclear Administration, and Nuclear Emergency Planning.
(2) Training/gualification of Emergency Response Personnel This area is closely associated with the less than desirable maintenance of staffing lists (see (I) above). In each of the three previous audits, a finding or observation has,,identified personnel assigned to positions for which they have not been adequately trained.
A (I) Call-Out Test Response While SSES response remained low in 1988 (see Observation VI.2), Nuclear Emergency Planning took steps to minimize equipment-related non-responses. A new low frequency paging system has been purchased for site-based personnel. The audit team views this as an enhancement to the program and anticipates improved performance in this area.
J (2) Procedure Maintenance and Distribution Improved control of procedures was observed during this year's assessment. This follows several years of weak performance with respect to procedural reviews and distribution. of the Emergency Plan and EPIP's.
(3) Equipment Inventories Although minor deficiencies were observed during this year's audit, controls have been strengthened to preclude significant inventory problems. PMIS has been updated with greater vigilance and NEP personnel review inventory results is greater depth than in previous years.
(b) Additionally, in response to this SRC comment, the audit team investigated a sample of observations/reconmendations from audit 87-085 to determine the potential for recurrence and the need for additional corrective actions. Results of this evaluation are provided in Attachment B of this report.
Of the twenty-two (22) items investigated: ,thirteen (13) were resolved/required no further action; two (2) were partially resolved and require some additional action; and seven (7)
remain unresolved as repeat deficiencies. Significant repeat deficiencies have been re-issued this year as Observations/
Recommendations in Section VI of this report including ¹1, ¹2,
¹21, ¹28.
SRC Comment ¹3 NgA should verify by interview that the EP organization is aware of "ANI/MAELU Engineering Inspection Criteria for Nuclear Liability Insurance, Section 6.0, Emergency Planning" and that none of the criter'ia are inadvertently overlooked.
Results of Audit See Observation VI.27 of this report.
VI. Observations/Recommendations
- 1. The audit team observed a significant lack of timeliness in resolving and closing drill deficiencies. This concern arose during a comparison of NEP's Open Items Tracking (OIT) report (dated 10/31/88) with the following documents:
HP drill critique HP Practice drill critique Full Scale drill critique Full Scale Practice drill critique Unannounced drill critique Per the OIT report, all drill deficiencies from 1988 drills/exercises remain open or unresolved. The SNEP did indicate however, that a number of deficiencies had been resolved and merely required records closeout. Although true, this explains only part of the backlog of open drill deficiencies.
Discussion:
The SSES Emergency Plan states that "Procedures are established to assure timely implementation of corrective action." In response, Nuclear Services established NSI-2.2.1, "Coordination, 0 I i dN fE d dtlÃ11 onta ne n ect on . o t s pr oce ure are post-exercise requirements, including a methodology for the resolution of drill deficiencies.
Oiscussions with NEP personnel revealed that this methodology is ineffective and as such has not been implemented. Rather than distributing drill deficiencies to appropriate managers via form NSI-2.2. 1A, NEP has chosen a round table format to develop corrective action plans and to assign responsibility for implementation of these plans. Mhile the round table format lends itself to effective solutions via a teamwork approach, it
is time-consuming and does not provide for efficient/timely correction of many deficiencies.
NgA agrees that the method defined in NSI-2.2.1 is not workable, given the lack of cooeitment to the process by the responsible managers. However, the round table approach is not a viable solution because it does not appear to assure the timely implementation of corrective actions.
The team recommends that Nuclear Services take immediate steps to prioritize the resolution of open drill deficiencies. Additional attention must be focused on tracking the status and accountable action party for each deficiency. Finally, NEP needs to establish its goals with respect to the closeout of drill deficiencies - i.e.,
What represents acceptable progress in closing out deficiencies?
How are negative trends corrected? To what degree is NEP responsible for implementation of corrective actions? What, additional support is required from Plant Staff to effect timely if any, results?
Audit investigations revealed that the SNEP assesses beeper performance monthly. Based on monthly coranunication drill data provided by the Security Group, the SNEP has developed charts to depict "Total Responses", "G.O. Responses" and "Non-Responses" for the years 1988, 1987 and 1986. Nuclear Emergency Planning then categorized pager system failures into three groups-beeper problems, people problems and unknown. (See Attachment C of this report for illustration)
An auditor's review of the "SSES Response" chart revealed that SSES response to the paging system for the year 1988 ranged from a above 60K to as low as 20%. (Note that the pager response by little 85K of III<<l TT If . 0 emergency response personnel were successfully contacted pp by pager system activation in 1988 communication drills.)
Based on a review of SSES response data for 1988, the audit team believes that the SSES paging system cannot be relied upon to staff personnel requirements within the time limits established in the Emergency Plan (f.e. 30-60 minutes of notification) during an actual emergency condition. This same conclusion was reached in 1985 by the then Superintendent of Plant, T. H. Crimmins, as evidenced by letter from Crimmins to "Site Personnel With Emergency Plan Assignments" dated 9/17/85. Also, observation/recommendation VI.82 from last year's audit of the Emergency Plan (87-085) reiterated Crimmin's concern that the call-out process is not effective.
Follow-up of actions taken to resolve this ongoing pager system problem revealed that the SNEP has ordered new pagers from the vendor AHTEL (PO 88-54717-1). With this, NEP plans to resolve the equipment-related problem of beepers not activating. However, no action plan has been developed to resolve the people-related aspect of nonresponsiveness to the call-out.
It is the audit team's opinion that the current Susquehanna SES on-call program is still in need of improvement. The audit team concurs with NEP's action to purchase a more reliable pager system, but believes that the purchase of a new pager system is only the first step in resolving the call-out problem at SSES. It is recomnended that pager test results compiled by NEP be evaluated annually by senior management to ensure that all aspects (both hardware and people problems) of the SSES pager problem receive adequate attention.
(Note 'that during the exit meeting, the Personnel and Administrative Supervisor questioned the validity of the data used to support the audit team's conclusions with respect to the people-related problems of call-out tests. Additionally, the Assistant Superintendant of Plant indicated that pager reliability is viewed as the biggest problem and that once 100% reliability is achieved, personnel problems will be investigated.)
- 3. NSI-2.2.5, Mana ement of Uncontrolled Emer enc Plannin Documents, Revision I, paragraph 5.2.2 states:
"The PSA SUPERVISOR updates and distributes the TSC/EOF Site Primary Contact/On-Call L'ist to the CR, SCC, TSC, A6-1, EOF, and the SSES Switchboard."
Auditor investigations into the implementation of the above requirement uncovered the following:
o Transmittal letter PLIS-31593 (dated ll/17/88) for distributing the latest Revision (rev. 10) of the TSC/EOF Primary Contact/On- Call List did not ensure that A6-I received the latest copy of this list. The letter requested the personnel listed below to ensure that a copy of this list was available at the locations indicated.
PEA Supervisor - TSC and Switchboard Supervisor of Security - SCC 8 ASCC Supervisor - Nuclear Emergency Planning - EOF Supervisor of Operations - Control Roan o A current Revision of the TSC/EOF Primary Contact/On-Call List was not available in the Control Room during an auditor'p walkdown on 12/28/88. Although Revisions 8 and 9 of the lists were found, a current Revision 10 list could not be provided.
It is recemended that the PhA Supervisor ensure that A6-1 and the Control Room receive a copy of the TSC/EOF Primary Contact/On-Call List as required by the NSI.
- 4. NSI-2.2.5, Revision I, Mana ement of Uncontrolled Emer enc Plannin Documents paragraph 5.2 . , states t at t e anager- uc ear Zdm>nistration:
"Updates and, distributes the G.O. Call-Out List to the EOF, GONESC, CR, TSC, SCC, and the SSES Switchboard."
A copy of the G.O. Call-Out List was not available in the Control Room during an auditor's walkdown on 12/28/88.
The transmittal letter (dated 10/19/88) for the latest Revision of the G.O. Call-Out List requested P.E. Taylor to ensure that a copy of this list was available in the Control Room and the Technical Support Center (TSC).
It is recomnended that P. E. Taylor make the list available in the Control Room (i.e. STA's office, Coamunicator's file) as requested in the transmittal letter to ensure compliance with the NSI requirement.
- 5. Employing applicable NSI-2.2.2 forms, an auditor performed an inventory of the Station KI and HP Van, Control Room Equipment and TSC Equipment. The following discrepancies were noted during. this inventory:
- a. Area: Control Room Equipment Date: 12/29/88 Form: NS I-2.2. 28 Anomalies: I) Twelve (12) Sel f Reading Dosimeters (0-50R) are required, only nine (9) were found.
- 2) An extra SCBA (three required, four available) has a hose that has fallen outside it's case.
- 3) Thirteen (13) cases of "Emergency Food Rations" are required, only twelve (12) were found.
- 4) Keys to HP Van dfd not include the key for a locker in HP Instrument Trailer (0'ill) that holds cold sensitive instruments, SRDs, and a check source that must be carried to the HP Van before the van can be considered completely equipped.
- b. Area: Station KI and HP Van Radiation Emergency Monitoring Equipment Date: 12/29/88 Form: NS I-2.2. 2G Anomalies: 1) .
Apparently, whenever the HP Van is fn motion, emergency equipment falls out of storage cabinets. Duct tape is used to keep cabinet doors from opening because cabinet
latches are in poor repair. Cabinets did not have internal nets or restraints to prevent jostling of equipment.
- 2) The H.P. Van door was left unlocked.
Leaving the van's rear door unlocked negates H.P. efforts for positive control over the HP Van emergency equipment.
- 3) H.P. Van emergency equipment cabinets were poorly labeled with respect to their contents. (e.g. Rad Low Volume Air Sampler AC powered was stored in a cabinet labeled "Rad ribbon, ~Rad ta e, and ~Rad si n")
- 4) The H.P. Van contained a controlled copy of the Emergency Plan assigned to Ray Hock.
The Emergency Plan is now at Revision 10, but the controlled copy in the van is at Revision 9.
Note: A copy of the Emergency Plan is not required to be in the H.P. Van. It is the auditor 's opinion that the manual was inadvertently misplaced in the van.
- 5) Six (6) 9-volt batteries are required in the van, but only four (4) were found.
- 6) The equipment listed below should be annotated with an asterisk (*) on the inventory form to indicate that it is actually stored in the HP Instrument Trailer (8111).
o Self Reading Dosimeter, 0-5R o Dosimeter Charger o Check Source
- 7) The work light found is not a fluorescent light, but an incandescent light.
- 8) Only one copy of procedures EP-IP-012 and EP-IP-013 was stored in the van, rather than the required two copies.
- 6. One member of the audit team attended Emergency Planning course EP053, "Off-Site Team Management", on 12/21/88 to maintain his qualification as an Offsite Team Director (OTD).
Observations/recommendations a through d below were noted during this auditor's emergency position retraining.
a ~ Training class for EP053 comprised of only Offsite Team Directors. Although the instructor performed an exercise to demonstrate OTD responsibilities, the class was void of comments, recommendations, and expectations from personnel that the OTD would typically interface with in an actual emergency.
It is recommended that annual OTD retraining consist of classroom training and integrated exercises facility training.
The EOF Support Manager and ancillary supervisors should have an opportunity to be introduced to their on-call EOF staff.,
- b. Not all qualified OTDs have participated in or observed an emergency event drill.
It is recomnended that before an OTD is added to the on-call list, he observe one full scale drill or practice drill. If this is not possible, the OTD should observe a drill within a specified time frame.
c ~ The position, Offsite Team Director, is listed as an emergency assignment in the TSC/EOF Primary Contact and On-Call List and the SSES (weekly) On-Call List. EP-IP-019, Mana ement Of Near-site and Offsite Emer enc Monitorin Teams, re ers to the as t e mergency on tor ng earn >rector .
It is recommended that in order to preclude confusion when referring to the OTD, emergency event lists and procedures consistently use the same title when referring to the OTD position.
- d. EP-IP-019, paragraph C.2.7(d), requires the OTD to record team locations and results from the status board on form EP-IP-019-2.
The status board and form EP-IP-019-2 are used to track monitoring team dose rates and activity levels at specific intervals of time and distance from the plant. Apparently the status board and form EP-IP-019-2 are effective when only tracking one team. Tracking more than one team results in poor allocation of space available on the EP-IP-019 form and the status board.
It is receanended that form EP-IP-019-2 and the status board be revised to be more effective. The Offsite Team Directors should meet and, as a group, collectively develop a practical status board and EPIP form.
- 7. A review of AD-gA-13l, Revision 3 and NSI-2.2.5, Revision I revealed inconsistent descriptions of the same staffing list. The NSI uses the term "Site-Based Personnel On-Call List", while the AD refers to this list as the "Plant On-Call Eligibility List" (paragraphs 4.1 and 4.2.4) and as the "Composite Roster of Station Personnel" (paragraph 4.2,3).
-.18-In order to preclude confusion over AD-gA-131 requirements, recomnended that the AD be revised to refer to the it is 8.
p 1 on-call personnel:
Reactor Engineer.
NPE
~1ii "Site-Based Personnel On-Call List" for consistency with the NSI.
EP-IP-029, Revision 5, Activation of TSC, does not provide d id Duty Planner, the gC
<<h f1t Supervisor, or the It is recommended that these positions be annotated as emergency event-related on the TSC/EOF (site) Primary Contact and On-Call List. EP-IP-029 should provide initial direction for all on-call personnel that do not have a specific EPIP dedicated to describing their work/emergency activity.
9 Attachment H of EP-IP-029 states that all TSC Coordinators (i.e.
Security, Maintenance, ISC and Chemistry) will "Prepare to assume responsibility when TSC is activated."
It is recommended that the EPIP be revised to expand on what the TSC Coordinator's responsibility will be and to provide a method for the TSC Coordinators to document their actions taken.
- 10. The position, "Public Information Tech Briefer", is listed as an emergency assignment in the TSC/EOF Primary Contact and On-Call List. EP-IP-031, Public Information Emer enc Procedures, refers to this emergency posit on as t e ec n>ca v sor assignment".
It is recomnended that emergency assignment lists and emergency procedures remain consistent when referring to identical positions.
NSI-2.2.2, Inventor Ins ection 0 erational Testin and Calibration er enc u ent an Su ies, Revis on 3,=-
Attachment , p aces t e responsi i ty for inventory and maintenance of emergency equipment on the Supervisor- Nuclear Emergency Planning (SNEP).
It is recoomended that when the SNEP requests Plant Staff to inventory or maintain emergency equipment and supplies, he not only requests written confirmation that Plant Staff activities are complete but also requests that deficiencies noted are reported to him. SNEP can then, by quantitative assessment, determine inventory or maintenance problem areas.
- 12. NSI-2.2.2; Inventor Ins ection 0 erational Testin and Calibration o er enc u ent an u es, Rev s on 3, descr es severa instance w ere t e N requests assistance from Plant Staff i.e. HP/Chem. Supv., Rad Ops. Supv., Plant Staff Emergency Planning Coordinator, Safety/health Consultant and Mechanical Maintenance Supervisor) in the controlling inventory and maintaining required emergency equipment.
It is recommended that appropriate section heads also review NSI-2.2.2 as part of the NSI Revision process in order to review/approve the support their staffs are requested to provide.
- 13. NSI-2.2.5, Mana ement of Uncontrolled Emer enc Plannin Documents, Revision 1, paragrap . . istri ution requirements o not re ect actual practice. For example:
o The Offsite Monitoring Team Call-In List is not distributed to the TSC and SCC.
o The Near-site Monitoring Team Call-In List, which is not an independent list but part of the TSC/EOF (site) Primary Contact and On-Call List, is not distributed to the Central Division Trouble Room.
It is receanended that paragraph 5.2.3 of the NSI be revised to reflect current list distribution practices. Additionally, because a list entitled Near-site Monitoring Team Call-In List does not exist as an independent list, it is recommended that NSI-2.2.5 be revised to delete all references to the Near-site Monitoring Team CalI'-In List. Also, the PMIS activity X0022, which ensures that the Near Site Monitoring Call Out List is maintained, should be deleted.
Activity X0024, which requires the periodic update of the TSC/EOF primary Contact and On-Call List, serves the same function as activity X0022.
, 14. NDI-QA-10.3. 1, Nuclear De artment uglification and Trainin ,
Revision 7, requires t e uperv sor to deve op and ma ntain an Operational Support Center (OSC) Primary Contact List and an OSC On-Call List.
The P&A Supervisor does not maintain the lists identified above.
Instead, he maintains equivalent lists for emergency staffing via the TSC/EOF Primary Contact and On-Call List and the SSES On-Call List.
It is recetmended that the PEA Supervisor and the Manager-Nuclear Administration (responsible for maintaining NDI-gA-10.3. 1) jointly determine title names of lists used to staff emergency organizations to ensure that list references are consistent in the NDI and sub-tier administrative procedures.
- 15. AD-gA-101, Revision 16, paragraph 4.3 states in part, "Each Section Head/Manager is responsible for assuring that personneI responsible for performing the duties of a responsible supervisor have been tr'ained and meet or exceed qualifications specified in Section 4.4 and have been designated as Level II or III Responsible Supervisor as appropriate."
A review of EP-IP's and discussions with the Supervisor-Nuclear Emergency Planning (SNEP) revealed that the SNEP has not been
designated as a Responsible Supervisor (any level). However he has performed the duties of the Responsible Supervisor (i.e. approval of 50.59 Determinations, periodic reviews, etc.).
It is reconmended that the Section Head/manager perform the necessary reviews in accordance with AD-gA-101 and designate, as .
appropriate, the SNEP and other members of the Emergency Planning organization as Level I, II or III Responsible Supervisors. During the January 30th exit meeting, the SNEP indicated that these actions were complete.
- 16. AD-gA-OOO, Revision 5, paragraph 6.8.1 states in part, "DCC should initiate a procedure Revision when 3 or more approved PCAF's have accumulated against a particular procedure, or when 60 days have elapsed from the date of approval on the oldest PCAF against the particular procedure".
The auditors observed that the following PCAFs posted against EP-IPs were all in excess of 90 days from their date of approval:
1-88-0457 1-88-0671 1-88-0669 1-88-0199 1-88-0196 1-88-0640 1-88-0670 It is recommended that DCC initiate a procedure Revision for the above PCAFs and perform a review of outstanding PCAFs to assure the 60 day requirement is met.
- 17. It was noted during a Review of NSI 2.2.4, Revision 1, that the only type of procedure Revision reviews permitted are PORC reviews and expedited reviews. (Reference paragraph 6.2.5). The NSI contains no provisions for alternate reviews of EP-IPs.
During a review of procedure EP-IP'-011, Revision 3, it was found that the review type was specified as "alternate". It is recomnended that NSI-2.2.4 be revised to include the alternate review format.
- 18. During a review of the NDI-8.1.3A forms generated for the review of EP-IP-Oll, Revision 3, black ink.
it was found that pencil was used instead of It is receanended that the responsible organizations be notified that the use of pencil on a gA document is not recommended (reference GET training), and that the 8. 1.3A form be duplicated and filed with the procedure.
- 19. AD-gA-101, Revision 16, paragraph 6.7.2, states "The preparer includes a Procedure Checklist, Attachment H, as the first sheet of the procedure review package and ensures that all items in the review section are completed".
Contrary to the above, it was noted that the procedure review package associated with EP-IP-038, Revision 4, "Reconstruction and Accident Close Out" did not include Attachment N.
It is recomnended that Attachment M be completed and filed with the original in DCC.
- 20. AD-QA-101, Revision 16, paragraph 6.6.7 states:
"Attachment N, Periodic Review Form, shall be used to document Periodic Reviews which result in no procedure Revision being required. A proposed Expiration Date may be specified on Attachment N. If the Review Date listed on Attachment N is within the 3 months preceeding the Expiration Date, then the Proposed Expiration Date must be no later than the current Expiration Date plus the procedure's. Periodic Review Frequency.
Otherwise, the Proposed Expiration Date must be no later than the Review Date plus the procedure's Periodic Review Frequency."
Contrary to the above, it was found during a review of EP-IP-007, Revision 10, that Attachment N was generated extending the procedure expiration date by approximately one month instead of the two year review frequency. This was done ~aust pr or to the procedure expiring and is not consistent with the intent of the above requirement.
This problem was corrected during the audit by properly revising the procedure in accordance with the guidelines established in AD-gA-101. Therefore, no further action is required. It is recommended however, that in the future Attachment N only be used for the procedure's periodic review.
- 21. NSI-2.2.4, Revision 1 contains forms NSI-2.2.4A and B. Per the procedure, these forms are required to be generated when changes are needed to the Emergency Plan or the Emergency Plan Implementing Procedures (EPIP's).
The auditors observed that these forms are not utilized. This condition was also noted during the 1987/1988 Emergency Plan audit.
It is recomended that the forms either be mandatory or be deleted from the procedure as a requirement.
- 22. NSI-2.2.4, Revision 1 contains requirements and responsibilities for the Emergency Plan Plant Staff Coordinator (EPPSC).
It was observed thru a review of the requirements and discussions with the EPPSC that several of the requirements no longer apply.
NgA recommends that NSI.-2.2.4 be revised to redefine the EPPSC function.
- 23. During a review of Appendix A of the Emergency Plan and the associated signed letters of agreement, the following problems were
, noted:
o Pennsylvania OER/BRP is listed in Appendix A as being one of the groups that have signed a letter of agreement.
Contrary to the above, during review of the letters of agreement and discussions with Emergency Plan personnel no letter was found or produced.
o The Hunlock Ambulance Association signed a letter of agreement on June 20, 1987. Appendix A of the E Plan does not list them as one of the support groups. (See observation VI.31 from audit 87'-085) o The Berwick Ambulance Association signed a letter of agreement on Oct. 27, 1988. Appendix A of the E Plan does not list them as one of the support groups.
It is recommended the Appendix A of the Emergency Plan be updated to reflect the actual letters of agreement. At the audit exit meeting, the SNEP stated that he would consider including language like "typical of" in Appendix A.
- 24. During a review of the Emergency Plan, the EPIPs and associated PCAFs, it was noted that QADR reviews were being signed for as being completed and performed. The following are examples of some of these procedures and PCAFs:
o The Procedure Checklist associated with EP-IP-011, Revision 3, indicates that a QAOR was completed and that forms were attached.
o PCAF 1-88-0722 (EP-IP-001), in block 17 indicates that a QAOR was performed (no comments).
o PCAF 1-89-0024 (EP-IP-001) same as above.
o PCAF-1-88-0782 (EP-IP-0782) same as above.
Discussions with Emergency Planning personnel indicated that a misunderstanding had occurred and that QAORs are not performed and had not been performed for the above examples or any other procedures.
NQA recomnends that Emergency Planning personnel hold a training session on the requirements of AD-QA-101 and AO-QA-000 so that compliance with regard to performance of QAORs are met.
- 25. NDI-QA-8. 1.3, Revision 2, paragraph 1.0 states in part, "To delineate those quality-related documents that require an independent Quality Assurance Document Review (QADR) as a part of their formal review for adequacy prior to being approved for use".
Further, NDI-QA-8.1.3 paragraph 4.1.2 states, "Technical Procedures TPs : Procedures whose preparation and issuance are contro e y the OQA Manual, but whose requirements do not directly respond to an OQA Manual Procedure, and are not, by definition, OQA Program documents. Examples of Technical Procedures are Plan Procedures such as:
Maintenance Procedures Calibration Procedures Emergency Procedures Temporary Procedures" It was ascertained during the audit that the Emergency Plan and the Emergency Plan Implementing Procedures do not receive a QADR in accordance with the above requirements.
NQA believes that an evaluation should be performed to determine the need for a QADR. Then, if applicable, perform QADRs or revise NDI-QA-8. 1.3 in order to clarify "Emergency Procedures".
(Note that the SNEP reemphasized that the problem identified her e stemmed from an interpretation of FSAR and NDI requirements.)
- 26. NDI-6.6.2, Revision 6, paragraph 6.6. 1 states in part, "Emergency Response Personnel must participate in a certification tabletop, drill or exercise at least once every four years".
The audit team obser ved that D. M. Confair (listed as IAC Coordinator) has not participated in a drill since 4/4/84.
It is recommended that D. M. Confair be scheduled during the next drill or exercise.
- 27. The following ceanent was received from the SRC by NQA for inclusion into the audit scope:
"Verify by interview that EP organization is aware of "ANI/MAELU Engineering Inspection Criteria for Nuclear Liability Insurance, Section 6.0, Emergency Planning" and that none of the criteria are inadvertently overlooked.
The following are the results of the interviews and a procedure review in accordance with the above procedure:
o Emergency Plan personnel were not aware of "ANI/MAELU
,Engineering Inspection Criteria 7or Nuclear Liability Insurance, Section 6.0, Emergency Planning".
o The Emergency Plan and/or the Emergency Plan Implementing Procedures reference and utilize NUREG-0654, "Planning Standards and Evaluation Criteria". The ANI/MAELU states
that NUREG-0654 closely parallels, both in form and in content, the appropriate inspection criteria. It goes on to say that the criteria contained in this single document (NUREG-0654) meets or exceeds their insurance criteria with only a few exceptions.
o The following exceptions as outlined in "ANI/MAELU Engineering Inspection Criteria for Nuclear Liability Insurance, Section 6.0, Emergency Planning" could not be verified to be contained in our Emergency Plan or implementing procedure. Each is listed in the above document under section 6. 1 Assi nment of Res onsibilit pages 10 thru 14.
Sections: 6.5. 1.1, 6.5. 1.2, 6.8.1.1, 6. 14.1.2, 6.17.1 and
- 6. 17.2 It is recommended that the EP Organization review the above sections to determine: (1) the need to address those items in the Emergency Plan, and (2) the need for a periodic review of the ANI/MAELU criteria for changes'in scope or procedure.
- 28. PPAL recently received a letter from the NRC on the subject "Emergency Communications Systems - Health Physics Network (HPN)."
In response to the Manager-NgA's request, the audit team evaluated the applicability of this letter to the SSES Emergency Plan.
Oue to problems encountered in establishing the HPN during an emergency preparedness exercise with a Region 1 licensee, the letter reminded PPhL of its responsibility to provide a qualified person to maintain an open, continuous communications channel with the NRC upon request. As the NRC response teams become staffed, either the NRC regional office or Headquarters may decide to establish a direct telephone link to the PPKL's dose assessment team. At such time, the NRC may expect PPSL to provide a technically qualified cennunicator to man the HPN who will then be the primary means of ceaaunicating health physics and dose assessment information to the NRC. The letter also provides rudimentary instruction on how an HPN communicator can connect to the HPN system.
Presently, the HPN comnunicator is not a SSES emergency position.
Although the Assistant Rad Support Manager is seated in the Rad Support Office-in the proximity of an HP line, he does not receive specific training or specific procedural instructions to be a
'technically qualified'PN coomunicator. The SSES emergency response program has always treated the HPN system line as an "NRC" line. PPhL only tests the HPN line periodically to ensure phone operability and does not establish the network during drills/exercises.
NEP is now in the process of determining, in detail, NRC needs of a dedicated HPN coomunicator. Once NRC needs are established,
training and procedures will be developed for the HPN comnunicator position.
It is 'recomnended that SNEP continue developing the HPN comaunicator position to prepare for the contingency that the NRC requests PP&L to provide a technically qualified comnunicator to man the HPN.
VII. Action Taken/Action Re uired The results of this audit were presented to Plant Staff and Nuclear Services personnel during an exit briefing on January 30, 1989.
Attendees at this meeting were receptive to and concurred with the findings and recommendations presented by the team. Specific comments and/or discussion items from the exit briefing have been factored into the appropriate section of this report.
Nuclear Services should provide a written response to the attached finding within thirty (30) days of receipt of this report. If corrective action cannot be completed within thirty (30) days, a response describing proposed actions should be provided within (30) days.
Prepared by: Approved by:
K . Leo - earn Leader e ~ ir ngineer - LevelII Supv. Engineer-Staff Auditing Attachments: A) Assessment of Previous Audits (1 page)
- 8) Status of Selected Observations/Recomnendations from Audit 87-085 (8 pages)
C) Response to 1988 Call-Out Tests (5 pages) krl/afsa59i:nf
NUCLERR QUALITY ASSURANCE FM)IHQ tC.
PPS L 1 ~
AQ)IT F IlCIINS SHEET Zo OhTKc
- 3. RKSFtNSIRL NNhkIZATIDHc 4. RKFMTKO SYc 5o hCTIVITY hLNITEDc Emer n
- 7. CQCTR!KLIHO OOCt~tT hte RENJI K%HTc NDI-6.6.2, Revision 6, paragraph 5.7 states that the Supervisor Nuclear-Emergency Planning is responsible for:
o Notifying the P&A Supervisor or Manager-Nuclear Adninistration when a candidate is qualified to be placed in an on-call rotation.
(Cont'd. on Page 2)
- 0. DK5CRIFTIOH OF FIHDIHOc Contrary to the above, a review of the TSC/EOF (site) Primary Contact and On-Call List revealed the following problems:
o Mr. E. W. Figard is listed under IKC Coordinator and additionally designated as the NERO Primary Coordinator. Upon a review of the training requirements it was ascertained that Mr. Figard never completed the required training and therefore was not qualified for the above position . The PKA Supervisor was never notified to remove Mr.
Figard from the on-call rotation.
(Cont'd. on Page 2)
RKCLJIREO hCTIOHc Q tCSK (CNRKCTED INCDIhTELY)
K) cÃNfcT coteITIDH g homaee FRKVEHTIOH N RKmmHCK 8, CtNRKCTIVK hCTIOH NY RKSFQOIRX Otic CXRIZJWT HhHhlÃNc
- 10. HOh VKRIFICRTIDHc VERIFIER c tQhF FON 8.1-R RKV ~ 3
Audit Finding No 88 IO7 OI Page 2 of 2
- 7. CONTROLLING DOCUMENT AND REQUIREMENT (CONT'D.):
o Notifying the Selection Manager and the P8A Supervisor or Manager-Nuclear Administration when an individual is no longer qualified to be in the on-call rotation.
- 8. DESCRIPTION OF FINDING (CONT '. ):
Note (I): This condit'ion was previously identified in Audit 87-085, dated March 14, 1988 as Observation 881.
(2): A Previous letter was sent to Mr. Figard from the Supervisor-Nuclear Emergency Planning indicating that as of 12/30/88 he still had not taken the required courses.
o Mr . N. E. Nelson was listed as an ISC Coordinator. Per PQS and discussions with the work group, Mr. N. E. Nelson has not been designated to fill that slot.
o Upon review of PQS it was noted that Mr. F. G, Malek had completed his training requirements for Security Coordinator on 9/19/88 but was never listed on the TSC/EOF (site) Primary Contact and On-Call List.
i)TLCSCÃZ 4
<<LSSESSlCNT Ot tRSVIOJS NQL LllDIIS<<
area of IJ>>scn>>>>s audit 4$ lli audie 44 Oii iud ic 47-085 audit ii 107 ter foraancc lienee TRENDS Trafnfni/gwltficatioa t$ - Throe f)) fadtvfdwla. tb - Stx (4) ladlvl4wls. t2 tire brliade tl ~)Ca c>> Coat 1 nusd 4!sairee-of Sit t)0 - Off-slee sieacy cratafaS. Aeervacfoas 7>> 15, 10. drill focus. 01Nfvs'clans 4 ~ 24 ~ ent betueea qualiflcsclen til - soleccioa fecas at seat co 01Nfvstioas 11>> 2) ~ ~ ad ass iiaaaac.
SRo )i>> il Dfills/EaerciNs t7 - Deficient aOC pert of aftra. Owwcfoa )7. 01oervsCfons I 15, 14, 01Nfvaclon 1. ~D>> raasa>> Drill deficiency
~>>
~
ty - Caaaate aoc seat to 1'7>> 1%>> 22>> 71>> 7$ >> 77, resolution proiresslvely less cb>>sly.
Sceffini Lists Observation 1. t) - Suppleaeatal Obwrvaclons ), 1>> ~Sce c: Nstncenance en4 Support Ltsc. 7>> 10, 1) ~ lb. ~ iotribucioa of accurate lists ta - trfaecy Contact conti>>a>>oa to be ~ treble, List.
ObNfvstfoas 27, 74, 7%>> 02, Callant Test Observacfoas 5, 4, 7, Sfs nant Co rovi >> Poor Saspooso ~ >> 5>> 10. SSSS response Co call-outs. Nsu equfpaent purcbsse4.
troceduro Nsf ntenuee Pb - tf-Pse
- St revfeue aoc seat to SSO.
tl -
St dfscrfbucfcs. Observations )7>> li, lanrcwliic Tlihcef'verall
~ ad Dfstrtbucfoa t12 ~5 No Stlt revfs>>>> lt>> 20>> 21>> 24>> 2$ ~ conceals observe4 in asfntenance t1 - Stft forest. fowo and 4istributlons of !tits an4
- Sft fovfauo aot seat co %SO. Observatfoaa ll>> li, 20>> St.
t) - St distribution. )0 ~ )5>> )4>> )7>> )%>> 41>>
Observations 0, 15, 17. 40, 4$ ,
inventories/Equfpasoc t4 - Rt te. Observatioas 10, 1$ , 21 ~ 22, 2), 01NrvaC iona 21 1 42 ~ 4) ~ Observscfons 5, 11, Scs none co fovi Nit Opera1l lity n - SOt EOeenacfNs
~maIS. cio . Sb>> 2$ ~ 24. 4$ >> 44>> 47 ~ 50>> 5$ >> 12. iavoacory asnsSNeac b>>proved.
No<<ever>> NF inventories/a>>Le!p-14>>
44, 40>> 7)>> 74. a>>ac coatinw to be prob]~cfc.
Spit/S-t tsn/SOt Observations 2 ~ 5>> 4>> 7>> 10>> tl Lech of calfbracioa proceduroo. Observations 2$ , 24, 40>> ObssfvacioAs 0 ~ No tread ovideac Srref s/laadeiuacfss 12>> ll>> 1%. P) lech of source chech procedure. $ 5 ~ 4$ >> 70, 72. 15 ~ 2)>> 27 t) Iaedosusce source chech
~ roc adores g Obesfvscioas 5, 0 11>> 1'2 ~ 13>> lb.
Ldd l t tonal Co>>>>sent s Lsrse eaaber of observational Sctfoes pla>>u>>sd fof procedure toor ccaptfsnce la spiC~
recaaaeadsc loss Irea previous rescfuctur faS aad reorisataac ioa. of Sood pef forasnco ratlnia ~
years eudfc (05.01 end O-s)-)0) reasfa open. Rocowad rNvs)wcfca.
LTTLCINCllT R
<<sTAIos op DL%RVLTfoas/RRCINoctgQzfogs 7Rocc 4DDIT gl-ooS" Obaarvat los ccwoadatton let los Tabes 4 Potential for Rocurronco Honthly Cfg ccwwtcatfon Cast vltb offslto Lfws are teated, not tnsttuaents. Ilontbty CIN Resolved: Response 1 ~ satisfactory. sudfc cosa varlf led that linea stats and cowty ageactas ls aot ~ full twc, amefcatfoa twtlsg vltb offslte state as4 vore tested sootbly to secure 2my opotatfon of CIN to offolta One sooth ~ call ls sado frna cha Coattol Roca, ooo aoncb free the TSC, ao4 ow aosth Stoa tho ROF. lt should be aotod that IR NoClcs gg+y county agoac los.
44 tocoaaondod usptuggod oad toplocod twit philosophy vas reeve 1w ted lf falls ~ lc cas be vlch ~ spare 0417 lines govotwonc agoncfos No futtboc'ction dowed necessary toIpcttoa tbe RNS systm to bo tasted free each aoeg to be Cwtod.
lascsllo4 locaclca. Rscomasd Chat che Casting pbllooopb7 for at4ta Sad county ogeattaa (au. arwT 4722).
be raevalwtod for effecttveaoss.
Ibo pager test fora (no fcaa suaber asstgsod) Rocowoadstloa sot accepted. Rather tbsa a44lng No further act!on.
abcul4 have aa catty ~ tash added.for cha R esCry bloch Co record the swber of cwoa chore "avsbor of cases vbate aa altetasto cosld soC aa alternate could soc he contacted, the ccwoat be contacted.<< it ptosea, das to tho wy ~ ecttsa of Cho es-call list vill he used.
tho fata la being cosplstod lt caasot ~ lwys ~ sovataatfsa psrforaod.
readily be detecafasd vkethat or ant aa
~ ltersate ws contacted. (Raf. ~T <<2O).
I. Recowsnd chat the overs)1 taaulto of tho psgst Naca fbcrtfs evslwtod. Paging syatoa holag evalwted Partial Resolutions Observer los 02 of this report delineates progress Costing bo ovslosCo4 ~117 jy owlor for oohasICWssta. Pafodtc reports vill he seat to M44 ls pager 474'tea ochancwonta ~ Tean vill topeaC tocoaaendaClcn Co detatafso vhothor tsspowfvsaoss ol personnel aestgssd to support tho \-plea ls
~ ccoptable. Lt ptsswt, ao oas lo ssafgsod perfoca chio ovatusctoa.
4 (Nsf. ~
~ snag%sat ~
4322).
thee pager towlte ba ovslwtod 4nnw117 aad rocotve 4pproprl4co aasageaoat vlslhlllty.
- 11. Dlstrliutloa of tbe Ssstgoacy plea Co offslte Icm vss follovad up vlth latter free C. N. Dressier Resolwdc Adequate )ustlflcatlon provided by SRHS for 1 year govotwoec agosctoo wch 44 tfSKI CRSI IOLI to K Rsffslt-Sapecvtaor~d Systoas h procedures. cetoattoa perlo4 of traswttcal focus. Nev aotbodology for RNR, etc., should ba checbod to owurs Chat all caattolllsg R-ylaa asawls via controlla4 dlacrlbut los 1 1st sbcu]4 agaacles have che lacosc Csvfstsa of che s-pfa. (Rof SHCI dgg-323) ~ ~re latwt tovfofos co govotwanc agencies Nota tbac This iten ahcccld ho Std high prlotlty by Cbe ~ lstrliutloa list we purge4 by Actor of I/3 and aotlflcatlon scop aad sso. Note that dfatttbutfoa prebtms lt ws stated hy D. DONslt that ~ tevlsloa ls aot loccata soot to ~ ll asnwt boldota
~ 14 occur OC Cbo ~ lane ~ Tbo ofgsod/tocofpt regal ted for SOS 73.0 esd that current practice cranwttcat loess (foes saabsr 32OR) ere (1.4. ~ 1 year retostlos of recor44) 1~ acceptable.
~ estroyod os aa awwt beefs. Thorofoco, dtscrlbut los co che effslte agaactos cwl~ aot
~ o coaflcao4 by ILL. 1C ls recomosdod Chat tbe receipt crsnsalttal/loess should aoc bo destroyed. SOS procodate 75,1 does aoc
~ covldo gul4asce cooceralag flllag of fora auobor 3204. procedure 75.0 should he revlse4.
Obssrvst ion Recowsndst ion Lotion Ssben 4 ~ Potent isl for Recurrence 1$ . lal $ .2 4oes not discuss drill "c~nts" vbich %F.OIT 4529 shove oo ocClcn/unresolved sn4
~ ppssr to be Iou level doffcfeactee. NSI $ .1 44'Ce for te401uClon no'4CNCC Sttbougb NS1-2.2.1 still 4oes aoc oddrcss Creckfng/trending of
~ lso does not discuss oaCorlng drill doffcfwcfos deficienclssr NIP hss estsbllsbed ~ nothing OPen Itsas Tree@fag (OIT) into ~ trscblsg or trendtag ptogt>> la ot44t te ~ 7scea. problws do esisc vlth this systoo (i. ~ . ~ crsccsbillty iron provi44 asnsgsasat vleibllfty W Iaprovtng steely docwonc thsc originsced docuaenc drill c~c to trscking syst>>
ciooliness of corrective ection Nuclwr'upper ls poott current ststus Of escb open ICea ls not provl4edl ~ ~ ~ ),
c should ov41u4co aehfog Iaprovesoeco in this Ic sppesrs that sddltfonsf fsprovwcnts in this ares should be
~ ursw4 shen Nuclsor Services revsaps NSI-2.2.1. (NoCO thsC no target date hss been estsbllsbe4 ia OIT for sctloa).
Observstloa dl of cbls report generste4 to reiterate NQL' cence cns ~
- 14. Ttwllnsss of ccaplecfag corrective octlcas is %7-0IT 4$ $ 0 shone>>casolved uitb no csrgst iste la noe4 of laptev>>eat Ihe full scale eserctw Sor tosotucfoa. ia eudit report, 411 Ipgg drill 4eflclency fteas rwofn open.
conducted oa 5/Ig/SI goaerstei eight (g) dtf II (No torgot 44to h44 bwn sstsblfsbed ln thl ~ 4re4) ~
ccaaents. Corrective occloa for four (4) of tbs 4ri1l c~cs ls overdue. Ibe Np 4rill conducted oa g/1$ /gy resulted fn foutcoes (Ik) drill co>>eats. Corrective action fot five (5) of tbo co>>sacs lo overdue II. Conduct of tbe drills does aoc. sppwr co evslusce vhsther boy reference esterfsI atilisei by
~T Ihfo
~ ctloa 4$ $ 1 dws noc estsbllsb csrgst 4sce for ICaa toaelas unresolved, No purtbor Lct tonl poltcu.lgl vlth the S~rvf sor of NQC Operstlons ruvwled thee thrw ($ ) fndfvfdusls froa his group vere ssslgnc4 ss Cascgeocy gespoaw personal is vp-Cc&s4. ~ aorgency Response personwl sod uould be pert lcipsting in upcoaing Cwduct of the 4rills Aal~ bs adsptod to ~ rfll~ Ne felt Cbst 444itlonsl sssfgaawt of his resources to cover svslusto vbether doc>>sots ouch ss Cho gp dtf lie uss aoc pr4ccicel gasrgency pl>>, R-Ips, >>Stgsacy tolepboae
~ irectorlss srs cssdlly avsf table aaeta awded i)though nwd for wstencss of sislniscrstive feces is iaporcsnc ~
W are up.to 4sce. Note that Che Opetstfcss sudlc Invsstfgstfoas shoved g-'pisa sn4 spit dlstrlbutlon vss noc shift superVIwr W ISO copies of chs g-Plan ~ tecuttwc probl>> pufthor ~ Cbe sudf t ccw observed slgnif Icsnc vere mt of dote by awy tovlsioae. This faproveaonte ln s4slnlstrstlve areas. 1949 NQl sud I t ut II evaluate ptoblw osistod for asap years W toaofwd vbother Cbls perforasnce centimes.
un4etected by drill pethorrssaca. pecbsps tho NQL Sutvellloaco group should awf tot 4rlll perforasace for this wpoct.
Ig. Sere are no copies of the g.pla or R-Ips Icos uss oneuotod b7 Socutlt7 pen4lag spptovsl by No further kctionl auditor verlf led that Socurity has received ia Security SOC or igfg. Ihe sopstvlsot of DOC W Kt, Security ufll beep ccatrolled copies coatrolled copies of selected p-lps.
Socuricy 4oes hsw oas (I) copy of cbe g-plea of molested R-174 la Che SCC, ASCC oa4 Security W ooe (I) copy of gy 174. 4&P shoal ~ Tref afng.
evslwte vbetber Security has sufficient nuabsre of gp 444 gp 17 as>>OIS W Chst (~&IT 4212 teasins uaresolve4).
they 4ro Ioc4'toi 4C Cho propst location
Observation Rkcosaendstion Action Tsben ~ totentisl for gscurrence
- 19. C-ttsn requirement tera. 9.1.2 oisces that W-OlT g))) indicates Chsc Ngt deleced requlrewnc No turtber Actlool A reviev of 10CFR)0, Appendix g, Section 1V.F.S "sll agencies vho participated la drills ere fa paragraph 9.1.2 froa Sasrgency Ftsn. revealed that participation of eacernsl orgsnisstlons ln 4rlll invice4 co cbe crit!ques.>> FtgL dose aoc crltlqws 1~ noc espliclcly required.
wec Chio ~ Cstsaenc ss vrlCCea Theraforay cbl ~ paragraph should be revised co raCtect cbe sccusl aaoaer la vhtch agencies perfora crit iqws.
- 21. Tbe Ht vsn uwd co ~rt eaergency preparedness Celled during boch drf lie (or prsccico drf lie) ia KtMT 4335 Cor octfra.
shove uarssolve4 vlch oo csrgec dote No torcher Accionl gob Susbner indicated that ~ nev HF von (Vehicle 42093-A) hsd been or4ered un4er che Colloving purchase
)94). coastdersctoa should be gtvea co fsprovfas or4ere l cbe rellsbtllcy of this whicle state fts failure seeas co bove sn taesdfsce adverse fafficc aa che lena F.O. o Control o s-tlsa. conefderecfoe should be given co psrhtag Cbe vehicle ia a Socage or toots))tag eagles b)och (hoss to 12554 14549 heaters. Also, ~ coacfeesacy plea should bs
~ vol wts4 Cor having ~ bechup vehicle. Ass 110CA 411509 Conv ere ica Rote@4 1 1037 412501 tlberglsso goo C IO Interior 110)g 419454 Sspscced ccaplsclon 4ocs io Junsy 1949r purchase of aev HF voa shou)4 alclgste reliability ccecerne.
2). NOI-QA-10.).l, Hev. 4, tera. 4.2.2 requires Ia response to Chio ltsa, IRF (ref. lEt-0)T 4)))) tore loll gesolvedl Nec leer Trsialag to develop aad aalacsia ~
~ serio of tralalag courses co he tahoe by cospered/contrasted ~-$ 2.2 ~
~ strtceo> tQS oad cha oa-call lice.
~-22.2A Change Verlffeat los personnel filling tha position listed la requests vera tossed so Collovol Attschaeat 2~ 1. Hith tbe acception of 'Technical Staffer Ol'nd 'Technical
- 1. Chango request co HTO for ~-52.1 sal !tatter 42', posltioa titles ln Nft-QC-52.1 hove been changed Contrary co cha above, ~ coapsrison of H)ffd)t-12.)A, vis Sav. ) of NTt or Qunge Sgg-o)2.
Accschasac 1 sa4 ssv. ) ef che cralalag astrtg resulted la cvo (2) dlocrepeaclasl natcher 2. Change reqwsc to II. )torrfoosy for FQs chpnges. 2. Verlfie4 changes asde to tQ).
Qwl icy Assurance Coordinator aor OC Coor4lascor stpsar oa Che trstatsg astrts. ), Cheaga request to S. Censeasr fcr oa-coll list. ). perl(ted each of eleven (ll) changes asde Co TSC/EOF Frlasry Coatact List (FL14-3159)).
~ urcber crslalag sa4 qwttftcsttcas of urgency restoase persowst could soc be assessed Cor ~ ll To cosptetsly resolve Chio lsswl positions 4ue co che tacoasteceacfee of postttoa tlcl~ llscs vlchta che Col)cvtas doc~tel 1. ISO should ~ (face reaslnlng changes to NTF-QL 52.1.
Observe'I lon Rocowondst log Action Tsbsn s potentlsl for Recurrence o N01~.10.$ .1o Rove Co Attscbaent 1 Nuclear Albllnlstrstfon snd NRP should Jointly resolve o Reylse Ttslslni Nstrls, Rev. $ lnconslstenclos rsaslninR la NOI Qt 10 $ 1 ~ Attschoont 1.
o GO sni TSCfROp Call out Lists o CO sni RRRS Oa-cell Lists o NIP~-52.2 ~ Rov, 2 ~ Atcocbasot 1 This concern uss elso docuasnced 44 Seem cion 'r'a Audtt Report 05~I "An stceopc ws INds to coopers the atataua
~ ccsptsblo level of quottftcstfoa oad Crstatag spec!fled ln N)1~-10.$ .1 ulth fafotastfoa contslned la selsctei personnel records.
Iaforastloa uso rosdlly svellohle for only seas bey poreomNC. The tosh couM sloe aot be cooplotely porfotaed for 411 personnel since there ls ao oas co-cw correspeailoace hocwoa
~ ostc los Cltlos la cho oaar0oacy otilalsoCloa
~ nd those speclfloi la Cll~-10.$ .2. A 0oaetst
~ ssoswonc should he conducted co sssuto thee ONto to ~ oae Co cae csrrespoadoaco betwea
~ astsoncy plNlclon titles la ptml Nlp 52.ll l01 Ql 10 $ 1l ~ Jch Act lvl't'7 'Rltlesl ptas NTI-Qt-$002A eni Other deouaeats.u NQL rocoNNads case ~ coattollei list of posit los titles he aalatolaei by Nuctost Rastsoncy plsaata0. Ao posltloa titles chsnaodh oil docuaente Cher tofotoacoi Cho list could ho updeted la ~ aero tlasly ~r.
24e NDI'IJA 10e$ ell ROVe 0l Pstoe ie2el SC4COOI ltoa ws never saswroi by tbe responsible porsaeet. Ih dhh ~
IW:
4l Dl I I d he hh hhhd. ~i ed d lech. hhd II di h del o ld hh h d ol h
'vbN teer Trslalaa list of ttslolsg util develop oai aolatsla ~
courses offered ead che
~ITfot resotucfIN.
0$ $ 0 ladlcstes unresolved Illth no tsr0oc la 2%00 sudtt of Rastgsocy plsnntng.
~ sco topllstcty tlufstroasese ssttsf led h7 44cll course."
Contrsry to ttN sbov<<, no NIC asttta could be found vhlch llsco crotafa0 courses serous toauletot7 reRutrWoatse Iaeteodl sech untt ol tnsttucttoa rotors to the spptoprtste to@el st or7 te0ul twonC ~ Addi C tons 1 I7 h ROC 1 est Ttslalna aslacslao ~ ttsttaR of trstatsg courses of feroi.
0baerwtlon Receeeeodatfon dation Teton s yotentlal for Recurrence lt i~ recovaen4ed that ÃfC raufev this regulreoenc. lf tbe aatria ls dseoed unnecesaacy, Rl-Qk-)0.).1 should be rarf se4.
If tbe aatrllL le doeood aecassaryy Ae Natria
~ bovid be yrayared.
)0. NSl-).C, Reu. 0, yaradrefh d.l.i.l atatea Yercfcal bars an4 avaoary of changes vill be a44e4 Reaoiwdt Verffie4 ln Reu. 11 to Raertcncy Fla.
ln pert that ~ Re%feed sections (of che to Roe. 11 of Che R-ties. (Ref. NRy-01T S)aa).
R-tlan) vltb pemaaoot chandae shall bo noted by ~ vertical liao in the left head
~ stdfn,+
Contrary to the abow, wrtfcal lines vere eot used co sots yeiaaaeot cheo0ss Node by Res. 10 of the Rosrhrocy tie. This to tbe fact that Re% 10 vss e ceoyleto
~ due
~
ruvrice'f che Rosr0sacy ytm.
Nga suspects chat ~ auaoary of chaadss sheet 4 distributed Co holders of castro)led R.ylea aanuele uhea wrtlcal lines are ast utlllsed to denote chaaRaa.
)1. Tbe auditor observed Ast Rualoch Crash Ror. 11 of Raerdency ties vill be reuteod iobulaace dssociation deca aot e00ear oa ~ ccordlaRly. - (Ref. ~fT d)C5). royort. yells-up dfecwsfon vltb QCy indicated that Roersency tbe list of e0eaclss ia dfyeodfa 4 of the tie vill b>> rerfsed to state "~tfcel letters of aRreeoent."
Roardency ylm. This list reycuseats Chase
~ Renclea that haw letters of eRremeac vlth ytRL for ~Nancy services. Nualech Crash ladvlece dsaecfetfeo afdaad letters of edit oa 4/)7/05 aad oa C/y)/Ry.
IN)t roc~ada that Rfyeodta 4 he revised
)5, to royre~t N51 a ccoylate list of aRencfae.
),4, Res, Or yare 4.1,) reRufres Cbs uss of yore Ndf-).dd co roRuast RoerReacy ylaa Cbaadaa. Tbo eudltOr ObeerW4 AaC Chio fera
~
dace d)SR indicates unresolved aad for ectfm.
Do Cerdet this rayort.
bas not boca wllfred. IQl racoooeods that .
Nuclear RaarNrocy ytaaataR fafora R-yla users of cbe fora' eaisceece ead fayleaeatatfm
~ e Cbodolody.
Obsofvat IOll pecoesendar lan Jcclon Tabes potentl ~ I for Recurrence al. Ic vas noted chat transnlctsl co the Hc of ~-DII S)$ $ Indfcates Chat Llcenslni has tabes No purcber accfonr Dlscwslonc ulcb v. v. vllltens revealed revlslone co Rp-lpe Ie perforaed la ~ h<<esr ao action la tAte area. Llceasfni' poslclon cha>> Rt-Ips are sent co RRc for Infornscfon vhlcb bypasses che Interne) ppIL ravlau Chat ooly and 4o noc r<<Infra RDI-QL-).).1 rcvfeu. IQ defers to Ia requtred for ell %C correspoadeace by LlcanslnR' Interpretation of Chic rc0utrcaent.
ISI-QI-).).I. It le reccmesded CAst Ruclaar Llcenslnt reeval wee this sceasrfo.
)&. Ruertency tlen, Rev. 10, para. %.2.2 re0ufrae ~WIT s)00 Indfcaces chat IN'ctlvlty4200$ ) Resolved! Ravlse4. Start data of )/I/RS should prevent ao aanwl full scale stars notf ffcstfoa sysCm ws up4atei for ctarfffcatfcn. racurraace of this It<<s.
(ARR) test.
Rtthoutb cbe cast uas conducted as re0ufred>
cbe NlS systea A!story Ill ~ for uorhtfst Ita 200$ ) abc's oo perfornaace fa 1007. Sots that cbe N Nlecory pile shoes chat IQe ecclvlcy uas wfved a 2/)2/02 utch ~ schedule seat due 4sts of 2/12/00.
ibe Iscb of atcsaclos cs deceit caste sn uafav&sbt ~
~ badou on en other%fee acceptable areas Rveo ON+II the testlni uas conducted thsreuRAIy, hCS <<as aoc updated aa4 no forasl LW Castled records wra foruarded to Rws. Ilgk rscasanads chat pffft be spproprf scaly llpdeced
- 22. Rnergency plea ~ Rev. 10r para, %.1.2 re0ufres ppdL co Reve procedures Ce assure Cfaety
~2 fer 4)II actfm.
shoes waresolvad and no Carbst 4aca
~ actton of aadtc report describes uorsentnR condlclon end failure of Iaptweacscfon of corrective sctfoas fsr ~ cocelsras to fulfill lntendei purpose.
ieflcfeacles fdenctffed dsrfag irf Its.
ConCrac7 Co Cha abovey P24L hee aa faadeRuats procedure escsbtfshed ta chfs ares.
lhe fapscc oa 0uslfcy le that drill ieflcleacles ncy aot be ctseed la ~ tfnety nenner Ibis concern ls ceeded ~ Inca 4rlll deflcleocles ar ~ eoc eeterai late ~
fornel crscblnR prodrm aai io aot resolve vis fbi City of upper asaadaaeat.
NQC recceeends thee Rt fortify ealeclaR procedures to ~re that 4rlll isflcleacfes
~ ra ade0uacely controlled.
ObMfllattnn Rkcnaaen&Clog Rct tna Taboo ~ ntenclel for Recurrence Is. RSI 3.1, Rev. 0 redufres QKt co ry&te cbe RFSIT 4302 fndfcstee cbsc Nls accfvfcfes sxoolo Resolved: Ibe auditors verified estsbffsbaent snd fapleaencecfon of ytCS Soeraency Tefepbaae Directory~ tbe Dear-etta ArsuRh S002$ wru escsbllebe4 co ensure 0usrcorly ~ cclvlcles. (see observstfon 413 ln cbls audie report).
laetcorfnc Tem Celt-fa List ~ ea4 tbe Offslts ~ sfaceaearo of Chose ltsts.
Honftorfns Tees Cell-fa Lists ~rcerfy.
Contrary to tbe sbsvs, evf4eaco oald aoC be presented to eheu Chat tbe lists are updated quarterly. IEp per~i fndfcscod Ast Ae telephone directory le up&cod avery 4 ooocSH
~ ad cbac tbe ltaafcerfas Tom Calf-fa Lfecs sro up&ted aaauslly.
ysllure co update Ae lists cou14 rewlt fa deieye ead con(eefus resufcfaS ahw ft fs necessary co celt la psreaNNI Co ~C S-plea. Ibe S-pleo ru0uftua Chat caofte oad el faire mls ba unused ufthfa %-40 afautas of aocfffcecfea, 3%. RSI 3.3, Rev. 0 requires As update of Che ~MT dyp3 fadfratos tbsC Suppf~tal Support Ltst Resofvedi Verified delecfon of Supplwencsl Support Lfsc end SupplsueaCal Support List, CaerDaacy Tetetheas ws ds1ocad sad that activities established fa yt6S ~ scablfebosaclfapiwencsclou of PNIS sccfvfcfee.
Directory, W Nosfcorfag Tees Lleco co be fer other lfsea. (See IRectvetfoa 4LT fa cbls audit report).
~ che4sled es4 doaaeatod vla yt(IS.
Cent rory co clN shave/ tbe up&to act 1 vfClos hove aoc bees secured lace le. Ths loch of
~ acerlaR the update of tbe lfste face yMIS bes resulted la oa up&Ca eystaa uhfch bse ooC perfaruNI wite Tbe audit tem reromaads chat Aose ltsca
~a ~ted fa eraerdeara ufth Che fruRueatfea de(feed la SSI S.yi 00 ~ Saerseaey plea, Rev, 10, fppWfs 4 re0ufras ~IT 43hb fsdfrates tlasc SaarDsasy plan revised Raseivedc Sfx (4) of the cblrceen (13) letters of esreeaenc.revfewd by Ae NaaaSer~iser Support co raaeu letcars ~ ad i%18 acClvltfes established cho wftor uere eisnsd since Obeervscfnn s80 we asde. sfa (4) ot efs of ssraweac every tuo (1) years, (4) wro sfSsed ulthfa cuo (3) year t los constraint.
4 revfeu of hlecorfrof rocor4s fa this eras revealed tbsc la Che poeC soC all letters of asroeoeac wre raaauad ufAfa Cuo (R) years ~
Durreatly, ell re0ufcad letters sra oa file.
IRt persecwl ers raafaded of Afs ra0ufraoeat aad tc ls receaaeadsd cher hector coapltearo be orbtevad durfaR euhseRusac ~fag of letters of acreeaests.
Observation Rsc~ndatfon Lctfon Taken ~ potsnttsl for Recurrence S-plan, Scv. 10, Ssctloa 4.0 ro9ufres tbe ICF-OIT 4594 fndlcates unresolved sn4 no tardst date
~ 1.
ooslte NSSO as4 of!etta ultlln 50-40 Ill to le nsonsd nfmtes of notfffcatfca.
for actfc>>. cc>>pllo4 by tl>> SCp. Ls ln 1917, 10% success rate ws not achieved once la SISS response to call-out tests. Overall, SISS response rsnbed fran tost shove QA to ss lou as IOC. (Ceneral Off(ca response aversSO4 SSb).
Contrary to tbe shove, a revfsu of the noathly call-out test results resulted la aasrous olservatfon OI of this audit report lss sencrate4 N)L's concerns in cases of the oa-call fadfvfdusl not rospoadfaS. resolvlnS tbe 'people probl~'ssocfated ultb this lou response rate.
based on ~ revfsu of rssulCO of the loathly call-out test for ~ leven (ll) ncatba fn 1SSI, there wre epproalnstely 15k cases skece tbe
~ ssfy>>4 oa-call fadfvfdual 414 not roepooi.
(of these 154, cbfrty~ (51) wro ceased
~ y beeper faf lures.)
Ibe shove results appear to sseSsst Clat tl>>
call out process 1 e noc effsctfvsly ho(ac topi~ted. (Secor ysrty~ (l1) peeplo are oa cho llscl cl>>raforo ~ fat faro rote fe
~ pproslostely 554/il a Q or 55b.) la so Sires neath ws tl>> SKcesa rota QAo Sddftfonally Chere wro<
0 Nfoe (9) cases lhasa alternates appeared no't to have boon contacted o Ibree (I) cases shore hceo phones had been
~ l scoooec ted.
o ylve (5) cases uhera tbe fndfvfdua) uss oaslto lut 414 nst toepead.
o one (1) case noted shoto cbe seventh
~ ltsraste bad to le canCacte4.
0 Several cases of snswrfaS aschfses
~ a>>>>rlnS but oot tlo fsdfvfdue1.
Ibe lapser oo ~ffty fs ths fasbfffty Co
~ toff tbe S-plea per~) ~roeeata fa the tfoe lfalts estsblfshed fa Cbe S.Plan
~ urlnS aa actual enerSeacy coodftfm.
BEEPER PEREORI;1AI':I':E TOTAL RESPONSES 100 70 60 50
-30 20 10 JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV OEC 1988
BEEPER PEREORMAIUCE GENERAL OFFICE RESPONSE 100 90 80 70 50 30 20 10 JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC 1988
BEEPER PEP.I-OF I:i.-"I I'.:E SSES RESPONSE 100 eo 60 r/ /
/
r r
30 20 10 rr,r 0
JAN FEB MAR APR h1AY JUN JUL AUG SEP OCT NOV DEC 198S
BEEPER PEREOR)viANCE RESPONSES/OhI SITE 100 q0 80 70 60 0
O 40 30 20 JAN FEB MAR APR h1AY JUN JUL AUG SEP OCT NOV DEC 1988 RESPONDED QN-SITE
BEEPER PERFORI>IAI'ICE NON-RESPONSES 40 35 30 25 20 15 10 0
JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC 1988 BEEPER PROB PEOPLE PROB UNKNOWN
PP8L RUDIT CHECKLIST
- 1. AUDIT NO. SS lO V
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cc: B. 0. Kenyon TW-16 March 14, 1988 H. W. Keiset A6-1 W. R. Licht A6-1 J. R. Miltenberger A6-1 M. L. Crist SSES K. R. Leone A2-2 R. E. Dixson SSES
- 4. A. Blakeslee SSES R. G. Byram SSES P. E. Taylor SSES S. H. Cantone A2-4 R. L. Doty A1-2 W. J, Heske A6-4 J. J. Graham SSES W. H. Lowthert SSES H. J. Palmer SSES J. M. Minneman SSES C. R. Whirl A2-2 SRMS Corresp. File A6-2 NQA Audit File SSES SUSQUEHANNA STEAM ELECTRIC STATION SUSQUEHANNA REYIEW COMMITTEE AUDIT OF THE EMERGENCY PLAN AUDIT 87-085 CCN 740020 FILES R12-1A/R12-1C PL I-54581 On behalf of the audit team, I wish 'to extend my thanks for the cooperation and support provided by members of your staff. Attached for your review and action is the report of 87-085.
The audit resulted in 6 findings and 82 recommendations. Attachment A is provided to aid in the correlation between work groups and the corresponding findings and recommendations. A'll recipients of this report are asked to refer to Attachment A in order to determine the findings or recommendations impacting their work group.
Please provide response to each of the findings directly on the audit finding sheet in Block 8 and return to NQA within (30) days of receipt of this report.
If corrective action cannot be located within 30 days, interim responses describing proposed actions and target dates for completion should be provided within 30 days.
Please advise if you have any comments or questions.
drh/crw/meb19c(20): n f Response Requi red: Yes Due Date: Within 30 days Attachments: Attachment A - Responsibility Matrix Audit Report 87-085
Recommended Responsibility Matrix
~Findin s Action Grou Interface s 1 SNEP SRMS, OCC 2 NTG 3 Mgr. Nuc. Adm.
SNEP 5 SNEP 16 SNEP Recommendations Co nizant Grou Interface s 1,2,3,5,6,7,8,9,13,16,18, SNEP 19,20,22,23,27,28,29,31, 32,33,35,36,37,38,39,40, 42,43,44,45,46,47,57,59, 60,61,62,63,68,69,70,71, 72,73,74,75,76,77,78,79,80 11 SNEP SRMS 17 SNEP N(A Surv. Group 82 SNEP PSA Supv., Mgr. Nuc. Adm.
4,10,12,15,20,21,22,26, Mgr. Nuc. Support/SNEP 30,35,56,58 23 SNEP NTG 34 Plant Supt.
14 NTG OPS 23,24,25,28,29,81 NTG 41,67 Supv. Nuc. Licensing 48,49,50,51,52,53,54,55 Operations 64,66 Chemistry 65 Chemistry Licensing
C' SSES PL 1-54581 CCN 740020 Files R12-1A/
R12-1C Audit of the Emergency Plan Audit 887-085 December 14, 1987 to Februar 9, 1988 I. ~Pur ose The purpose of the audit was to assess the effectiveness of the Susquehanna Steam Electric Station (SSES) Emergency Plan and implementing procedures. This audit satisfies the requirement for the Susquehanna Review Committee annual audit of the Emergency Plan (E.
Plan) as required by SSES Technical Specification Paragraph 6.5.2.e.
I I. ~Sco e The scope of the audit included the following:
o A review of the documentation generated as a result of the implementation of EPIPs was conducted in an effort to determine compliance with the procedural requirements.
o Equipment to be utilized by members of the emergency organization during an emergency condition was inventoried and inspected to insure it is in working order (calibrated if necessary).
o Documentation generated as a result of periodic emergency drills and exercises was reviewed in order to determine if the major aspects of the emergency plan were reflected in the drills. In addition, an effort was made to insure that the drills are conducted at required intervals and that any deficiencies noted as a result of post-drill.
critiques were resolved in a timely manner.
o Controlled copies of procedures/drawings/manuals assigned to specified emergency locations (TSC, EOF, etc.) were reviewed to ensure they wer'e complete and reflected the latest revision.
o The level of preparedness of the Chemistry/decon faci lities located at the EOF was assessed.
o The onsite accountability process was reviewed.
o The emergency on-call program was examined.
o The degree of preparedness of emergency facilities and supplies was evaluated.
o Personnel training and staffing was evaluated to determine whether required training/retraining was completed.
o The review and approval cycle of EPIPs was evaluated.
SSES PL I-54581 CCN 740020 Files R12-lA/
R12-1C o The verification and validation process of EOPs was evaluated.
o Training records were evaluated to ensure that outside agencies were retrained at the required frequency.
o Documentation was reviewed to ensure that operational tests of the coomunication systems and Alert Notification System (ANS) are conducted at the required frequency.
The scope also included the following three (3) SRC comnents transmitted in PLI-53229 dated 12/3/87 which are listed below:
o The audit should specifically include follow-up on all documentation of problems in the audited area since the last audit and an examination of the previous audit documentation to determine why the problems were not uncovered on the previous audit. Documentation of problems since the last audit would be contained in such sources as reports of drills, performance indicator trends, INPO.evaluations, NRC Reports, LERs, SOORs, etc.
o The audit should review the last emergency exercise and the corrective action resulting therefrom.
o The audit should assess the performance of the emergency organization during the actual Unusual Event, which occurred on September 23, 1987, against Emergency Plan procedures and programs. Compare actual performance to drill performance.
I I I. ~Summa r An overall assessment is that Emergency Preparedness from a "performance" standpoint continues to receive acceptable ratings in emergency drills and exercises. Also, a SALP rating of 1 has been received several years in a row.
In spite of the high ratings in the performance" category, the results of the audit indicate that there is much room for improvement when
'he viewed from the "compliance" standpoint. findings, in general, deal
'ith basic issues and elements of emergency preparedness. Similarly, a large number of recomnendations were wri tten which also deal with basic program elements. It should be noted that the Emergency Plan subject area is interpreted as not falling within the OPS gA requirements.
Therefore, no findings could be written based on OPS requirements. If the OPS program did apply, many of the recommendations could be written as findings. For this reason, reconmendations made in the Emergency Plan audit should be viewed with greater significance than recommendations issued in other audits. It would be wise for NEP to action seriously consider all the recommendations and take corrective where deemed appropriate. it also should be noted that several of the findings (and recommendations) are repeat issues that were identified in
3 SSES PL I-54581 CCN 740020 Fi1es R12-1A/
R12-1C previous audits. These issues deserve serious management attention.
Also worthy of note is the fact that drills and exercises are not able to detect compliance issues, since several of the conditions noted in the recommendations existed for several years and remained undetected even though drill and exercise results were satisfactory. It also should be noted that INPO no longer evaluates the emergency planning area. Similarly, the NRC does not perfo'rm many evaluations of the Emergency (E. Plan) except during drills.
The audit resulted in 6 findings and 82 observations/recommendations, The findings deal with E. Plan di,stribution document control (finding 1), fire brigade training records (finding 2), control and update of lists {findings 3,4), review of EP-IPs (finding 5), and lack of documented management review after accidents (finding 6).
The following recommendations are considered to be significant, and deal with CTN conmunication testing {P3); pager tests {f6,7); NSI interface reviews (~12); failure to meet INPO good practices (813); drill deficiencies not being entered into a tracking/trending program, timeliness of drill corrective actions, drills not being able to detect "compliance issues" { 15, 16, 17,78); procedures continually going through major changes (820); HP,van failures and lack of a backup vehicle (121);
inconsistency of various lists (¹23,79,80); validity of EP-IPs {839);
EP-IP submittals to NRC bypassing internal review (841); out of date material in G.O. support manager's book (846); periodic review of the SSES-EPG (448); EOP verification ; .ocess (855); emergency information booklet distribution to motels (~57); emergency plan suggested equipment supplies (>58); inventories of selected emergency kits (861); incorrect revisions of forms at inventoried locations (0'62); entering the PASS testing into PMIS (d65); EOF Chem Lab observations from last audit still open (f68); handling of injured contaminated personnel unusual events
(¹71,72,73,75); and effectiveness of monthly call out drills (f82).
IV. General Information udst earn Members: 0* D. R. Heffelfinger - Coord. Engr. (Team Leader)
¹* K. R. Leone - Engineer - Level II NQA
- R. E. Dixson - Project Engineer NQA Controlling Documents; 10CFR50.47 Emergency Plan 10CFR50, Appendix E Emergency Planning 5 Preparedness FSAR 13.3 Emergency Planning FSAR 18.1 Response to Requirements in NUREG 0737 FSAR 18.1.21 Post-Accident Sampling SSES Technical Appendix A, Section 6.5.2.8e Specification, NDI-2.1.5 Rev, 4 Nuclear Department On-call Duty Roster Sys.
NDI-6.6.1 Rev. 4 SSES Nuclear Emergency Planning ND1-6.6.2 Rev. 4 Selection, Traininq and Certification of Emergency Response Personnel
4 SSES PL I-54581 CCN 740020 Files R12-1A/
R12-1C NDI-QA-10,3.1 Rev. 6 Nuclear Department Qualification and Training AD-QA-100 Rev. 5 Station Organization and Responsibilities AD-QA-131 Rev. 2 Plant Management 'Call Out Procedure AD-QA-330 Rev. 3 Symptom-Oriented EOP Writer's Guide AD-QA-331 Rev. 0 Verification Program for Symptom-Oriented EOP AD-QA-332 .Rev. 1 Validation Program for Symptom-Oriented EOP OI-AD-002 Rev. 14 Operation Procedure Control CH-SY-004 Rev.' Functional Test of Unit 1 and 2 Post-Accident Sampling Station (PASS) I SSES Emergency Plan Rev. 10 Emergency Plan Implementation Procedures (EPIP)
Nuclear Support Instruction Manual INPO 87-019 Maintaining Emergency Preparedness Manual INPO EP-801 Generic Guidance for Emergency Preparedness Review INPO EP-808 Dissemination of Emergency Information to the Transient Population Pei sonnel Contacted:
J. M. Minneman - Supv. NEP P, E. Taylor - Lead STA M. L. Cr ist - Compliance Consultant R. H. Ha 1m - NEP R. G. Byram -'Supt. of Plant W. F. Tabor - Sr. Tech Asst. NEP C. F. Roszkowski - Sr. Nuclear Emergency Planner R. T. Hock - HP W. W. Williams - Project Licensing Specialist R. C. Good - Steno/Clerk-General K. G. Hillman - Sr. Nuclear Plant Spec. - OPS D. F. Dreisbach - NTG - Instructor (Fire Brigade)
C. E. Burke - Chemistry Supervisor H. J. Palmer - Supervisor of Operations V. J. Shellenberger - Nuclear Support Clerical Assistant D. P. Castellano - Assistant to PSA Supervisor S. E. Davis -, Fire Protection Engineer - SSES P. S. Brown - Nuclear Department Library D. F. McGann - Compliance Engineer C. L. Foreman - Technical Writer - Level II S. H. Cantone - Mgr. Nuclear Support M. A. Eddinger - DCC .Steno/Cl erk-General G. N. Dressier - Nuclear Emergency Planner C. Fe dako - Supv. Nuclear Training Support Svcs.
P. M. Gavlick - DCC Steno/Clerk-General A. F. McKiniry - Asst. Supv.-DCC J. H. Lex - Nucl'ear General Training Supv.
G. L. Torphy - Training Document Control Specialist - Nuclear J. J. Krueoer - Steno/Clerk-General - Nuclear Admin.
R. J, Prego - QA Supervisor - Operations M. A. Cernese - STA
SSES PL I-54581 CCN 740020 Fi 1 es RI2-IA/
R12-1C D.,M. Kapuschinsky - Sr, Nuclear Plant Specialist - Operations G. L. Merrill - Power Prod. Engr.-Operations A. J. Dominguez - Sr. Proj. Engr.-Operations D. G. Wright - Asst. Chem. Foreman J. G. Ref 1.ing - Sr. Proj. Engr.-Nuclear Systems H. D. Woodeshick - Spec. Asst. to Pres.-SSES I. A. Kaplan ' - Mgr.-Energy Info.-SSES D. K. Shane - Asst. Fore-HP P, J. McGlynn - Health Physic Spec. - Level II F. G. Malek - PSA Supervisor D. A. Crispell - Safety 8 Health Consultant D. K. McGarry - Sr. NOA Analyst R. A. Sutliff - Asst. Fore.-HP
- Attended Exit Meeting 0 Attended Entrance Meeting
~Findin s A, Items Re uirin Corrective Action
- 1. NSI-3.6 Rev. 0 describes specific requirements for distribution and control of copies of the Emergency Plan.
Contrary to the above, numerous discrepancies were noted including out of date E. Plan copies in the Operation Shift Supervisor Office, TSC, and HP Van. This finding is a repeat of finding 85-119-03. Refer to audit finding 87-085-01 for details.
Oualit Im act Assessment - The impact on quality is that out of date reverence >nformat~on is available for use at vital locations. This is clearly unacceptable.
- 2. NTP-gA-53. 1 Rev. 3 para. 6.5.8 requires that all fire brigade drills shall be documented on Form NTP-gA-53. IA.
Contrary to the above, no completed forms NTP-gA-53. 1A could be located for numerous quarterly fire drills in 1986 and 1987.
Refer to audit finding 87-085-02 for details.
Oualit Impact Assessment - Failure to complete the form casts doubts as to whether a the detailed aspects of the drill were fully evaluated, deficiencies identified, and corrective action taken.
- 3. NSI 3.7 Rev, 0 requires the Manager-NA to update the Supplemental Support List annually.
SSES PL I-54581 CCN 740020 Files R12-lA/
R12-jc Contrary to the above, the Supplemental Support List was not updated in 1987. Refer to audit finding 87-085-03 for details.
ualit Im act Assessment - Failure to update the supplemental Support List cou d resu t in proper emergency staffing not being available, contrary to requirements defined in 10CFR50,47(b).
- 4. NDI-gA-10.3. I Rev. 6 requires the TSC/EOF Primary Contact List to be approved by the Senior VP-Nuclear.
Contrary to the above, the TSC/EOF Primary Contact List has not been approved by the Senior VP-Nuclear. Refer to audit finding 87-085-04 for details.
Oualit Im act Assessment - The lack of review and approval by enior Management cou d have a negative impact on quality.
- 5. NDI 6.6.1 Rev. 4 para. 7.0 requires records of document reviews to be submitted to SRMS.,
Contrary to the above, numerous deficiencies were noted in the review cycle 'of EP-IPs. Refer to audit finding 87-085-5 for details.
vali t Im act Assessment - The impact on quality is the lack of a > sty o show>ng that reviews were conducted by proper, individuals and comments resolved.
- 6. EP-IP-.038 Rev. 2 requires the VP Nuclear Operations to review and approve all reports associated with an emergency, and to implement a followup corrective action program as appropriate.
Contrary to the above, the required reports were not always prepared for actual emergency events. Refer to audit finding 87-085-6 for details.
ualit Im act Assessment - The lack of preparing a report and approving it at the proper level could result in the performance of the Emergency Organization not being evaluated and corrective actions not being pursued.
B. Items Immediatel Corrected No Res onse Re uired
- 1. AD-gA-330, Rev. 3, Para. 6. 11.3.b states, "Procedure Changes (PCAFs) to Flowcharts shall be implemented as follows:
( 1) Overlay affected portion of the flowchart with white correction tape, white adhesive 'label, or equivalent.,
(2) Neatly revise the affected portion of the flowchart:
SSES PL I-54581 CCN 740020 Files R12-lA/
R12-1C (3) Record the PCAF number on the flowchart.
(4) Laminate the change with scotch brand or equivalent mending tape.
Contrary to the above, NQA found on 1/14/88 that PCAF 1-88-0001 to E0-100-102, Rev. 1 and PCAF 2-88-0001 to E0-200-102, Rev. 1 had not been implemented on the respective flowcharts in the control rooms, at the simulator, and in the Operations Staff area. NQA imnediately notified the Sr. Results Engr-OPS of this problem and, he promptly initiated the requi red corrective action as per Para. 6. 11.3.b of AD-QA-330, Rev. 3. NQA verified the implementation of this corrective action in the control rooms and at the simulator on 1/21/88. NQA verified the implementation of this corrective action in the Operation Staff area on 2/1/88, C. Items in Com liance
- 1. Revision 13 of the supplemental support list (SSL) is correctly formatted and lists individuals by area of expertise in accordance with NDI-QA-10.3. 1, revision 6, paragraph 6.3. 1.5. This is based on a review of the SSL.
- 2. Per the requirements of NDI-6.6. 1, Revision 4, paragraph 6.2, thirty-one (31) of thirty-one (31) Emergency Plan Implementing Procedures were approved by the superintendent
=
of Plant or his delegate.
- 3. Based on general observation of General Office Bulletin boards, the G.O. on-call duty roster is proper ly posted.
- 4. The auditor, through a comparison of the SSES on-call list (dated 12/21/87 to 12/28/87) and the TSC/EOF Primary Contact List, determined that eligible personnel are accurately identified on the latter. This is responsive to paragraph 6.1.3 of AD-QA-131.
- 5. Per 10CFR50, Appendix E, Section IV.F, the Emergency Plan requires "Basic Health Physics Indoctrination and Training" for local services (medical and fire's rescue) personnel.
- 6. Revision 10 of the SSES Emergency Plan was processed in accordance with NDI-QA-3.3.1, NRC Corres ondence Review, and forwarded to the. comnission wit in t irty ays o the change. (See 10CFR50, Appendix E, Section V and NSI-3.6,,
Rev. 0, paragraph 6. 1.4.8)
- 7. In accordance with FSAR, section 18. 1.21.3.4.4, SSES has established a formal training program (EP0024 and EP0025) to
SSES PL I-54581 CCN 740020 Files R12- IA/
R12-1C ensure a pool of qualified PASS operators is availabl'e.
NTP-gA-41.2, revision 2, Chemistr Technician Certification
~pro ram, prescribes this tratning.
- 8. All emergency response positions outlined in sections 6.2 through 6.3.3.2 of the Emergency Plan appear on revision 3 of the Emergency Plan Training Matrix.
- 9. The auditor verified that Nuclear Emergency Planning has established letters of agreement with agencies responsible for the treatment of patients from SSES who are contaminated or involved in a radiation incident. (See Emergency Plan, Section 7.4.3)
- 10. Workshops were held in'987 to train state, county and municipal emergency management agencies. Courses included "Basic Radiation", "The Effective EOC", "Municipal/County Communications," "Intro. to Emergency Response",
"Dosimetry", and "Power Plant Primer". This training satisfies specific requirements contained in E Plan, section 9.1.1.
- 11. Based on a sample of thirty (30) Emergency Plan Implementing Procedures (EPIPs), twenty-eight (28) were formatted in accordance with NS1-3.6, revision 0, paragraph 6.2.1. The remaining 2 EPIPs are documented in observation/recommenda-tion number 38.
- 12. Based on general observation of the sample defined above, revisions to EPIPs are properly denoted by vertical lines in the margin.
- 13. The content of Emergency Plan, Rev. 10, was reviewed and compared to the required format and contents described in 10CFR50 Appendix E. No discrepancies were noted.
- 14. The E. plan is exer cised annually. The drills which were conducted on 4/29/87 and 8/25/87 were reviewed.
- 15. Formal critiques are conducted to identify deficient areas.
The two drills in 1987 were reviewed and identification of deficient areas was confirmed.
- 16. EP-IPs (and revisions) are submitted to the NRC. The standard form letter used by DCC was reviewed.
Recommendation 41 was written since the form letter bypasses certain review requirements specified in NDI-QA-3.3. 1.
- 17. E. Plan Rev. ?0 paragraph 9. 1.2 requires 10 different types of dri lls to be conducted. The ten required drills were
Cl SSES PL I -54581 CCN 740020 Files R12-1A/
R12-1C conducted in 1987 based upon a review of drill records available at the EOF.
NSI 3.5 Surveillance Test of Emer enc Communication
~e> ment 18 The emergency response personnel call out procedure is tested monthly by security. Individuals and call in times are annotated on a check off list. SCC controller documents problems and deficiencies. This is based on a review of test documents for 11 months in 1987. The tests were conducted as required. Problems were noted and are described in finding 87-085-13 and recommendations 5, 6, and 7.
- 19. The CTN System to offsite agencies is tested monthly.
Similarly, the NRC ENS and HPN lines in both the TSC and EOF are tested monthly. This is based on a review of completed forms NSI 3,5A during 1987. Recommendation 3 was written concerning the manner in which CTN testing is performed.
20, On an annual basis, a schedule is developed for dates and times of communication checks. The schedule is .sent to PEMA, LCEMA, CEMA, and Special Office of the President. The schedule is contained in PLES-2662 dated 2/3/87.
- 21. Form NSI-3.5A is completed to document communication tests.
This is based on a review of the completed forms for 1987,
Completed forms NSI-3.5E were reviewed for the alarms. A problem was noted (finding 87-085-02) in that PMIS was not updated to show completion of the testing. The monthly "silent radio test" and the quarterly "growl test" were completed as required. Recommendation 8 was written to identify that none of the records are forwarded to SRMS.
Forwarding to SRMS is recommended.
tom-Oriented EOP Writer's Guide AD- A-330
- 23. NgA verified that the SSES-Emergency Procedure Guidelines (EPG) is included within the Operations periodic review program on a two year frequency. It is scheduled for the second quarter of 1987, 1989 and 1991. Despite being scheduled for the second quarter of 1987, no periodic review was performed. Refer to Observation/Recommendation No. 48 for specific details.
na NgA verified that a complete, controlled copy of all EOPs and bases are located in each control room, the training
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R12-1C simulator, DCC and at the Unit 1 and 2 remote shutdown panels as directed by OI-AD-002, Rev. 14.
- 25. NQA verified that the ten Unit 1 and ten Unit 2 flowcharts are kept in the quantities and locations listed below:
Unit 1 Control Room - Two Unit 1 sets Unit 2 Control Room - Two Unit 2 sets Simulator - One Unit 1 set, One Unit 2 set Operations Staff - One Unit 1 set, One Unit 2 set NQA verified that these flowcharts were the current revision. NQA did find that one Unit 1 and one Unit 2 f'lowchart had not been updated for a PCAF. Refer to Items Immediately Corrected in Section V.B. of this report for specific details.
26, NQA verified that the SSES-EPG, Rev. 1 {effective November 1987) was evaluated for safety impact. Since this revision ~
was minor it only required verification in accordance with AD-QA-331 to ensure SSES EPG intent was maintained. NQA verified that Forms AD-QA-331-1 and 2 were used to document the verification of the technical accuracy of the revised steps. NQA found that some revised steps were not documented as being verified. Refer to Observation/
Recommendation No. 52 for specific details. NQA verified that Systems Engineering performed an Evaluation of the Proposed Changes to SSES EOP's (PLI-52935) in support of SSES-EPG, Rev. 1 changes.
Verification Pro ram for S m tom-Oriented EOPs AD- A-331
- 27. NQA verified that most of the EOP Verification Forms were completed fully, as appropriate, during the verification process performed during November 1987 for all the EOPs.
Refer to Observation/Recommendation No. 49 for specific details for those which weren't complete fully/correctly.
In addition, refer to Observation/Recommendation No. 51 regarding the retention of the verification/validation packages, Also, NQA found that the Discrepancy Log Book is not utilized as documented in Observation/Recommendation No. 50.
Likewise, NQA found an EOP .step that wasn't verified as discussed in Observation/Recommendation No. 55. Finally, refer to Observation/Recommendation Nos. 53 and 54 for other miscellaneous minor comnents.
Validation Prooram for Symptom-Oriented EOPs (AD- A-332)
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R12-1C
- 28. N(A verified that the six scenarios developed to use in the validation of EO-1(2)00-104 changes made via PCAFs 1-87-726 and 2-87-235, respectively, met the criteria of AD-gA-332, Rev. 0, Para. 6.3,
- 29. NgA could not find that any of the following forms were utilized to document validation of EO-1( 2)00-104 changes made via PCAFs 1-87-726 and 2-87-235, respectively:
Forms AD-QA-331-1, AD-gA-332-1 and AD-gA-331-4.
However, NOA verified that the Secondary Containment Control Validation Report (PLI-52578) which was transmitted to SRMS contained all of the required information contained on these forms. Refer to Observation Recommendation No. 51 regarding the retention of validation documentation.
In addition, NOA verified that PLI-52578 recommendation Nos.*
- 1) and 2) were incorporated into EO-1(2)00-104 and that recommendation No. 3) is scheduled to be implemented via MA Nos. S86076, S86033 and S83065 beginning the first week of February 1988 as based on information from a Tech Staff individual on 2/1/88.
Post-Accident Sam lin S stem (PASS
- 30. NgA verified that Unit 2 PASS was tested approximately semi-annually during 1987 to ensure long term operabi lity in accordance with FSAR 18.1.21.3.4.4. However, problems were noted in the testing of the Unit 1 PASS in that the frequency specified in the FSAR (semi-annually) did not appear to be met. Observation/ Recommendation 64, 65, 66 and 67 address anomalies in PASS testing.
Note: The following items were assessed against INPO Good Practice EP-801.
- 31. NgA verified that samples obtained from functional test (CH-SY-004) are used in comparative tests.
- 32. NgA verified that the full scale exercise on 4/29/87 satis-factorily demonstrated the use of post-accident sampling equipment to obtain, transport, and analyze simulated samples of reactor coolant or containment air samples under conditions involving simulated fuel damage.
- 33. NOA followed-up on the following observations/recommenda-tions from last years audit 886-088 that were being tracked by NEP Open Items Tracking (OIT) as listed below:
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R12-jc Audit f86-088 NEP OIT NEP Status NgA Followup Obs./Rec. No. Comments87-289 Refer to Obs./Rec. No, 66 87-307 Disposition appears satisfactory 87-304 Refer to Obs./Rec. No. 68 87-300 Refer to Obs./Rec. No. 69
,87-298 Disposition appears satisfactory 87-305 Refer to Obs./Rec. No. 68 Public Education and Information Emer enc Plan Section 9.4
- 34. NgA verified that under the direction of the Supervisor-Nuclear Emergency Planning, the following methods are utilized to ensure that emergency planning education and information is provided and transmitted to residents and transients in the EPZ at least Annually:
o A full-page ad in local newspapers, summarizing the actions to be taken by residents has not been published; however, quarter-page ads were published annually to notify residents of the full-scale emergency sir'en test.
Refer to Observation/Recommendation No. 56 for specific details.
o Printed instructions and evacuation maps (i.e., al'1 included within an Emergency Information Booklet) were distributed to EPZ residents within both PPSL and UGI service areas during the fourth quarter of 1987. A sample of ten NgA personnel living in both service areas including one new comer to the EPZ, revealed that all ten had received their emergency information. These instructions included educational information on radiation and instructions to contact the special office of the President for additional information.
o In cooperation with PENA, LCEN and CEMA, printed instructions for public alerting and evacuation (i.e. 6 pages of Emergency Responses Information-SSES within blue pages) were placed in local 10-mile EPZ telephone directories, This was based on a 100K review of the, te1ephone directories serving the following eight localities within the 10 mile EPZ: Conyngham-Drums, Dallas, Shickshinny, Nuangola, Wyoming Valley, Berwick, Bloomsburg, and Hazleton..
o Printed instructions and evacuation maps (i.e. all, included within an Emergency Information Booklet) were
- 13- SSES PLI-54581 CCN 740020 Fi)es R12-IA/
R12-1C distributed to the following sample of mote')s and hotels in the quantities listed below:
No. of Emergency Information Booklets Willow Run Inn Red Maple Hotel Riverview Motel Hotel Colone Look-out Motor Lodge Refer to Observation/Recommendation No. 57 regarding the distribution of adequate reserves of these booklets and other considerations suggested in INPO Good Practice EP-808.
o A media seminar was held on 9/17/87 at the Susquehanna Energy Information Center with representatives from the following three organizations in attendance for the four-hour session: Times-Leader, Press-Enterprise, and Morning Call. A fourth organization, WYOU-TV attended briefly. The program included the following:
- Introductory comments from Herb Woodeshick who explained the function of the Special Office of the President-SSES as it relates to media activities and the nature of the seminar.
- Bob Byram presented a number of overviews depicting Susquehanna's performance in several different categories over the last several months as well as over the past three years.
- Ken Shank described the extensive radiological and non-radiological monitoring program that has been in existence dating back to 1971, two years before construction began.
- Ted Jacobsen gave a tour of the Ecology III lab facilities and described the activities that support the non-radiological monitoring functions.
Finally, NgA learned that approximately 52 various media organizations (i.e., newspaper, television, radio) were invited to attend this media seminar.
o During 1987, N(A learned that the 10 in-plant tours were given to a total of thirty-nine media personnel, In addition, in-p'lant tours we. e given to 2 Emergency Management Groups and 25 Municipalities, A total of 2<6
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R12-1C tours with an audience of 1,766 were conducted during 1987. In addition a total of 199 non-tour programs with an audience of 10,322 were conducted during 1987. One of these specifically addressed Nuclear Emergency Planning to an audience of 10 newcomers. During the suraner, two I-week Nuclear Energy Seminars were conducted with 60 teachers.
o Inside Susquehanna, a newsletter published for residents of the area around the SSES by PPSL Co.'s Special Office of the President, was distributed January, July and December 1987 and included many articles relative to nuclear emergency planning.
- E ui ment Information Listin s Emer enc Plan A endix D
- 35. NgA.verified that most of the items listed in the following enclosures were addressed in NSI-2.2.2, Rev. 2 (Inventory, Inspection, Operational Testing, and Calibration of Emergency Equipment and Supplies) as listed below:
Enclosure Form s) NSI-2.2.2 Station Decontamination K Area Equipment Damage Control Equipment Storage Box Contents Onsite Search and Rescue/
First Aid Ambulance Kit Hospital E,F Field Monitoring Team Equipment Radiation Emergency Environmental B Sample Kit Contents Health Physics Van Radiation Emergency Monitoring Equipment Emergency Equipment for Initial J Incident Response Technical Support Center Equipment
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R12-1C Emergency Operations Facility Equipment HP/Decontamination Equipment/
Supplies 10 GONESC Equipment and Supplies GOESC Equipment and Supplies Refer to Observation/Recommendation No. 58 for discrepancies.
EOF Chemistr Lab Emer enc Preparation EP-IP-042)
- 36. NgA inspection'f the EOF Chemistry Laboratory revealed no addi tiona 1 concerns except for these raised during last year's audit i86-088.
- 37. NOA followed-up on the following observations/recommendation from last year's audit .=86-088 that were being tracked by NEP OIT as listed below:
Audit 086-088 NEP OIT NEP Status NgA Followup Obs./Rec. No. Item No. C-Closed, 0-0 en Comments 8 87-297 Refer to Obs./Rec, 9 87-296 No. 68 10 '87-299 11 87-292 Disposition appears satisfactory.
12 87-294 Disposition appears satisfactory.
Inventor, Inspection, 0 erational Testin, and Calibration o meraenc = ui ment and su ies NSI-3.4/2.2.2
- 38. NOA learned that NSI-3.4, Rev. 1 was replaced by NSI-2.2.2, Rev. 2 (effective date 12/28/87). Refer to Observation/Re-commendation No. 59 for procedure review comments.
o NOA reviewed PHIS 1987 historical records for the following PM Activities which are used for scheduling the performance of periodic inventories:
- 16 SSES PL I-54581 CCN '740020 Files R12-IA/
R12-1C Activit No. Oescri tion x0001 Inventory emergency operations facility equipment.
x0002 Inventory radiation emergency environ-mental sample kits located at the Biological Lab.
x0003 Inventory General Office Nuclear Engineering Support Center Emergency Equipment and Supplies.
x0004 Inventory General Of fice Engineering Support Center Emergency Equipment and Supplies.
x0005 Inventory Emergency Equipment Located at Berwick Hospital.
x0006 Inventory Emergency Equipment located at Geisinger Medical Center.
x0007 Inventory station Potassium Iodide and Health Physics van radiation emergency monitoring equipment.
x0008 Inventory radiation emergency near-site and off-site monitoring equipment.
x0009 Inventory ambulance emergency kits located at the North and South Gatehouse.
x0010 Inventory control room emergency equipment supplies.
x0011 Inventory and inspect the eleven 0-Con station located at SSES.
x Inventory and inspect emergency operations facility 0-Con area and 0012'0013 Health Physics supplies.
Inventory and Inspect Technical'upport Center Equipment.
x0014 Inventory and inspect on-site search and rescue first aid equipment.
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R12-1C x0015 Inventory and inspect damage control equipment storage box.
x0016 Inventory and inspect emergency chemistry lab supplies located in emergency operations facility chemistry lab.
In addition, NQA reviewed the hard copy documentation of the above PAIS records. Refer to Observation/Recommendation Nos. 60 and 61 for evaluation of the usage of PMIS for scheduling inventories and actual discrepancies noted.
o Since the following locations had not been inventoried within the last two years audits (i.e. Audit ¹'s85-119 and 86-088) or the surveillance performed last year (i.e.
QASR 887- 112) by NQA personnel, they were selected as the sample for this audit to be independently inventoried by NQA using the appropriate NSI-2.2.2 form:
Form (NSI-2.2.2 ) Descri tion NQA Comments GONESC Emergency Equipment Inventories were ade-and supplies quate; however, refer GOESC Emergency Equipment to obs./rec. Nos. 42-47 and Supplies for areas of concern.
Berwick Hospital Radiation Inventories were satis-Emergency Equipment and factory as based on NSI-Supplies 2.2.2 form; however, Geisinger Medical Center refer to obs./rec. No.
Radiation Emergency Equip- 73 regarding the appa-ment and supplies rent 1ack of required Ambulance Emergency Equip- forms/procedures at ment Kit these locations.
Station Decontamination Area Equipment .
RM El. 691'-301 Inventories were satis-646'-36 factory with the except-646'-35 ion of items identified 676'-229 in obs./rec. No. 62.
CS EL. 676'-107 In addition, NQA verified, that the following items which were added and/or increased in quantity at the listed locations by NSI-2,2.2, Rev. 2 were present:
Form (NSI-2.2.2 ) Location Item Quantit A EOF Equipment EOF Operations Manual ( 1)
Rad Survey/SRD/Air
\'
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R12-1C Sample Data (25)
Form EP-I P-019-4 Technical Problems Priority List (50)
Form EP-IP-030-4 Emergency Status (50)
Form EP-IP-030-6 Off-site Release (50)
Trending Form Personnel Decon- Disposable bath towels (24) tamination station Equipment (only checked those loca-tions listed above)
TSC Equipment Emergency Plan Imple- (6 sets) menting procedures Finally, refer to observation/recomnendation No. 63 concerning the possible need to inventory items needed at the H.O.C./Special Office of the President.
D. Status of Findin s from Previous Audits Audit 86-088 identified (5) five findings. Four (4) of the findings remain open. Three (3) of the open findings deal with HP instrumentation/calibration issues and have target dates for completion of 3/1/88. One finding deals with lack of completion of E. Plan training. Corrective action to this finding appears to be ineffective as evidenced by identification of similar conditions during this audit. (Refer to observation 881 of this report.)
E. SRC Comments o Comment The audit should specifically include follow-up on all documentation of problems in the audited area since the last audit and an examination of the previous audit documentation to determine why the problems were not uncovered on the previous audit.
Documentation of problems since the last audit would be contained in such sources as reports of drills, performance indicator trends, INPO evaluations, NRC Reports, LERs, SOORs, etc.
o Result The (FSE) Full Scale Exercise (4/29/87) and HP Drill (8/25/87) were reviewed. The FSE identified 2 drill deficiencies and the HP Drill identified 5 drill deficiencies. All of the deficiencies were performance related and are of a nature that would not be detectable in an audit format (unless the
- 19- SSES PL I-54581 CCN 740020 'iles R12-1A/
R12-1C audit was conducted on a real-time basis during the FSE or HP Drill).
A search of the 399 Unit 1 SOORs and 166 Unit 2 SOORs identified only one (SOOR 1-87-021) in the E.
Plan area. This condition was a failure or mis-communication which occurred within CENA. There-fore, this event would not be detectable during an audit. No LERs were written in E. Plan area,. The INPO Evaluation in 1986 did not evaluate the E. Plan area. An interview with the INPO Evaluation team presently on s-ite revealed that INPO no longer evaluates the E. Plan area.
o Comment The audit should review the 'last emergency exercise and the corrective action resulting therefrom.
o Result While investigating the first comment, it was noted that the two (2) drill deficiencies from the FSE (4/29/87) were closed, but six of the eight drill comments remain open, For the HP drill (8/25/87),
three (3) of the five (5) drill deficiencies remain open and nine (9) of the fourteen ( 14) coments remain open.
The following actions were taken by NgA during this portion of the audit:
(A) Recommendation 77 was written to address a lack of procedures for timely closeout of drill deficiencies.
(8) Recommendations 15 and 16 were issued concerning lack of entering drill deficiencies and comments into a tracking/trending program to provide management visibility and timeliness of corrective action.
o Coavaent The audit should assess the performance of the organization during the actual Unusual 'mergency Event, which occurred on September 23, 1987, against Emergency Plan procedures and programs. Compare actual performance to drill performance.
o Result Performance of the emergency organization during the following events was evaluated:
SSES PL I-54581 CCN 740020 Files R12-lA/
R12-1C Event Condition Related Documents
- 1) Steam Line Plug Unusual Event SOOR 1-87-0265 Ejection
- 2) ESW Pump Degra- Alert SOOR 1-86-174, 180 dation
- 3) Contaminated Unusual Event SOOR 1-88-013 Injured Worker This evaluation was somewhat difficult to perform since there is no unique record package or file location which documents performance of the Emergency Organization after an actual emergency event.. A search of controlling documents was performed by NgA to determine whether a requirement existed for a post-event evaluation to be performed by SNEP. EP-IP-038 Rev. 2, Reconstruction and Accident Closeout, provides a requirement for the VP Nuclear Operations to review and approve self appraisal reports on the functioning of the emergency organization after an actual emergency event.
The following actions were taken by NgA during this portion of the audit:
(A) Finding 87-085-06 was written to document the lack of performance of post accident reviews.
(8) Observations/Recommendations 70,71,72,73,74 and 75 were issued to document various problems which were uncovered. Please refer to section VI of this report for a complete description of observation/recommendations 70,71,72,73 74, and 75.
VI. Observations and Recommendations In addition to the formal audit findings, 82 recomnendations are made.
The recommendations should be evaluated by each responsible work group and appropriate action taken. Attachment A is provided to correlate recommendations to the appropriate work group. Recommendations are as follows:
Comnunication Tests
- 1. Communication drill forms, NSI 2.2.3A have poorly defined headings such as Test Area which is completed differently by different people. Some people complete it as a PPSL location, others complete it as an offsite agency location. The form should be revised to remove ambiguity and to ensure proper information is entered.
Records for monthly communication drill with offsite government
't SSES PL I -54581 CCN 740020 Files R12-1A/
R12-1C agencies (old form NSI 3.5A, new form NSI 2.2.3A) are not forwarded to DCC for entry into SRMS.
- 2. Poor agreement exists between hard copies of test records and dates in PMIS for worklist completion. Recommend that efforts be made to improve performance in this area. This is caused by the fact that PMIS is being utilized to track completion of the communication drills and has a quarterly frequency, whereas the E. Plan and NSI 2.2.3 require a monthly drill frequency. The drills are being done monthly.
3, Monthly CTN communication test with offsite state and county agencies is not a full test, One month a, call is made from the Control Room, one month from the TSC, and one month from the EOF.
It should be noted that IE Notice 86-97 requires the ENS system to be tested from each installed location. Recommend that the testing philosophy for state and county agencies be reevaluated for effectiveness.
4, NSIs are not revised in a timely enough manner nor properly utilized in field to reflect changing conditions, Example: New phone system was installed in October 1987 deleting hotlines and installing CTN system, but old testing procedure NSI 3.5 is still in use. Form NSI 2.2.3A is being used but procedure NSI 2.2.3 has not been issued.
Recomnend that efforts be made to issuing and revising NSIs more efficiently and timely,
~Pa er Test
- 5. Security does not have a written procedure for performing emergency response call out drill that is done monthly, Security does perform the test in a consistent manner. It is recommended that the need for a procedure be evaluated.
- 6. The pager test form (no form number assigned) should have an entry blank added for the "number of cases where an alternate could not be contacted." At present, due to,the way the form is being completed it cannot always readily be determined whether or not an alternate was contacted.
- 7. Recommend that the overall results of the pager testing be. evaluated annually by senior management to determine whether responsiveness of personnel assigned to support the E, Plan is acceptable. At present, no one is assigned to perform this evaluation.
Alert Noti ication S stem ANS Testin Records of the silent alarm test and growl test are not forwarded to DCC or SRMS. This testing also is not documented in PMIS.
Recorrrnend that the processing of these records be reevaluated.
SSES PLI-54581 CCN 740020 Files R12-1A/
R12-1C
- 9. During the annual ANS test, the records for siren number IBE had a comment that the right front corner of the siren was loose. Also, the records for siren number 5BE had a comment that the rotating siren was hitting tree limbs. Neither of these were considered failures; however, no corrective action was in evidence to make the necessary repairs. Recommend that the condition of these two sirens be checked in the near future.
General
- 10. NSI 2.2.3 Section 7.0 has a misleading statement which says that PMIS as outlined in AD-00-540 will provide the method of controlling overall documentation of operational tests. This is not true as fo l ows:
1 (a) Monthly pager test results are not entered into PMIS.
(b) ANS testing is not entered into PMIS for a silent test and growl test.
Distribution of the Emergency Plan to offsite government agencies such as LCEMA, CCEMA, FEMA, DER, etc. should be checked to ensure that all agencies have the latest revision of the E. Plan. This item should be given high priority by the SNEP and SRMS. Note that distribution problems did occur at the plant. The signed/receipt transmittal forms (form number 3208) are destroyed on an annual basis. Therefore, distribution to the offsite agencies could not be confirmed by N(A. It is recommended that the receipt transmittal/forms should not be destroyed. SRMS procedure P5.0 does not provide guidance concerning filing of form number 3208.
Procedure P5 0 should be revised.
~
- 12. The NSI procedure system does not have a mechanism which provides a review of the NSI by interfacing organizations. There are situations where responsibilities are assigned to work groups outside of Nuclear Support and that work group did not review the NSI during the review cycle.
- 13. The following statements in INPO 87-019, Maintenance Emergency Preparedness Manual, are not being met:
(a) Para 3.2.1.3 A quarterly status report should be prepared to inform upper management of the status of problems.
(b) Para 3.2.2 Corrective actions should be trended (c) Para. 5.5.5 Radios used to communicate with emergency teams and among emergency facilities should be tested monthly,
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R12- IC Quarterl Fire Drills and Trainin
- 14. When the training roster forms (NT?-QA-'11.3A and NTP-QA-13.2A) are completed for Operations and Security for the quarterly fire drills and training, the NTG instructor should complete the forms to identify the operations or training shift (A,B,C,D,E,F) that is in attendance. At present, it is very difficult to ascertain whether all personnel on each shift have completed the drills and training.
The course numbers are F8004,5,6,7,8,9,10 and 11. It is recommended
. that Operations 'and Training develop a better mechanism for tracking completed fire brigade training and drills. Operations should consider adopting a mechanism similar to the methods used by Security to track completed fire brigade training and drills.
It should be noted during the fire protection audit in Finding 87-044-03 that numerous fire brigade members from Operations did not complete the required quarterly training or participate in the quarterly drills. This finding is still open and has an obvious impact on emergency preparedness. A finding was not written since there already is an open finding in this area.
Drills
- 15. NSI 3.3 does not discuss drill "comments" which appear to be low level deficiencies. NSI 3.3 also does not discuss entering drill deficiencies into a tracking or trending program in order to provide management visibility and improving timeliness of corrective action.
Nuclear Support should evaluate making improvements in this area.
- 16. Timeliness of completing corrective actions is in need of improvement. The full scale exercise conducted on 5/18/87 generated eight drill comments. Corrective action for four of the drill comments is overdue. The HP drill conducted on 8/25/87 resulted in 14 drill comments. Corrective action for five of the comments is overdue.
- 17. Conduct of the drills does not appear to evaluate whether key reference material utilized by emergency response personnel is up-to-date. Conduct of the drills should be adapted to evaluate whether documents such as the Emergency Plan, EP-IPs, emergency telephone directories are readily available where needed and are up-to-date, Note that the Operations shift supervisor and TSC copies of the E. Plan were out of date by many revisions. This problem existed for many years and remained undetected by drill performance. Perhaps the NQA Surveillance group should monitor drill performance for this aspect.
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R12-1C General
- 18. There are no copies of the E. Plan or EP-IPs in Security SCC or ASCC. The supervisor of Security does have one copy of the E. Plan and one copy of EP-IPs. SNEP should evaluate whether Security has sufficient numbers of EP and EP-IP manuals and that they are located at the proper location.
- 19. E. Plan requirement Para. 9.1.2 states that "all agencies who participated in drills are invited to the critiques." PPSL does'not meet this statement as written. Therefore this paragraph should be revised to reflect the actual manner in which agencies perform critiques.
- 20. Procedures at various levels (E. 'Plan, EP-IPs, NSIs) appear to be in a dynamic state of flux. Major commitments are made, deleted, re'vised and rewritten frequently. The procedures in general do not receive a review by interfacing departments. It is recon+ended that the procedures be prepared in a more methodical manner.
Consideration should be given to having QA in the review cycle of these procedures.
- 21. The HP van used to support emergency preparedness failed during both drills (or practice drills) in 1987. Consideration should be given to improving the reliability of this vehicle since its failure seems to have an immediate adverse impact on the E. Plan. Consideration should be given to parking the vehicle in a garage or installing engine block heaters. Also a contingency plan should be evaluated for having a backup vehicle.
- 22. A thorough search of STAIRS and a thorough search of the two drills in 1987 has revealed that none of the forms in the EP-IPs could be located in SRMS. It is hard to imagine that a full scale exercise does not result in the completion of any of the 50 forms that exist in the EP-IP form index (Rev. 57). NEP should evaluate the use of the forms and where completed forms should be retained. There is no direction given in the EP-IPs or NSIs to describe where completed EP-IP forms are to be retained.
- 23. NDI-QA-10.3.1 Rev. 6 Para. 6.2.1 requires Nuclear Training to develop and maintain a matrix of training courses to be taken by personnel filling-the position listed in Attachment 1.
Contrary to the above, a comparison of Attachment 1 and Rev. 3 of the training matrix resulted in two discrepancies; neither Quality Assurance Coordinator nor OSC Coordinator appear on the training matrix, Further :raining and qualifications of emergency response personnel could no. be assessed for all positions due to the inconsistencies of position-title lists within the following documents:
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R12-1C o NDI-QA-10.3. 1, Rev. 6, Attachment 1 o E-Plan Training Matrix, Rev. 3 o GO and TSC/EOF Callout Lists o GO and SSES On-call Lists o NTP-QA-52. 1, Rev. 2, Attachment 1 This conc'em was also documented as observation 'r'n Audit Report 85-01:
"An attempt was made to compare the minimum acceptable level of qualification and training specified in NDI-QA-10.3.1 with information contained in selected personnel records. Information was readily available for only some key personnel. The task could also not be completely performed for all personnel since there is no one-to-one correspondence between position titles in the emergency organization and those specified in NDI-QA-10.3. 1. A general assessment should be conducted to assure that there is a one-to-one correspondence between emergency position titles in Plan, NTP-52. 1, NDI-QA-10.3. 1, PQS Job Activity Titles, Form NTI-QA-3002A and other documents,"
NQA recorrmends that a controlled list of position titles be maintained by Nuclear Emergency Planning. As position titles changed, all documents that referenced the list could be updated in a more timely manner.
- 24. NDI-QA-10.3, 1, Rev. 6, Para. 6.2.1 states; "Nuclear Training will develop and maintain a list of training courses offered and the regulatory requirements satisfied by each course."
Contrary to the above, no NTG matrix could be found which lists training courses versus regulatory requirements. Instead, each unit of instruction refers to the appropriate regulatory requirement.
Additionally, Nuclear Training maintains a listing of training courses offered.
It is recommended that NTG review this requirement. If the matrix is deemed unnecessary, NDI-QA-10.3. 1 should be revised. If the matrix is deemed necessary, the matrix should be prepared.
- 25. The audi tor observed that the Chemistry Technician Certification Program -- Chemistry Implementing Technical Procedures Sheet (Form NTP-QA-41.2C) requires the technician to certify on EP-IP-021, Site Emergency Evacuation. This procedure does not appear on Revision 133 of the EP-:P irdex as an active procedure.
NTG should remove/revise the inaccurate reference.
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R12-1C
- 26. NDI-QA-10.3,1, Revision 6, Paragraph 3.0 lists EP-IP-018 as a reference. Paragraphs 6.3.1.3 and 6.3.1.4 also directs user to EP-IP-018. This does not appear on the EP-IP index as an active procedure.
Nuclear Support should remove these references from the NDI and assure that the correct reference is substituted.
- 27. The auditor observed that the Nearsite Radiation Monitoring Team and Offsite Monitoring Team Call-out Rosters appear as Exhibits A and 8 (respectively) to an uncontrolled procedure entitled, "Radiological Monitoring-Teams Call-out Procedure." Neither list is dated or provided with a revision number. The only date on the procedure appears with the typists notation.
The audit team recommends that these lists be updated in accordance with existing requirements (see Audit Finding No. 87-085-06).
the rosters and the subject procedure should be 'dditionally, clearly marked with revision number and revision date..
- 28. During a review of 27 NDI-6.6.2A forms (Predesignated Emergency Response Personnel Selection or Deletion Form) contained in a binder located at the NTG, the auditor observed the following:
- a. Fourteen were originals and thirteen were copies. (NQA recommends that originals be maintained at one location.)
- b. Five had no signature by the SNEP or selection manager.
- c. Two 'piggybacked'dditions and deletions on the same form.
(SNEP should establish policy.)
- d. Two had no effective date.
- e. Nine could not be located in SRMS.
It is recommended that the forms be reviewed and properly processed, E-Plan
- 29. The Emergency Plan, Rev. 10, Paragraph 9.1.1 states that:
"All unescorted personnel entering or working within the SSES controlled zone receive, as a minimum, the following instructions:
This appears to be an overcommitment. The only training provided in this area appears in GET-01, General Employee Training, and is limited to categories of emergency events, purpose of E-Plan, and
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R12-1C the listing of the E-Plan and EP-IPs in the handout's reference section.
NQA suggests that NEP and NTG reassess the E-Plan requirement and initiate appropriate corrective actions (i .e. revise E-Plan to indicate that training is introductory in nature or provide additional training) ~
- 30. NSI-3.6, Rev. 0, Paragraph 6.1.4. 1 states in part that, "Revised sections {of the E-Plan) with permanent changes shall be noted by a vertical line in the left hand margin."
Contrary to the above, vertical lines were not used to note permanent changes made by revision 10 of the Emergency Plan. This was due to the fact that Revision 10 was a complete 'rewrite'f the Emergency Plan.
NQA suggests that a summary of changes sheet be distributed to holders of controlled E-Plan manuals when vertical lines are not utilized to denote changes.
- 31. The auditor observed that Hunlock Creek Ambulance Association does not appear on the list of agencies in Appendix A of the Emergency Plan. This list represents those agencies that have letters of agreement with PPIIL for emergency services. Hunlock Creek Ambulance Association signed letters of agreement on 6/17/85 and on 6/25/87.
NQA recommends that Appendix A be revised to represent a complete list of agencies.
- 32. The following letters of agreement could not be found in SRMS:
o Agreement letter with Reliance dated 8/20/86 o Agreement letter with Luzerne County dated 12/3/86 o Agreement letter with Bechtel dated 5/84 {no signed copy)
It is recommended that the letters be forwarded from the EOF to SRMS,
- 33. The auditor observed that NEP has not updated/backdated PMIS for the most recent agreement letters for the following agencies:
Shi cks hinny Fire 09/12/86 Luzerne 12/03/86 Reliance Ambulance 08/20/86 Col umbi a 08/14/86 PEMA 03/03/87 Geisinger 08/07/86 NQA suggests that appropriate entries be made to PMIS.
- 34. Emergency Plan, Revision 10, Paragraph 9.2 and NSI-3.6, Revision 0, Paragraph 6.:.4 requires PORC to review, approve and submit a summary of i-Plan cnanges to the SRC.
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R12-IC The suttmary of changes provided by PORC (see PORC minutes, meeting no.86-174 via PLIS-25397) is significantly more brief than the summary provided to the NRC (Ref. PLA-2777).
NgA questions the level of detail in the PORC sumary and suggests that this su+nary be transmitted under a separate cover letter to the SRC. Consideration should be given to coordinating the sumary efforts.
- 35. NSI-3.6, Revision 0, Paragraph 6.1.3 requires the use of Form NS1-3.6A to request Emergency Plan changes. The auditor observed that this form has not be utilized. NgA recommends that Nuclear Emergency Planning inform E-Plan users of the form's existence and implementation methodology.
EP-IP Review
- 36. During a review of EP-IPs, it was observed that EP-IP-012, Rev. 5 coversheet did not indicate a PORC meeting number, procedure type or review type, Nuclear Emergency Planning should correct the deficiencies by placing correct information on the subject coversheet.
- 37. The auditors observed EP-IP-003, Rev. 2 and EP-IP-014, Rev. 3 in one of the EP-IP manuals located at the EOF. These procedures do not appear on the Rev. 133 of the EP-IP matrix of active procedures. It is recommended that the four manuals of EP-IPs at the EOF be reviewed to assure that all procedures which have been deleted are removed from the EP-IP manuals.
- 38. The audit team observed two EP-IPs (EP-IP-009, Rev. 7 and EP-IP-022, Rev, 1) that 's~itched'he content of sections 4.0 and 5.0. This is contrary to the format guidelines provided in NSI-3.6, Rev. 0, Paragraph 6.2. 1.
This represents a minor nonconformance with no quality impact; however, it is suggested that the subject EP-IPs be restructured during the next review cycle.
- 39. Additionally deficiencies concerning EP-IPs indicate that several EP-IPs contain outdated references:
EP-IP ~oeficieec EP-IP-006, Rev. 1 EP-IP-014 appears in references section but does not appear on index (Rev. 133) as a current procedure.
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R12-1C PCAF 1-87-823 removed EP-IP-102 from Page 4 but not from reference section.
EP- IP-017, Rev. 2 EP-IP-015, EP-IP-021, EP-IP-041 appear in reference section but do not appear on index as current procedure.
EP-IP-029, Rev. 2 EP-IP-018 appears as reference but does not appear on index.
EP-IP-034, Rev. 6 EP-IP-010 appears as reference but does
- not appear on index.
EP-IP-035, Rev. 5 EP-IP-010 appears as reference but does not appear on index.
These discrepancies resulted from a cursory review of the EP-IPs. The auditor did not evaluate procedures for technical adequacy; however, from an administrative perspective, these procedures may be out of date, NEP should consider initiating an overall EP-IP review to verify the technical adequacy (i.e. is the information up-to-date) of each procedure.
- 40. The auditor noted that the radiation survey directions provided in Section A.4.2 of Attachment A (Nearsite Monitoring Team) to EP-IP-013 are inconsistent with those in Section 8.4.2 of Attachment B (Offsite Monitoring Team).
NgA recommends that NEP revise Section A.4.2 to read, "At this point, take an OPEN WINDOW and CLOSE WINDOW reading 3 feet from the ground."
- 41. It was noted that transmittal to the NRC of revisions to EP-IPs is performed in a manner which bypasses the internal PPSL review that is required for all NRC correspondence by NDI-0A-3.3. 1. It is recoranended that Nuclear Licensing reevaluate this scenario.
Inventor (Allentown 42 . Form NSI-2,2 .2C requires the GONESC to have a Norelco tape recorder with microphone, No extra tape is available for the Norelco {reel) tape recorder. The only tape in the machine is falling apart and appears to be nonfunctional. Tapes are no longer sold. Nuclear Administration should consider replacing the recorder.
- 43. E-Plan, Appendix 0, Enclosure 10 recommends that the emergency telephone listing notebook and emergency resources manual be available at GONESC as typical equipment; however, GO support
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R12-"1C manager's book contains several phone listings of emergency numbers.
It is not clear that these phone lists meet the E-Plan requirement.
NQA recommends that, 1) the emergency resources manual and emergency telephone listing directory be defined within the E-Plan, and 2) that the-subject listings be maintained at the GONESC as manuals for easy reference.
- 44. Form NSI-2.2.2C requires the GONESC to have emergency drill release forms. Emergency drill release forms are not available in the GONESC inventory of emergency equipment and supplies. CMC (Corporate Management Committee) version is updated by Nuclear Administration personnel frequently. For this reason, the CMC release form is not stored with GONESC supplies. The 'notepad'ersion isn't stored with GONESC supplies either. (Note, blank forms are available at the GONESC.)
NQA suggests that Nuclear Administration and Nuclear Emergency Planning reevaluate the need for this form as a GONESC supply. If necessary for efficient GONESC operation, forms should be stored with other GONESC supplies. If, however, the forms are not necessary, the GONESC inventory form should be revised accordingly.
- 45. Enclosure 10 to Appendix D of the Emergency Plan includes "extra batteries for pocket tape recorder" as a typical item included in GONESC inventory of equipment and supplies. Extra batteries'are not included in the GONESC storage cabinet and instead are located in a clerk's desk drawer.
It is recommended that extra batteries be included in the storage cabinet with the pocket tape recorder.
- 46. During a review of the GO support manager's book, several instances were observed of out-of-date and potentially out-of-date materials.
These included:
- a. Attachment 11 to Tab 2, "Nuclear Network Qualified Operators List," dated 5/1/85 (Revision 1). C. Foreman transferred.
b, Tab 3, "Nuclear Department Key Personnel List," Rev. 14 of Attachment 1 to NDI-10. 1.2. Currently, Attachment 1 is at Rev.
15.
- c. Tab 4, "Other Key PPSL Personnel List," Rev. 1, dated 6/29/85.
- d. Construction Department Key Personnel List, dated 5/20/86,
- e. Tab 5, Allegheny Electric and PGSM Phone Numbers, no date or revision.
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R12-1C
- f. Tab 6, Other Utilities (phone numbers), dated 5/30/85,
- 9. Tab 7, Industry Phone Numbers, no date or revision.
- h. Tab 8, "Consultants List," dated 2/8/83.
- i. Tab 10, "Helicopter Service," no revision or date.
NgA recommends that these items be reviewed for accuracy (and corrected) and that a review cycle be established to ensure manual is maintained up-to-date.
- 47. Form NSI-2,2.2C requires the GONESC to have an INPO directory. NgA observed that the INPO telephone directory located in the GONESC storage cabinet is dated October 1984.
Nuclear Administration personnel should ensure that this revision is the most current.
S ptom-Oriented EOP Writer's Guide
- 48. AD-(}A-330, Rev. 3, Para. 6.2.3.b states, "Periodic review of the SSES-EPG should be performed at least every two'ears. The SSES-EPG data table and Appendix C data table shall be checked to ensure that the values are current and correct. All SSES-EPG steps should be checked for agreement with SSES design."
Contrary.to the above, no periodic review was performed during March 1987 which was 2 years since issuance of the SSES-EPG, Rev. 0.
Following discussions with NgA personnel during Audit 87-005 (Audit of Plant Operations) which resulted in Observation/Recommendation No. 5, Operations issued PLIS-26240, dated 04/10/87, to NFdmSE-Systems Engineering requesting the review of EPG Rev. 3 Plant Data to ensure that plant modifications have not invalidated any of the calculations. This review was stated to be required to fulfill the 2 year review requirement and was needed by June 30, 1987. In addition, this letter requested the review of EPG Rev . 4 and its Appendix C for technical adequacy for implementation of Susquehanna.
This review was stated to be required in 1987 to support revision of the current, Emergency Operating Procedures (EOP) in 1988. To date, neither one of these two reviews have been performed. Per discussion with J. Refling of Systems Engineering on 1/12/88, NgA was informed that these two reviews are going to be done as part of the EOP rewrite, He estimated that it would be at least midyear 1988 before this would be completed.
N(A recommends that Plant Staff management evaluate the safety impact of not performing a periodic review of the SSES-EPG at the typical 2 year requency and initiate such a review, if warranted.
Consideration should be given to making this a requirement (shall)
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R12-1C instead of a recommendation (should) within Para. 6.2.3.b of AD-QA-330 based upon these evaluation results.
Verification Pro ram for S stem-Oriented EOPs
- 49. AD-QA-331,, Rev. 0, Para. 6.4 states, "The EOP Verification Forms shall be completed fully, as appropriate, for each procedure."
Contrary to the above, NQA noted that the DR number was not recorded on Forms AD-QA-331-1, -3 and -4 for any of the EOPs reviewed during the verification process during November 1987. In addition, the resolution block on Form AD-QA-331-1 was not completed either.
Similar items were noted on verification documentation for two PCAFs performed during September 1987. In addition the following omissions/inaccuracies were noted for the EOPs reviewed in November 1987:
o Form AD-QA-331-1 for E0-200-100, Rev. 1 does not have revision block filled in.
o Two forms AD-QA-331-4 for E0-100-102, Rev. 1 do not have revision block filled in.
o Form AD-QA-331-1 for E0-200-102, Rev. 1 does not have revision block filled in.
o Two forms 'AD-QA-331-1 exist for E0-100-112, Rev. 1 and none exist for E0-200-112, R'ev. l. One of these forms does not have revision block filled in.
o Forms AD-QA-331-1 and -3 for E0-200-113, Rev. 2 have Revision 1 listed.
50, AD-QA-331, Rev. 0, Para. 6.4.4.f states in part, "All discrepancies are entered into the Discrepancy Log Book."
Contrary to the above, NQA found that no such log book was utilized for logging discrepancies identified during the verification process of the EOPs reviewed during November 1987.
NQA recommends that Operations utilize the Discrepancy Log Book or else change the procedure to not require its use.
- 51. AD-QA-331, Rev. 0, Para. 7. 1 states, "Records generated by this procedure shall be maintained in accordance with AD-QA-101."
AD-QA-332, Rev. 1, Para. 7.0 states, "All documentation generated by the validation process shall be maintained in accordance with AD-QA-100, Procedure Program." Note: AD-QA-100 should be AD-QA-101.
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R12-1C Based on the above, NQA recommends that Operations forward the verification package (i.e. Forms AD-QA-331-1, -2, -3 and/or -4) to DCC along with the respective SSES-EPG or EOP revision. At present, all verification information is on file in the Operations staff area for both revisions 0 and 1 including any applicable PCAfs to these revisions. Consideration should also be given to forwarding any associated validation packages (i.e. forms AD-QA-331-1, -4 and AD-QA-332-1) to DCC, if utilized.
52, While, reviewing the documentation associated with the verification performed for the SSES-EPG, Rev. 1, NQA noted that the following steps were not documented as being verified even though they were changed as indicated by a revision bar in the left hand margin:
~Ste No.
Pg, 12, Source Document No. 1 Pg. 13, Source Document No. 1 Since these source documents are the justification for deleting EPG cautions out of the SSES-EPG, NQA felt that they should have been verified to ensure that the EPG cautions are still being addressed within the administrative procedures listed as source documents.
Per discussion with Operations personnel, NQA was informed that these steps would not have been required to be verified since the only change was a result of reordering paragraphs within the source documents. However, Operations and NQA personnel mutually agreed that it would be a good idea to denote these paragraphs with a footnote within the administrative procedures to signify that they are indeed a commitment and as such cannot be removed unless they are included elsewhere.
- 53. AD-QA-331, Rev. 0, Para. 6.4.4 states in part, "Resolution of all DR's is mandatory."
Contrary to the above, NQA found that the documentation for the resolutions to the discrepancies associated with E0-1(2)00-102, Rev.
1 did not completely document all the cited items. Evaluation of these items by NQA indicates that th'e items appear to have been resolved but not documented as such.
NQA recommends that Operations personnel who resolve discrepancies be reminded of the importance of properly documenting the resolution to all the items of the discrepancy.
g4 While reviewing the documentation associated with the verification performed for the EOPs during November 1987, NQA noted that Form AD-QA-331-3 should include a document number space for traceability.
In addition, the soace for revision should state revision/PCAF on this form as well as on Forms AD-QA-331-1 and -4.
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R12-1C
- 55. AD-QA-331, Rev. 0, para. 6.3.2 states in part, "The Verifier must ensure that all information contained in the EOP(s) has been properly incorporated from the source documents.
- a. The verifier shall ensure that the EOPs are technically correct - i.e., they accurately reflect the SSES-EPG."
Contrary to the above, while reviewing documentation associated with the verification performed for the SSES-EPG, Rev. 1 and all the EOPs during November 1987, NQA noted that step RC/Q-42 of E0-1(2)00-102, Rev, 1 was not documented as being verified even though its source step RC/Q-5.5 was changed during SSES-EPG, Rev. 1. As a result of this incomplete technical adequacy review, step RC/Q-42 of both EO-l(2)00-102, Rev. 1 was incorrect from the effective date of Rev. 1 (i .e., 11/20/87 for Unit 1, 12/12/87 for Unit 2) 'until the issuance date of PCAF 1(2)-88-0001 on 1/5/88.
NQA recognized that Operations caught this omission themselves and corrected the discrepancy with the exception of the affected flowcharts as described in Items Immediately Corrected No. 01; however, NQA continued to pursue with the initial verification individual the root cause of the- omission. Per discussion with this initial verifier, NQA learned that his methodology employed for ensuring that E0-1(2)00-102, Rev. 1 was technically correct consisted of verifying that all steps that were revised, as indicated by a revision bar on the left hand margin, were consistent with the SSES-EPG, Rev. 1. He stated that his methodology would not ensure that all revised steps in the SSES-EPG, Rev. 1 were adequately reflected in the EOPs if a change was not indicated by a revision bar in the EOP, as in this case Upon notification of this, NQA performed a verification of the technical adequacy of selected steps of various EOPs that would have required changes based upon changes made within the SSES-EPG, Rev. 1. Since NQA did not find any EOPs that did not accurately reflect the SSES-EPG, there appears to presently be no adverse quality impact to the current revisions of the EOPs since the one isolated instance has been corrected.
However, NQA recommends that personnel performing the verification process be thoroughly familiarized with the methods to be utilized to ensure that the EOPs as well as the SSES-EPG are both technically accurate and/or written correctly. Strong consideration should also be given to adding additional procedural
. guidance to ensure that this problem doesn't recur in the future.
Public Education And Information
- 56. Emergency Plan, Rev. 10, Para. 9.4 states in part, "Under the direction of the Supervisor-Nuclear Emergency Planning, the following methods are utilized to ensure that emergency planning
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RI2-IC education and information is provided and transmitted to residents and transients in the EPZ at least annual ly:
o A full-page ad in the local newspapers, summarizing the actions to be taken by residents, is published."
Contrary to the above, NgA learned through discussions with personnel at the Special Office of the President-Susquehanna and NEP personnel-that a ful'1-page ad has not been ever published; however, quarter-page ads are published annually to notify residents of the full-scale emergency siren test. Based upon the following overlapping methods employed by PPSL annually, NgA believes that sufficient emergency planning information is provided and transmitted to residents in the EPZ:
o Printed instructions and'evacuation maps are distributed to EPZ residents.
o In cooperation with PEMA, LCEN and LEN, printed instructions for public alerting and evacuation are placed in local 10-mile EPZ telephone directories.
NgA recommends that NEP evaluate the necessity of placing a full-page ad in the local newspapers annually and either start running such an ad or delete this method from the Emergency Plan, as applicable.
- 57. INPO Good Practice {GP) EP-808 {Dissemination of Emergency Information To The Transient Population), December 1987, Para. 5.3, state's in part, "Detailed information, such as that provided to permanent residents within the EPZ, also should be available at motels.... Adequate reserves of the brochures should be at these facilities to be displayed, provided on request, or stored for emergency use."
Contrary to the above, NgA noted the following quantities were available at the sample of motels and hotels listed below within the EPZ:
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R12-1C No. of Emergency No. of Information Booklets Rooms Willow Run Inn 2 12 Red Maple Motel 1 10 Riverview Motel 1 12 Hotel Colone 1 49 Look-Out Motor Lodge 1 20 All of these booklets were kept in the office of each location.
Per discussion with the management of these facilities, it was unanimous that if they were sent enough copies they would place a booklet in each room.
NgA recommends that NEP, in cooperations with LCEMA and CEMA, consider supplyinog sufficient copies for all the rooms at motels and hotels within the EPZ, especially in light of the fact that two of the above motels (Red Maple and Riverview) do not have telephones in their rooms and as such would not have ready access to emergency information contained within the blue pages of the telephone directory. Strong consideration should also be given to posting protective action information (Para. 5.2 of INPO GP EP-808) and/or general information (Para. 5.1 of 'INPO GP EP-808) in those appropriate locations within the EPZ (Para. 6. 1 of INPO GP EP-808).
Finally, NgA recommends that NEP personnel should sample random locations or facilities periodically to determine if materials are available, need to be replenished, and are displayed properly (Para. 10 of INPO GP EP-808).
Emer enc Plan Sup ested E ui ment/Su lies
- 58. Emergency Plan, Rev. 10, Appendix 0 (Equipment Information Listings) suggests that the following emergency equipment/supplies be maintained available for emergency use.:
Enclosure ) Typical Station Decontamination Area Equipment Disposable Razors Scissors Tweezers NOTE: Comma should be deleted after spare frisker and prior to probe.
m Enclosure 2 Typical Ambulance Emergency Equipment Kit Thermoluminescent Dosimeter Badges Typical Hospital Radiation Emergency Equipment and Supplies
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R12- lc Decontami na ti on Tab 1 e Top Typi ca 1 Field Monitoring Emergency Equipment and Supplies Extension cord NOTE: Dual Channel Analyzer, detector, and power cord should be deleted if air samples are not analyzed by the nearsite monitoring team. Typical Health Physics Van Radiation Emergency Monitoring Equipment
- 'ial ofStation NOTE:
Potassium Iodide Tablets KI maintains 100 vials. Typical Emergency Equipment For Initial Incident
Response
SCBA Equipment adequate, to support 5 people for 6 hours6.944444e-5 days <br />0.00167 hours <br />9.920635e-6 weeks <br />2.283e-6 months <br /> NOTE: Control Room Equipment only lists three SCBA and doesn't list any extra tanks.
- 'mergency Planning Map with offsite sampling locations
- 'nsite
- 'ap Monitoring Locations Map overlays for Dose Projection
- 'irst Aid Kit Typical- Emergency Operations Facility Equipment Flashlight First Aid Kit Stretcher Emergency Forms Data Form from EP-IP 013 HP/Decontamination Equipment/Suppl i es
- 'opy of HP-TP-624 - "Personnel Decontamination"
- 'ersonnel Contamination Report Forms Hand Cream Disposable Razors Pocket Knife
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R12-1C Enclosure 10 Typical GONESC Equipment and Supplies Emergency Telephone Listing Notebook Emergency Resources Manual Magnetic Signs Tapes for Pocket Tape Recorder Extra Batteries for Pocket Tape Recorder NOTE: Inter-Company should be Intracompany Typical GOESC Equipment and Supplies
- 'lant
- 'inal Technical Specifications Safety Analysis Report
- 'ystem Description Manuals NOTE: Since System Description Manuals are no longer controlled documents should reference Design Description Manuals
- 'team Tables
- These items were removed when NSI-3.4, Rev. 1 was replaced by NSI-2.2.2, Rev. 2 {effective date 12/28/87).
Contrary to the above, NSI-2.2.2 {Inventory, Inspection, Operational Testing, And Calibration Of Emergency Equipment And Supplies), Rev. 2 does not contain the above items within the applicable inventory lists.
NgA recommends that NEP evaluate the necessity of these items and either add them to the inventory lists or delete them from Appendix 0 of the Emergency Plan, as applicable.
Inventor , Inspection, Operational Testin and Calibration of Emerqenc u> ment and uo ies
- 59. While reviewing NSI-2.2.2, Rev. 2, NgA found the following inaccuracies/omissions/inconsistencies.
e o Reference 3.8 should be entitled Preventive Maintenance
~Schedui in Sye tern.
o Para. 5.2.2 should state "Ensuring that the Bio Lab conducts inspection ...."
o Para, 5.2.3 refers to GOESC emergency equipment and supplies; however, the inventory list was deleted.
o Para. 5.2.5 should state Technical Supervisor instead of Plant Staff Emergency Planning Coordinator.
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R12-1C o Para. 5.2,8 should be added to state "Inspection and inventory of EOF Equipment (excluding H.P. equipment), Near-Site and Off-Site Monitoring Kits and EOF Chemistry Lab Supplies."
o Attachment A, Item A.4 should state - coordinate with Bio Lab.
o Attachment A, Item G location should state Turbine Building El.
676 instead of Control Structure El. 656.
o Form NSI-2.2.2A, Rev. 1
- should include an EOF Support Manager Action Step Folder
- should delete the In-plant Rad Data Form. EP-IP-030-5
- should include form numbers for the following forms:
Off-Site Team Designation Form (EOF Monitoring Teams-no form number?)
Off-Site Release Trending Form (EP-IP-030-7) o Form NSI-2.2.2B, Rev. 1 should include the required quantity of kits to be maintained (Per conversation with W. Tabor, 2 teams are required).
o Form NSI-2.2.2G, Rev. 1 should specify what extra data sheets are. required by form number.
- should delete copy of EP-IP-013 since it applies to near site and offsite emergency monitoring teams.
o Form NSI-2.2.2H, Rev. 2
- should reference Inventory Form NSI-2.2.2H' should list Air Sample Data Sheets, EP-IF-013-6, for Off-Site Kit instead of EP-IP-013-3.
o Form NSI-2.2.2K, Rev. 2
- under decontamination chemicals - is SSA 676 correct? Also, noted that decontamination chemicals are at all radwaste building locations.
o Form NSI-2.2.2L, Rev. 1
- under other health physics supplies, should state particulate instead of portable filter papers.
NgA recommends that NEP consider incorporating those applicable comments into the next revision of NSI-2.2.2
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R12-1C
- 60. NSI-2.2.2, Rev. 2, Para. 6.1.3 states, "The SNEP shall perform/coordinate inventories, inspections, and calibrations required quarterly and listed in Attachment A."
NSI-2.2.2, Rev. 2, Para. 7. 1.1 states, "The SNEP will ensure the weekly completion of any PNIS PN Worklists and submittal to the PMIS center."
Contrary to the above, a review of PMIS historical records revealed that the following two quarterly inventories'ere not performed within the allowable performance time (1 month) as identified in AD-00-540, Rev. 6, Para. 6.2.3:
Descri tion Time Period X0009 Inventory Ambulance Emergency 11/24/86-4/24/87 Kits located at the North and South Gatehouse X0012 Inventory And Inspect Emergency Facility 8/13/87-12/21/87'perations D-Con Area And Health Physics Supplies In addition, since the assigned schedule type within PHIS is floating (i.e. the activity due date is equal to the frequency added to the last performance date) rather than fixed (i.e. the activity due date is equal to the frequency added to the last acti vi ty due date, regardless of the last completion date), a review was performed to assess whether any three consecutive intervals would exceed three times the frequency [3 x 1 qtr (92 days)= (276 days)] plus one allowable performance time (1 month or 31 days) as required for Tech. Spec. surveillances. This review yielded the following six inventories out of a total of sixteen inventories which would not meet this criteria:
No. of Days Activity Greater Than No. Descri tion X0006 . Inventory Emerg. Equi pment 2/12/87-12/31/87 15 Located at Geisinger Medical Center X0009 Inventory Ambulance 11/24/86-11/19/87 53 Emergency Kits Located at the North and South Gatehouse X0012 Inventory And Inspect 2/10/87-12/21/87 Emergency Operations Facility 0-Con Area And
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R12-1C Health physics Supplies X0013 Inventory And Inspect 11/24/86-10/19/87 22 Technical Support Center Equipment X0014 Inventory And Inspect 11/25/86-10/6/87 On Site Search And Rescue First Aid Equipment X0015 Inventory And Inspect 2/11/87-12/31/87 16 Oamage Control Equipment Storage Box Based on the above information, N(A recommends that NEP evaluate the possibility of changing the schedule type from floating to fixed to ensure that required quarterly inventories are indeed performed quarterly instead of only three times per year.
- 61. While reviewing documentation associated with NSI-2.2.2, Rev. 2 and/or NSI-3.4, Rev. 1 for inventories conducted during 1987, NgA found that there was no documentation available to substantiate the following two emergency kits were inventoried during PM Activity X0008 for the listed time periods:
PMIS 1987 Historical Time Period File for X0008 Near Site d2 2/10/87-8/6/87 2/10, 3/23, 4/30, 8/6, 9/4, 12/4 Off Site dl 4/1/87-12/4/87 Per discussion with an NEP individual, NgA was informed that no documentation exists for these two cases because the kits were sealed and as such didn't need to be inventoried. However, subsequent research revealed that the HP instrumentation is not stored within these kits and as such would have had to been inventoried.
NgA recommends that NEP modify the inventory lists of those inventories which utilize break-away security seals or other mechanisms to entire positive control over equipment/supplies to require a signoff stating that seal was verified to be intact and designates which items are sealed if all aren't sealed. In addition, NgA recomnends NEP personnel ensure that for each PM activity completion date submitted to PMIS that complete documentation exists for all the required inventories for that particular PM activity (i.e. PM Activity X0008 requires a total of
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R12-1C six kits to be inventoried -- two nearsite and four offsite) or else NEP should consider separating those PM activities which require multiple inventories to be performed into separate PM activity for each (i.e. PM Activity X0008 would be six separate PM activities).
- 62. While performing an inventory of the Radwaste Building and Control Structure personnel decontamination stations on 1/8/88, NQA noted that all five of these locations contained Rev. 2 instead of Rev. 3 of Form AD-00-720-2 (Personnel Decontamination Report). Further investigation by NQA revealed that Rev. 2 of this form was changed by PCAF. 1-86-120 on 10/27/86 as identified in Observation/
Recommendation No. 22 of last year's audit of the emergency plan (Audit No.86-088). In addition, NQA found that the copy of HP-TP-624 at the Control Structure location was still the wrong revision as was identified in Observation/Recommendation No. 22. In response to Observation/Recommendation No. 22, NEP added revision spaces to Form NSI-2.2.2K (Personnel Decontamination Station Equipment), Rev. 2 (effective date 12/28/87); however, this inventory has not been required to be performed since issuance of the revised form. Per discussion with NEP personnel, NQA learned that inventory problems have been identified previously concerning the existence of expired KI (potassium iodide) tablets and silver zeolite cartridges at various locations. Further research by NQA has revealed that NSI-3.4, Rev. 1 contained an Attachment B which attempted to identify inventory/inspection requirements every quarter or after each use.
NQA recommends that NEP add the following to all applicable items on those applicable inventory forms within NSI-2.2.2:
o Blocks to record the revision numbers for all documents, procedures and forms that are listed and not a controlled satellite file maintained by DCC.
o Blocks to record expiration dates of all those items that have a shelf-life (i.e. KI, decon chemicals, iodine canisters, etc.).
o Blocks to record calibration due dates of a'll those instruments that require calibration.
In addition, NQA recommends that NEP add clear instructions within NSI-2.2 (i.e. possibly similar to what Attachment B of NSI-3.4, Rev.
1 contained) to ensure that personnel performing the inventory know exactly what tasks are required of them for all equipment/ supplies inventoried, such as:
o General Equi ment and Su lies/Res iratot E ui ment Inspect/inventory. Replace, if damaged or missing or wrong revision or not fully charged.
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R12-1C o Shelf-Life Items Verify expiration date. Replace, if near or beyond expiration date .
o Instrumentation Verify calibration calibration.
due date. Replace if near or out of Test {source and/or battery).
o ~TLD Bad es Inventory/Replace.
By utilizing both of these recommendations, NgA believes that NEP personnel will have better control over the performance of the periodic inventories which are performed to assure that required emergency equipment and supplies are available for immediate emergency use when the conditions warrant their use.
63, While scanning the EP-IPs, NgA noted that the following action steps within EP-IP-031, Rev. 3 (Public Information Emergency Procedures) refer to items which various emergency response personnel pick up from storage in the bookcase across from the office of the manager, Energy Information-SSES:
Action Ste Items B.1.1. a Equipment Package C.1.1 News Media Contact Reports, Clipboard and Equipment Package D.l.l.a Communications Log, Notification Forms, Tape Recorder and Other Office Supplies F. 1.1 Blank News Release Forms and Equipment Package In addition, Attachment 0 contains the following inventory/take lists -- Media Operations Center:
o MOC Basement Storage o Office Supplies o Susquehanna Energy Information Center Take List o Allentown Take List NOA recommends that NEP personnel evaluate the necessity of including any or all oi these items and/or inventory/take lists
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R12-1C within a periodic inventory program as per NSI-2.2.2 for other locations that contain emergency equipment and supplies. In addition, no reference within EP-IP-031 could be found as to the purpose of Attachment 0 as well as what personnel are responsible for implementing actions concerning the various inventory/take lists.
Post Accident Sam lin S stem PASS
- 64. CH-SY-004, Rev. 5, Para. 7.8,8 states, "The Chemistry Foreman will transmit the original test to DCC on completion of his/her review."
Contrary to the above, NgA note'd that the original documentation associated with the following tests was still on file in the Chemistry records area as of 1/29/88:
Unit No. Performance Dates 1 1/16/87, 5/27/87, 1/17/88 7/6/87, 9/21/87, 10/21/87 N(A recommends that this original documentation be transmitted to OCC for retention.
- 65. NgA recommends that Chemistry pursue adding CH-SY-004, Functional Test of Unit 1 and 2 Post-Accident Sampling Station (PASS), as a PM activity with a fixed schedule type to ensure that proper scheduling of this FSAR commitment is assured in the future.
A review of actual performance dates for CH-SY-004 revealed the following:
Unit I Comments 5/27/87 This interval of 235 days is in excess 1/17/88. of Tech Spec allowed limit of 184 days plus 25K (46 days) or net allowable of 230 days.
FSAR Rev 36 Para. 18. l. 21.3.4.4 requires the PASS to be tested semi-annually. It is recomnended that Licensing pursue obtaining a definition for the term semi-annual in the FSAR. In particular Licensing should determine whether any grace period is allowed.
The Licensing investigation should be generic in nature and address other test frequencies (i.e. monthly, quarterly, annual) specified in the FSAR.
- 66. FSAR, Rev. 36, Para. 18. 1.21.3.4.4 states, "To ensure the long-term operability of the PASS, it will be tested semiannually."
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R12-1C After, reviewing CH-SY-004 which is utilized to perform PASS functional tests, NQA recomnends that the above reference to the FSAR be included within Section 2.0 (References). In addition, as committed to in NEP Open Items Tracking No.87-289 Chemistry needs to incorporate the test frequency within Section 1.0 (Purpose) of CH-SY-004 during its next revision.
- 67. FSAR, Rev. 35, Table 1.8-1 (SSES Project Glossary of Terms), Sheet 28, defines surveillance frequency in part as, "The operating cycle interval as pertaining to instrument and electrical surveillance shall never exceed 15 months."
NQA recommends that Licensing personnel evaluate the impact of this requirement in light of ihe fact that SSES operates on an 18 month fuel cycle.
- 68. During NQA review of NEP Open Items Tracking (OIT) Items, NQA noted that the below-listed observations/recoranendations all relative to the EOF Chemistry Lab from last year's audit of the emergency plan (Audit 86-088) 'are still open:
Observation/Recommendation No. NEP OIT Item No.
3 87-304 6 87-305 8 87-297 9 87-296 10 87-299 NQA recommends that these items be evaluated in a more timely manner to ensure that noted .deficiencies are corrected in an expeditious fashion in order to not compromise the emergency preparedness of the EOF Chemistry Lab to function, if warranted.
- 69. While reviewing the disposition to NEP OIT Item No.87-300, NQA noted that EP- IP-047, Rev. 5, Para. C. 1.3 has the following typographical error under the sample vial dose rate column: 8-12 should be 8-120.
NQA recommends that NEP ensure that this error be corrected during the next revision of EP-IP-047.
Unusual Event -- In'ured/Contaminated Personnel
- 70. While reviewing the documentation associated with the activation of the emergency plan on 1/13/88, NQA noted that Form EP-IP-002-1 is not readily adaptable for upgrades/downgrades, termination and/or static updates.
NQA recommends that NEP consider modifying the form as follows:
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R12-1C Change "A. The INCIDENT was declared as a(n):"
to "A. The INCIDENT was (declared, upgraded/downgraded, terminated, static updated) as a(n):"
This would allow the form to be more readily adaptable for all the conditions that might be encountered upon activation of the emergency plan which wou)d require emergency notifications.
- 71. While reviewing the documentation associated with the activation of the emergency plan on 1/13/88, NgA noted that the unusual event was terminated based on the time the ambu'lance left site enroute to the Berwick Hospital. A similar unusual event occurred on 3/21/86 and was terminated based on the same criteria (i.e. the ambulance leaving site enroute to the hospital). NgA believes that the termination of the unusual event should occur at the time the contaminated individual is decontaminated and the subsequent completion of the following Health Physics responsibilities as stated in EP-IP-006:
o Survey ambulance and release when clean, o Frisk ambulance attendants and release when clean.
o Survey hospital receiving and treatment areas and release when clean.
o Frisk medical personnel and release when clean.
o Collect any protective clothing used and any potentially contaminated materials and return to SSES.
In both of the above, cases, the unusual event should not have been terminated until all the above HP action were completed.
Decontamination and surveys took place at the Berwick Hospital.
- 72. While reviewing the action step associated with terminating an emergency condition, NgA noted that Para. A.3.6 of'P-IP-002, Rev.
8 states, "The PSA Supervisor is instructed to collect all emergency records and enter into SRMS."
Per discussion with the P8A supervisor, NgA was informed by him that this statement only applies if the TSC is activated and applies only to those records generated by TSC personnel.
NgA,disagrees with his interpretation based upon the superintendent of plant's requirement within EP-IP-038 (Reconstruction and Accident Close Out) to prepare a report following activation of the emergency plan. In order to prepare this report, it would be beneficial to utilize all the emergency records generated during the emergency.
NgA recommends that all the EP-IPs contain a final statement in those action steps which require the completion, of forms similar
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R12-1C to: Forward emergency records to PSA supervisor for submittal to SRMS. This item is a repeat of a condition previously identified in prior audit 85-119 finding number 1.
- 73. While reviewing the documentation associated with the activation of the emergency plan on 1/13/88, NgA noted that Forms EP-IP-006-1 and
-2 were not completed; however, .N(A found the following documentation which includes some but not all of the required information -from those forms:
o Attachment F (SSES First Aid Data Sheet), SP No. 12, Rev. 3 contains information required on Form EP-IP-006-1, Rev. 0, Page 1 of 2.
o Hospital Form (Contaminated Victim'ketches), Rev. 1 (February 1984) contains information required on Form EP-IP-006-1, Rev. 0, Page 2 of 2.
o Form SY-00-033-5 (Emergency Response Form), Rev. 0 and PPSL Form 3104 (SSES-Area Survey Map, 9/84) contain information required on Form EP-IP-006-2 (Ambulance Medical Emergency Data Sheet),
Rev. 0, Page 1 of 2 except SRD number, reading and finger rings.
o Hospital form (Personnel Dosimetry Log), Rev. 1 (February 1984) and Order Sheet of the Berwick Hospital Corporation contain information required on Form EP-IP-006-2 (Hospital Medical Emergency Data Sheet), Rev. 0, Page 2 of 2.
Based on N(A investigation of the reason for the failure to utilize EP-IP-006 forms listed above, NgA found that the reason is a result of not requiring these forms to be included in the emergency supplies at the appropriate locations as listed below:
o Form NSI-2.2. I (Ambulance Emergency Equipment Kit), Rev. 2 does not require Form EP-IP-006-2, Page 1 nor a copy of EP-IP-006 to be present.
o Form NSI-2.2.2E,F (Berwick Hospital, Geisinger Medical Center Radiation Emergency Equipment and Supplies), Rev. 1 does not require Form EP-IP-006-2, Page 2 nor a copy of EP-IP-006 to be present.
NgA recommends that these NSI inventory forms be changed to require the above-listed EP-IP forms and procedure to be present at the above-listed locations.
In addition, NgA recormends that the following items be added to Forms NSI-2.2.2E,F since the individual by definition will not be decontaminated prior to leaving site:
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R12-1C o Copy of HP-TP-624 o Personnel Contamination Reports Form AD-00-720-2 o Blank Area Survey Maps o Form EP-IP-006-1, Page 2 Finally, NQA recommends that NEP evaluate the possibility of utilizing a two-page carbon copy style form similar to First Aid Data Sheet (Attachment F of SP No. 12, Rev. 3) to avoid unnecessary duplications .of efforts by emergency response personnel (i .e .
Security, first aid team, Health Physics, hospital personnel, etc.)
and to ensure that all parties receive documentation of emergency records, especially in the case of ambulance and hospital personnel concerning the nuclear liability concerns if at a later date a radiation-induced cancer lawsuit were to surface. The latter part of this recommendation is based upon the fact that no documentation exists to substantiate the ambulance attendants and hospital medical personnel were frisked and determined to be clean prior to release following the event on 1/13/88. NQA verified through discussion with representatives of both organizations that indeed Health Physics personnel did perform such a frisk. The following suggestions are offered:
o Modify Security Form SY-00-035-5 to include all information required of Form EP-IP-006-2, Page I and utilize a three-page carbon copy style form for Security, Health Physics and ambulance records. In addition, it may be beneficial to record both initial and final SRD readings. Finally, it should al'low for easier documentation of ambulance attendants personnel contamination surveys prior to release. Similarly a copy of the area .survey map should be given to ambulance attendants, if utilized' Utilize a two-page carbon copy style form for Health Physics and hospital records of Form EP-IP-006-2, Page 2. Discontinue use of ho'spital form (Personnel Dosimetry Log) and Order Sheet of the Berwick Hospital Corporation. Finally, it should be modified to allow for easier documentation of hospital medical personnel contamination surveys prior to release. Similarly, a copy of the area survey map should be given to hospital personnel, if utilized.
o Discontinue use of Form EP-IP-006-1, Page I and instead refer to Attachment F, SP No. 12 for utilization during all first aid response (i.e. contaminated as well as non-contaminated victims).
o Discontinue use of hospital form (Contaminated Victim Sketches),
Rev. 1 (February 1984) and utilize a two-page carbon copy style form for Health Physics and ambulance/hospital records of Form EP-IP-006-i, Page 2.
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R12- IC 74 . While reviewing EP-IP-006, Rev . 1 in conjunction with reviewing documentation from the unusual event of 1/13/88 and discussing implementation with affected personnel, NgA has the following questions:
~Para ra h uestion/Basis for uestion B. l. 7 Does this mean that Security is responsible for issuing SRDs and/or finger rings from ambulance kit and completing Form EP-IP-006-2, Page 1?
Presently Form EP-IP-006-2, Page 1 doesn't get completed.
0,2.10 Is it necessary to replace victim's and any responding personnel 's dosimetry prior to leaving site on ambulance? Presently, it doesn't appear to happen.
D.4.1.c Shouldn't sentence start off, "Collect dosimetry and ... "? Refer to Para. D.4.6 for similar step in reference to medical personnel.
D,4.1.d Should sentence have word "personnel" after he1icopter? Refer to Para. D.4. 1 which states personnel.
NgA recommends that NEP evaluate these questions and take necessary actions to ensure corrections are made, as warranted.
In addition, NgA recommends that the following steps be added after Para. 0.4.7:
o Restock depleted items in ambulance and/or hospital emergency kits.
o Forward emergency records (i.e. Forms EP-IP-006-1,2) to PSA supervisor for submittal to SRHS.
- 75. While reviewing the documentation associated with the unusual event on 1/13/88, NgA compared observations/recommendations 70-74 against the evaluations performed during, 1) the last similar actual event on 3/21/86, and 2) the last similar drill on 1/20/88. NgA found that no similar comments were included relative to NgA concerns, especially related to the lack of documentation on Form EP-IP-006-1,2. To the contrary, in the drill critique report the following is found:
~0b ective Score (1-Satisfactory)
Demonstrate the adequacy CR-1 (No other category
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R12-1C of the SSES Emergency Plan for field personnel) and implementing pro-cedures applicable to the scenario.
B.S Demonstrate proper record- CR-1 (No other category keeping and data display for field personnel) in emergency response faci 1 i ties.
C.g Demonstrate proper radi- CR-1 (No other category ation exposure record- for field personnel) keeping for emergency personnel.
Per discussion with an NQA individual who was an HP in-plant referee during the above drill, he stated as noted in QASR 88-012 LHealth Contaminated Injury (Drill)] that completion of Form 'hysics:
EP-IP-006-1 was not done during the drill but was stated to have been in progress at drill termination. In addition, NQA could not find any mention of similar documentation problems upon examination of the last actual event evaluation.
NQA recommends that NEP consider one and/or both of these options to ensure that drills and/or actual emergency plan activations are evaluated for completion of required documentation:
o Ensure the completion of required documentation during the simulation of an emergency condition. Referees should=evaluate this as one of their objectives.
o Evaluate the completion of required documentation during the followup evaluation of actual emergency plan activations.
Observations Ori inall Classified as Findin s Ref.Section VII
- 76. Emergency Plan Rev. 10 Para. 9,1,2 requires an annual full scale alarm notification system (ANS) test.
Although the test was conducted as required, the PHIS system history file for worklist item X0053 shows no performance in 1987.
Note that the PH History File shows that this activity was waived on 2/12/87 with a schedule next due date of 2/12/88.
The lack of attention to detail casts an unfavorable shadow on an otherwise acceptable area. Even though the testing was conducted thoroughly, PHIS was not updated and no formal ANS testing records were forwarded to SRMS. NQA recommends that PMIS be appropriately updated,
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R12-1C
- 77. Emergency Plan Rev. 10 Para. 9. 1.2 requires PPSL to have procedures to assure timely implementation of corrective actions for deficiencies identified during drills.
arear'he Contrary to the above, PPhL has an inadequate procedure established in, this, impact on quality is that drill deficiencies may not be closed in a timely manner. This concern is compounded since drill deficiencies are not entered into a formal tracking program and do not receive visibility of upper management.
NgA recommends that NEP fortify existing procedures to assure that drill deficiencies are adequately controlled.
- 78. NSI 3.7 Rev. 0 requires SHEP to update the Emergency Telephone Directory, the Near-site Monitoring Team Call-in List, and the Offsite Monitoring Team Call-in Lists quarterly.
Contrary to the above, evidence could not be presented to show that the lists are updated quarterly. HEP personnel indicated that the telephone directory is updated every 6 months and that the monitoring team call-in lists are updated annually.
Failure to update the lists could result in delays and confusion resulting when it is necessary to call in personnel to support the E. Plan. The E. Plan requires that onsite and offsite HEROs be manned within 30-60 minutes of notification.
- 79. NSI 3.7 Rev. 0 requires the update, of the Supplemental Support List, Emergency Telephone Directory, and Monitoring Team Lists to be scheduled and documented via PMIS.
Contrary to the above, the update activities have not been entered into PMIS. The lack of entering the update of the lists into PMIS has resulted in an update system which has not performed we11.
The audit team recommends that these'ists be updated in accordance with the frequencies defined in NSI 3.7.
- 80. Emergency Plan Rev. 10 Appendix A requires the Manager-Nuclear Support to renew letters of agreement every 2 yrs.
A review of historical records in this area revialed that in the past not all letters of, agreement were renewed within 2 years.
Currently all required letters are on file. NEP personnel are remineded of this requirement and it is recommended that better compliance be achieved during subsequent updating of letters of agreements.
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R12-1C
- 81. NDI-6.6.2 and NDI-QA-10.3.1 specify the training and retraining requirements established for personnel assigned to the emergency organization.
Contrary to the above, examples were noted of failure to meet the training/retraining requirements. Felock {TSC Coordinator) did not complete'P040 and Figard (18C Coordinator) did not complete EP001 or EP054.
Failure to meet the training/ retraining requirements could result in a poorly functioning emergency organization.
NgA recommends that these individuals be removed from the on-call rotation until all required training is completed.
- 82. E. Plan Rev. 10 section 6.0 requires the onsite NERO and offsite NERO to be manned within 30-60 minutes of notification.
Contrary to the above, a review of the monthly call out test results resulted in numerous cases of the on-call individual not responding.
Sased on a review of results of the monthly call-out test for 11 months in 1987, there were approximately 154 cases where the assigned on-call individual did not respond. {Of th'ese 154, 37 were caused by beeper failures.)
The above results appear to sugggest that the call-out process is not effectively being implemented. {Note: Forty-one people are on the list, therefore failure rate is approx. 154/41 x 11 or 33K.)
In no given month was the success rate 100K.
Additionally there were:
o Nine cases where alternates appeared not to have been contacted.
o Three cases where home phones had been disconnected.
o Five cases where the individual was onsite but did not respond.
o One case noted where the seventh alternate had to be contacted.
o Several cases of answering machines answering but not the individual, The impact on quality is. the inability to staff the E. Plan personnel requirements in the time limits established in the E.
Plan during an actual emergency condition.
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R12-1C VII. Action/Taken/Re uired The audit findings and observations/recommendations were presented and discussed at an exit meeting held on February 9, 1988. There was general agreement among those present. However, the Manager Nuclear Services stated that he felt that no findings could be written which were based solely on an NSI requirement which does not have a QA designator in its procedure number. The Manager Nuclear Services also stated that he realized this issue could not be resolved at the exit meeting and that he would discuss the issue further with the Manager-NQA. It should be noted that none of the NSIs which deal with Emergency Planning have a QA designator. It also should be noted that firm requirements which exist in 10CFR50.47, 10CFR50 Appendix E, Emergency Plan, FSAR, or Technical Specifications were used as a basis for the findings. If an NSI is written as an implementing procedure for these upper tier licensing documents then it appears that the NSI should have a QA designator.
A meeting was held on March 4, 1988 attended by Manager Nuclear Services, Manager NQA, and Supervising Engineer-NQA Auditing to discuss the above issue raised by the Manager Nuclear Services. At this meeting, each of the fourteen audit findings were reviewed in detail.
Sased on this review, several audit findings were reclassified as observations based on determinations that the cited conditions were either administrative breakdowns of NSI requirements, repeat conditions of previously identified anomalies already documented as NQA audit findings, or had no quality impact even though procedural noncompliance was noted. The following summarizes the final status of each of the fourteen previously documented findings:
Ori inal Findin Current Status 87-085-01 AFR $ 87-085-01 87-085-02 Observation 876 87-085-03 AFR f87-085-02 87-085-04 Observation 877 87-085-05 AFR 887-085-03 87-085-06 Observation 078 87-085-07 Observation 479 87-085-08 AFR 887-085-04 87-085-09 Observation 880 87-085-10 Rolled into observation 823 87-085-11 Observation 881 87-085-013 Observation 882 87-085-014 AFR 887-085-06 Another finding dealing with the testing frequency for the PASS was discussed at the exit meeting and was subsequently downgraded and factored into observation/recommendations 064,65,66, and 67. The required frequency of testing is specified in the FSAR as semi-annual.
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R12-1C No tolerance is specified in the FSAR and no clear definition has been established. Testing of the Unit 1 PASS exceeded both the commonly understood definition (6 months) and the Tech Spec tolerance of +25~.
Also the PASS test procedure does not have a frequency written in the procedure nor does it reference that the test is required by the FSAR.
The test is not scheduled by PNIS and completed test records have not been consistently forwarded to DCC. The Chemistry Supervisor stated comp'l,iance with the 25% tolerance allowed by the Technical Specifica-tions was not a viable requirement since the test is required by the FSAR and not the Technical Specifications.
The response to these audit findings should be made in block f8 of the attached finding sheets and should be provided within 30 days of issuance of this report. If corrective action cannot be completed within this time frame, the response should outline proposed actions with target dates for completion.
Prepared by: (w>+Ae@/X r ~
D. . e e anger Coordinating Engineer - Audit Team Leader Approved by:
C. R. M Supervising Engineer - NgA drh/crw/meblgc(20): nf
NUCLEAR QUALITY ASSURANCE RUDXT FXNDXNG SHEET
- 1. REPORTEO BY: D.R. Heffelfin er DATE:
- 2. AGTIYITY BFING AUDITED: mer enc annwfn FINOING NO:
- 3. ORGANIZATION/LOCATION: N E a e I of 2 S. CONTROLLING DOCUMENT ANO REQUIREMENT:
10CFR 50.47(b) states in part, "The onsite and offsite emergency response plans for nuclear power reactors must meet the following standards ... (No.
- 16) Responsibi li ties for plan development and review and for distr ibution of emergency plans are established, and planners are properly trained."
(Continued ...)
- 7. ii3ESCRIPTION OF FINDING:
A. A review of controlled manuals of the E. Plan revealed that none have been stamped "controlled."
B. A review of controlled documents revealed that several copies of the E.
Plan are out of date. Examples were copy no. I assigned to supervisor of OPS (shift supervisor office) at Rev. 6, TSC library at Rev. 9 (copy no.
69), and HP van at Rev. 9. Correct rev. level is Rev. 10 dated 12/86.
C. The distribution list of the E. Plan does not contain all controlled copies at SSES. The distribution list for the E. Plan has not been periodically reviewed by the SNEP.
Note: This is a repeat of Audit Finding 85-119-03.
ACTION REQUIRED: . CORRECT CONOID ION .
nOORESS PREVENTION OF RECURRENCE B. ACTION TAKEN BY RESPONSIBLE ORGAN'ZATION:
COGNIZANT MANAGER DATE
- 9. PL NQA VERIFICATION OF ACTION TAKEN - COMMENTS:
VERIFIEO BY: DATE:
NQAP FORM 9.1-2 REV. 2
AUDIT FINDING SHEET Finding No, 87-O85 O1 Page 2 of 2
- 6. CONTROLLING OOCUMENT ANO REQUIREMENT: (Continued ...)
NSI-3.6, Rev. 0, Para. 6. 1.5, (. 1) states that copies of the emergency plan issued to controlled manuals or satellite files shall be red-stamped "controlled." (.2) states that satellite files containing controlled copies of the E. Plan shall be maintained by SRMS. -(.3) states that distribution lists of controlled copies of the E. Plan shall be maintained by the SNEP.
The SNEP shall also periodically review the accuracy of distribution lists.
NUCLEAR QUALITY ASSURANCE AUDIT FINDING SHEET
- 1. REPORTEO BY: D.R. Heffelfin er OATE:
- 2. AcTIYITY BEING AuoI TEo: merqenc annin . FINDING NO:
- 3. ORGANIZATION/LOCATION: uc ear rainin S pa e 1'o ction arty: uc ear raining 8 . CONTROLLING OOCUMENT ANO REQU I REMEN T:
A. NTP-QA-53.1, Rev. 3, Para. 6.5.8 states that all dril ls (fire brigade) shall be documented on Form NTP-QA-53. 1A.
E. Plan Rev. 10 .Para. 9. 1.2 requires a quarterly fire drill.
(Continued ...)
- 7. OESCRIPTION OF FINOING:
A. Contrary to the above, no completed forms NTP-QA-53. 1A could'be located for courses:
FB 004 First Quarter Drill 1987 FB 005 Second Quarter Drill )987 FB 007 Fourth Quarter Drill 1986 B. NTP-QA-53. 1, Rev. 3 reached the procedure expiration date on 8/29/87. The required 2 year review has not been completed. Also, a new coversheet has not been issued with a revised expiration date.
ACTION REQUIREO: CORRECT CONOITION AOORESS PREVENTION OF RECURRENCE B. ACTION TAKEN BY RESPONSIBLE ORGAN:ZAT ION:
COGNIZANT MANAGER OATE
- 9. PL NQA VERIFICATION OF ACTION TAKEN COMHENTS:
VERIFIEO BY: OATE:
NQAP FORM 9.1-2 REV. 2
AUDIT FINDING SHEET Finding No. 87-085-O2 Page 2 of 2
- 6. CONTROLLING DOCUMENT AND REQUIREMENT: (Continued ...)
- 8. NTP-QA-21.1, Rev. 3, Para. 6.a.2 states that NTPs and STCPs should be reviewed every 2 years. Procedures which do not require a revision will have a revised expiration date entered on the coversheet.
NUCLERR QUALITY ASSURRNCE AUDIT FINDING SHEET
- 1. REPORTED BY: K. R. Leone 4, ORTE; 2/22/88
- 2. ACTIVITY BEING AUOITEO: mer en Pl annina
- 3. ORGANIZATION/LOCATION:
- 6. CONTROLLING DOCUMENT ANO REQUIREMENT:
NDI-gA-10.3.1, Rev. 6, Para. 6.3.1.6 states, "All emergency organization lists will be updated to ensure that proper emergency staffing is always available."
NSI 3.7, Rev. 0, Para. 6.2.1 states, "The Manager-NA shall update the
-Supplemental Support List annually."
- 7. DESCRIPTION OF FINDING:
Contrary to the above, the Supplemental Support List (SSL) was not updated in 1987.
RCT!ON REQUIRFO:
ADDRESS PREVENTION OF RECURRENCE B.,ACTION TAKEN BY RESPONSIBLE ORGANIZATION:
COGNIZANT MANAGER S. PL NQA VFRIFICATION OF ACTION TRKEN COMMENTS:
VERIFIEO BY: DATE:
NQAP FORM S.1-2 RFV ~ 2
NUCLEAR QUALITY ASSURANCE RUDlT F'INDXNG SHEET 1 . REPORTEO BY: K.R. Leone ann>no A. DATE:
- 5. FINDING NG:
'- /Il
- 2. ACTIVITY BEING AUOITEO: mer enc 3 . ORGANI ~ATION/LOCATION: SNEP
- 8. CONTROLLING OOCUHENT ANO REQUIREHENT:
NDl-gA-10.3.1, Rev. 6, Para. 6.3.1.3 states, "The Primary Contact Lists will designate the lead individuals to filI the emergency management positions listed in Attachment 1, In the event of an emergency, an attempt will be made to contact these people as described in EP-IP-018. These lists must be approved by the Senior Vice President-Nuclear."
- 7. OESCRIPTION OF FINOING:
Contrary to the above, the present TSC/EOF Primary Contact List (Rev. 4) has not been approved by the senior vice president-Nuclear.
ACTION REQUIREO: . CORRECT CONOITION AOORESS PREVENTION OF RECURRENCE
- 8. ACTION TAKEN BY RESPONSIBLE ORGAN:ZATION:
COGNIZRNT HANAGER OATE 9 ?L NQA VERIFICATION OF ACTION TAKEN COHHENTS:
VERIFIEO BY: OATE:
QAP F ORH 9. 1-2 REV . 2
NUCLEAR QUALITY ASSURANCE RuoIT fINDIblG SHEET Pa e 1 of 2
- 1. REPORTED BY: K. R. Leone
- 2. ACTIVITY BEING AUDITED:
- 3. ORGANIZATION/LOCATION:
- 6. CONTROLLING DOCUMENT AND REQUIREMENT:
A. NDI-6.6.1, Rev. 4, Para. 7.0 "Records" states, "The following records shall be submitted to the SRMS in accordance with the SRMS procedures to be retained for the period of time as established by applicable departmental,,or regulatory requirements." corporate, (Continued on Page 2 of 2) 7 . DESCRIPTION OF FINDING:
Contrary to the above, EP-IP biennial reviews, periodic reviews and revision reviews are not documented on NDI-qA-8. 1.3A forms.
There are no NDI-(A-8.1.3A forms available to evidence reviews of any EP-IPs.
ACTION REQUIRED:
ADDRESS PREVENTION OF RECURRENCE
- 8. ACTION TAKEN BY RESPONSIBLE ORGANIZATION:
COGNIZANT MANAGER S. PL NQA VERIFICATION OF ACTION TAKEN - COMMENTS:
VERIFIED BY: DATE:
NQAP FORM 8.1-2 REV ~ 2
AUDIT FINDING SHEET Finding No. 87-085-05 Page 2 of 2
- 6. CONTROLLING DOCUMENT AND REQUIREMENT: (Continued ...)
Para. 7.2 states, "Comments and resolutions thereof generated during the review of the PPSL SSES Emergency Plan and Emergency Plan Implementing Procedures. These records are retained as evidence of proper completion of review and shall be maintained in accordance with SRMS requirements.
'Only the most recent revision should be retained; earlier revisions may be destroyed."
B. NSI-3.6, Rev. 0, Para. 6.22 "EP-IP Reviews" states "Periodic Reviews Periodic review shall be in accordance with AD-(A-101.
Biennial Reviews At least biennially, the SNEP shall ensure that all EP-IPs are updated in the following manner:
The LTR shall coordinate and document a formal review I
of the EP-IP using Form NDI-gA-8. 1.3A.
Revisions (Perm Chan es) The SNEP shall ensure that the EP-IP is processed in accordance with AD-gA-101 and forwarded to the EPPSC.
Issuance EP-IPs will be issued in accordance with AD-gA-101."
C. AD-gA-101, Rev. 15, Para. 6.6.1, "Procedure Preparation" states in part, "Originators/Preparers shall: ... Forward procedure to reviewing groups and resolve comments made during the review process. Document the review on Document Review Form NDI-(A-8. 1.3A.
D. NDI-gA-8.1.3 is not applicable in its entirety as evidenced by Para. 2.0, "Scope," below:
"This instruction applies to quality-related documents identified in Attachment 1. The review requirements and/or forms of this instruction may be used to perform other reviews (e.g. to comply with requirements of OPS-9); however, if so used appropriate functional unit procedures shall reference the applicable provisions."
The procedure referenced above only references Form NDI-gA-8.1.3A.
NUCLEAR QUALITY ASSURANCE AUDIT FINDING SHEET
~2!
- 1. REPORTED BY: 0. R. Heffel finger
- 2. ACTIVITY BEING AUDITED:
- 3. ORGANIZATION/LOCATION:
- 5. FINDING NO: ~~~
- 6. CONTROLLING DOCUMENT AND REQUIREMENT:
EP-IP-038, Rev. 2, Reconstruction and Accident Closeout, requires the issuance of reports by the superintendent of plant, manager NSAG, Chem/HP supervisor, Rad and Environmental Services supervisor. The VP Nuclear Operations is required to review and approve all reports associated with an emergency, and to implement a followup corrective action program as appropriate.
- 7. DESCRIPTION OF FINDING:
A. After the fol'lowing accident events, the required reports were not prepared. Also review and approval by the VP Nuclear Operations could not be shown.
ACTION REQUIRED: 'ORRECT CONDITION ADDRESS PREVENTION OF RECURRENCE
- 8. ACTION TAKEN BY RESPONSIBLE ORGANIZATION:
COGNIZANT MANAGER DATE S. PL NQA VERIFICATION OF ACTION TAKEN <<COMMENTS:
VERIFIED BY: DATE:
NQAP FORM F 1-2 REV ~ 2
AUDIT FINDING SHEET Finding No. 87-085-06 Page 2 of 2
- 7. DESCRIPTION OF FINDING:
Event Condition Date Contaminated Injury Unusual Event 03/21/86 Steam Line Plug Unusual Event 09/23/87 Ejection B. There does not seem to be a consistent mechanism for evaluating the performance and implementation of the E. Plan on "the day after" an event has occurred. AD-gA-415, "Post Reactor Transient/Scram/Shutdown Evaluation," was partially used for the steam line plug ejection event but was not used for the ESW pump degradation alert.
RUOIT CHECKLIST ORGANIZATION AUDIT/LOCATION: 3. AUDIT AREA 4 PREPARED BY/DATE CHECKLIST NO./REV is lr ry i ip'.
Em~emc'f t t-~N S. RE IQlkD 8 /DAT 7. PAGE 1 OF Be 10.
CHAR. REFERENCE NO. 9. AUDIT CHARACTERISTIC DOCUMENT 11. COMMENTS
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Dear Tom:
V There are two courses worthy of your participation prior to the 1986 Exercise for Susquehanna SES. These are: Dose Assessment and Protective Actions and Emergency Classification. For ease of attendance and since these courses go hand in hand, they are always provided on the same day - the first in the morning and the'econd in the afternoon.
These will be offered *twice before the practice exercise:
Date Location
- February 5 8:00 am 12:00 noon Allentown 1:00 pm - 4:00 pm
- February ll 8:00 am - 12:00 noon Susquehanna Training Center 12:30 pm - 3:30 pm March 14 8:00 am - 12:00 noon Susquehanna Training Center 12:30 pm - 3:30 pm To schedule for any of these courses you can contact me directly or call Linda Oberrender, HTG Scheduler, at the training center, 717-542-3506.
Charles R. Wike, Jr.
Supervisor-Nuclear Emergency Planning CRW/mm cc: L. Oberrender SSES/NTC
RUOIT CHECKLIST (>/g Q PP8L COtfKNT CONTINUATION SHEET AUOIT NO.
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