ML18152A070

Submits Summary of 970311 Meeting in Atlanta,Ga to Discuss Issues Re Insp of Implementation of 10CFR50.65.List of Attendees & Matl Used in Presentation Encl

ML18152A070
Person / Time
Site:	Surry
Issue date:	03/17/1997
From:	Belisle G NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION II)
To:	Ohanlon J VIRGINIA POWER (VIRGINIA ELECTRIC & POWER CO.)
References
EA-97-055, EA-97-55, NUDOCS 9703280002
Download: ML18152A070 (49)

Text

March 17, 1997 EA 97-055 Virginia Electric and Power Company ATTN:

Mr. J. P. O'Hanlon Senior Vice President Nuclear Innsbrook Technical Center 5000 Dominion Boulevard Glen Allen, VA 23060

SUBJECT:

MEETING

SUMMARY

- PREDECISIONAL ENFORCEMENT CONFERENCE SURRY NUCLEAR STATION - DOCKET NOS. 50-280, 50-281.

Dear Mr. O'Hanlon:

This refers to the meeting conducted at th~ NRC Region II Office in Atlanta, Georgia on March 11, 1997.

The meeting's purpose was to discuss the issues related to our inspection of your implementation of 10 CFR 50.65, "Requirements for Monitoring the Effectiveness of Maintenance at Nuclear Power Plants."

.In accordance with Section 2.790 of the NRC's "Rules of Practice," Part 2, Title 10 Code of Federal Regulations, a copy of this letter and its enclosures will be placed in the NRC Public Document Room.

Should you have any questions concerning thi~ letter, plea?e contact us.

Docket Nos. 50-280, 50-281 Lice~se Nos. DPR-32, DPR~37

Enclosures:

1. list of Attendees Sincerely,

. Original signed by George A. Belisle George*A. Belisle, Chief Reactor Projects Branch 5 Division of Reactor Projects

2.

Predecisional.Enforcement Conference Handout

• 91 u9~G

3.

NRC Predecisional Enforcement Conference Handout

'"'cc w/encls:

M. L. *Bowling, Manager Nuclear Licensing & Operations Support Virginia Electric & Power Company Innsbrook Technical Center 5000 Dominion Boulevard Glen Allen, VA 23060

. cc w/encls continued: See page 2 9703280002 970317 PDR ADOCK 05000280*

G PDR

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I VEPCO cc w/encls: Continued David A. Christian, Mana~er Surry Power Station Virginia Electric & Power Company 5570 Hog Island Road Surry, VA 23883 W. R. Matthews, Manager North Anna Power Station P. 0. Box 402 Mineral, VA 23117 Ray D. Peace, Chairman Surry County Board of Supervisors P. 0. Box 130 Dendron, VA 23839 *.

Dr. W. T. Lough Virginia State Corporation Commission Division of Energy Regulation

• p. 0. Box 1197 Richmond, VA 23209 Michael W. Maupin Hunton and Williams Riverfront,Plaza, East Tower

. 951 E. Byrd Street Richmond, VA 23219 Robe'rt B: Strobe. M. D., M. P.H.

State Health Commissioner.

Office of the Commissioner Virginia Department of Health P. 0.

• Box 2448

.. Richmond, VA 23218 Attorney General Supreme Court Building 900 East Main Street Richmond, VA 23219 Distribution w/encls:

See* page 3

2.

VEPCO Distribution w/encls:

G. Edison.- NRR J. Lieberman, OE B. Summers, OE (2 letterhead copies)

R. Gibbs, RII P. Fill ion, RII D. Jones, RII W. Stansberry, RII C. Payne. RII PUBLIC NRC Resid~nt Inspector U.S. Nuclear Regulatory Commission Surry Nuclear Power Station 5850 Hog Island Road Surry, VA 23883 NRC Resident Inspector U.S. Nuclear Regulatory Commission 1024 Haley Drive Mineral, VA 23117.

FFI II* D P RII

• I SIGNATURE ~

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3 03 /

/ 97 03 /

/ 97 03 /

/ 97 YES NO YES NO YES

• NO :

LIST OF ATTENDEES NRC Attendees:

L.A. Reyes, Regional Administrator, Region II CRII)

J. P. Jaudons, Director, Division of Reactor Safety (DRS), RII D. M. Verrelli, Technical Assistant, DRS, RII W. E. Holland, Acting Chief, Maintenance Branch, DRS, RII B. Uryc, Director, Enforcement and Investi'gation Coordination Staff (EICS),

RII L. J. Watson, Senior Enforcement Specialist, EICS, RII C. F. Evans, Regional Counsel, RII F. M. Reinhart, Acting Director, Project Directorate II-1. Office of Nucle'ar Reactor Regulation (NRR)**

G. E. Edison, Senior Project Manager,.Project Directorate Il-1, NRR R. P. Correia, Chief, Reliability and Maintenance Section, NRR G. A. Belisle, Chief, Reactor Projects Branch 5, Division of.Reactor Projects CORP), RII R. A. Musser, Senior Resident Inspector, Surry Power Station L. W. Garner, Project Engineer, DRP, RII**

P. M. Byron, Resident Inspector, Surry Power -Station**

R. D. Gibbs, Reacto"r Inspector, DRS, RII Licensee Attendees:

J. P. O'Hanlon, Senior Vice President, Nuclear Power M. R. Kansler~ Vice Presideht, Nuclear Operations T. M. Williams, Manager, Nuclear Oversight L. N. Hartz, Manager, Nuclear Engineering _and Services

• D. A. Christian, Station Manager, Surry W. R. Matthews, Station Manager, North Anna J. H. *McCarthy, Assistant Station Manager, Operations*and Maintenance, Surry D. A. Sommers, Supervisor, Corporate Licensing C. G. Lovett, Supervisor, Station Licensing

• • Attended by Telephone ENCLOSURE 1

• . Pre-Decisional*

• Enforcement* Conference March 11, 1997 ENCLOSURE 2

Opening *Comments J.P. O'Hanlon

• . Senior Vice-President Nuclear SURRY POWER STATION "Nuelear Safety First" e

• Management Perspective M. R. Kansler Vice-President* *

• Nuclear Operations SURRY POWER STATION "Nul'lear Safety First" e

Agenda VIRGINIA POWER Opening Comments *

• J.P. O'Hanlon ManagementPerspective M. R. Kansler M.aintenance Rule J. H. McCarthy Self-Assessment.

Corrective Actions L. N. Hartz Conclusions M. R. Kansler Closing Comments J.P. O'Hanlon 4

SURRY POWER STATION

• "Nuclear Sctfety Fir.~t"

Management Perspective VIRGINIA POWER

• We have carefully evaluated the Maintenance Rule issues..

5

- Virginia Po~er failed to a:dequately implement the Rule, both at Surry and North Anna.

• Plant safety and materiel conditi_on are maintained at a high level The development and implementation of the Maintenance Rule were not up to Virginia Power's high standards

- The corrective action program is sound SURRY POWER STATION "Nuclear Safety Fir.~f" e

Management Perspective VIRGINIA. POWER

• fhe Maintenance Rule issues*can be grouped into e

6 three areas

- Weaknesses in the development of the program scope

• and process

- Inadequate implementation of the established program

.- Inadequate resolution of deficiencies identified during previous assessments

• SURRY POWER STATION "Nuclear Safety Firsf"

Management Assess.ment VIRGINIA POWER

• .We have examined our approach to Maintenance Rule program development and have conducted an independent assessment of the.management factors. The.following weaknesses were identified:

- Management knowledge of the implementing guidelines (NUMARC 93-01) ivas insuflicient

- There was a lack of manag~ment focus *

- Program ownership was not well developed

- JtanagemeTit oversight of program development was not adequate *

• 7 SURRY POWER STATION "Nu,*leur Sufety First"

Management Assessment VIRGINIA POWER

• The Maintenance Rule*implementation weaknesses are n*ot repres~ntative of other Virginia Power programs

• We are ensuring-that these weaknesses are*not present in other programs.

- ConfigurationManagement

- Enhancements to MOV Program (GL 96-05)

-- Severe Accident Management Guidelines

• The develop~ent of future programs *will be independently assessed 8

SURRY POWER STATION "N11C'lear Safety First"

~~

. Station Performance VIRGINIA POWER

• The performance. of the s_tation demonstrates that the maintenance program is effective 9

- Nuclear safety has always been and continues to be our focus Safety-related equipJ!lent performance has improved

- Plant equipment is well maintained. Materiel condition is very good

- Several complex equipment performance issues have been resolved * * *

- Goals have been established and corrective action plans have been developed for (a)(l) category SSCs

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SURRY POWER STATION "Nuelear Safety First" e

e*

VIRGINIA POWER Previous Maintenance Rule -

Assessments

• Recommendations from previous Maintenance Rule assessments were-not adequately managed

• These recommendations were* initially_ tracked

• outside of the corrective action program e

• Previous Maintenan~e Rule assessment

• e 10

_ recommendations were reviewed during the most recent team assessment and were addressed in the Maintenance Rule Team report

-~~t-~~~'. ~' *,.;.

SURRY POWER STATION "Nueletu-Safety First"

-~

VIRGINIA POWER Self-Assessment Program.

• Recent self-assessments are being reviewed to ensure any identified deviating conditions are

. being addressed through the corrective action progr_am

• The self-assessment program* has been clarified to ensure identified deviating conditions are I

I I I

e:

I I

I addressed through the corrective action program e

11 SURRY POWER STATION "Nuclear Sct{efy First"

Management's Commitment VIRGINIA POWER

• Virginia Power is committed to thorough, prompt

_ corrective actions and full compliance with the Maintenance Rule

• A dedicated recovery team has been established to re-validate *and, as necessary, revise the program for both Surry and North_Anna

• To ensure full co_mpliance, a_n independent follow-up assessment of the Maintenance Rule program will be conducted -

12 SURRY POWER STATION "Nut'lear Saf,!ly Fir.~#"

Maintenance Rule

• • Self-Assessment J. H. McCa~thy

.

• Assistant Station Manager

.Operations & Maintenance SURRY POWER STATION "N11deur Saft.>fy Fir.~f"

VIRGINIA POWER Pilot Program Self Assessment April1996..

Nuclear Oversight Maintenance Audit

• O~tober*1996 14 Maintenance Rule

.Chronology Nuclear Oversight Readiness Review July 1996-NEIMRule *

• workshop

• October 1996 Nuclear Oversight Follow,;.up

, August 1996 MRuleTeam Self-Assessment

.. November 1996 SURRY POWER STATION "Nuelear Safety First" e

-~

Maintenance Rule VIRGINIA POWER 10 CFR 50.65 NUMARC 93-01 Industry Guideline VPAP-0815 Maintenance Rule Program 15 SURRY POWER STATION "Nueleur* Safety First"

- I

Maintenance Rule VIRGINIA POWER

• . Scoping PSA, RAW, RRW e

• Performance Expert Panel Criteria

• Monitoring*

_Database, Programs

• Goal Setting Working Group, Programs e

• On-Line Critical Parameters, POD Maintenance

• Assessm.ents VPAP-0815.

16 SURRY POWER STATION "Nucleur Safety First"

. Self-Assessment Resul*ts VIRGINIA POWER

• s*urry Power Station is not in compliance with all of the requirements of the Maintenance Rule

• NUMAilC 93-01 methods _were not.fully used.

Scoping, p~rformance criteria, and monitoring were affected.

• Procedure compliaric*e issues were identified

• Previous**assessments were not_ effective 17 SURRY POWER STATION "Nudem* Scifefy Pir11f"

VIRGINIA POWER 18 (A)

VS *"H" bus Emergswgr Air Handler train (A)

VS "J" bus E mergswgr Air Handler train Example SW.Emergency SW Emergency SW "A" Train

• SW "B" Train

... 1,,

" ~

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.~ :.~ :;,:

Done SW Emergency SW "C" Train

[

Unit 1

• Risk Significant. _______ J SURRY POWER STATION "N1H*le11r Safety Fir*st" e

Example VIRGINIA POWER 19

.Elle f.dit

.System Description

Maintenance Rule Beports Help Why? 03/5/97 Changed from red to white due to placing in (a)(1) with some corrective actions com leted.

Performance Criteria:

<750 Hrs Unavailability or no MRFFs within any 12 month period End Date.

MarkNu~ber Qty MRFF MPFF

. I Review Comments...

I Functions...

I

• Boundary...

IScoping Comments,..

(::omments 021241.1997..... E:.~1!1.:::P..:::.~~......... *................................

...................... °... '... °..?.......... !............ *:.1-'r........... S..~.9.:':.~ ~ '1..... f..?..r...... °..:::.~~.!.:::.S.~.:.~.°..~...... * +

01/23/ 199?

1-SllJ-P-lA 0.00 N

N Started for 0-0PT-SliJ-001 11/02/1996 lSllJ-P-lA 92.?5 N

N TAGGED OUT FOR PUMP HAINTK 10/ 18/ l996 1-SllJ-P-lA 0.02 N

N Started *per OPT-SliJ-3 10/09/1996 1-SllJ-P-lA 0.00 N

N Started for O-OPT-SliJ-002 10/08/1996 1-SllJ-P-lA 3.. 13 N

N Tagged out fo.r suction bow 10/01/1996 1-SliJ-P-lA 0.00 N

N Started for O-OPT-SliJ-001 09/19/1996 1-SllJ-P-lA 4.58 N

N Tagged out for suction bow 09/19/1996 1-SllJ-P-lA 0.00 N

N Started following suction 09/ ll/ 1996 1-SllJ-P-lA 0.00 N

N Initially -

as found flow 09/ ll/ 1996 1-SllJ-P-lA 0.00 N

N Started for O-OPT-SliJ-001 09/05/1996 1-SllJ-P-lA 47.95 N

N Tagged out fcir troubleshoo +

Done SURRY POWER STATION "Nut"lear Safety First" e

VIRGINIA POWER

• S_coping

• Performance Criteria

• Monitoring

• Goal Setting

• On-Line Maintenance 20 Example: ESW Pumps

• Monitored* in the scope of the Rµle as a safety-related SSC Risk. significant SS<:

Pe~iodic t~st data is evaluated and trended Comprehensive* Level 1. action plan Critical safety parameters &

on-line maintenance matrix SURRY POWER STATION "Nudem* Safety First"

VIRGINIA POWER Example:

• Radiation Monitoring

• Scoping

• P_erformance*

Criteria

• Monitoring

• Goal Setting &.

Corrective Actions 21 Monitored in. the scope of the rule Non-risk significant SSC Plan_t vs. component level Radiation monitors are

• being replaced SURRY POWER STATION "NuC'le11r Safety f'irst" I

VIRGINIA POWER

• Maintenance Rule Team Actions

• Training

• Scoping

• Risk Significant SSCs revised

• (a)(IJ

• 36 month review

• Database

• Sargent & Lundy

22.

SURRY POWER STATION "N11de11r Safety First" e

Recommendations

• VIRGINIA POWER

• Re-analyze the*scope and: performance criteria to

. establish a monitoring program that' achieves full compliance

• Improve the knowledge level. to ensure that program requirements are consistently

. imp.lemented

• Identify.the management factors inv*olved 23 SURRY POWER STATION "Nul'leur Su.fety First"

Corrective Actions L. N. Hartz Manager

• Nucl~ar Engineering SURRY POWER STATION "Nudeur Safety Firsf"

Recovery Plan VIRGINIA POWER

• A dedicated recovery team has been established to re-validate and, as necessary, revise the

• Maintenance Rule program for both Surry and North Anna*

• - A subject*expert ~as been contracted to assist the

~am e

- A new expert pa_nel has been formed in accordance e

25 with NUMAR*C 93-01

- Training and certification have been completed for the expert panel SURRY POWER STATION "Nu,*letzr Scifety First" I.

I

. Recovery Plan VIRGINIA POWER I

\\

• A comprehensive action plan has. been developed, e

which addresses:.

- Previous assessment recommendations

- *Maintenance Rule Team Report

- Sargent & Lundy assessment'

- Inspection Report issues *

• The action plan will achieve and maintain full compliance with the Maintenance Rule for both Surry and North Anna 26 SURRY POWER STATION.

"NUt*lem* Safety First" e

\\I

Re*covery Plan Milestones VIRGINIA POWER Act~vity North Anna Surry Scoping*

March22 April.26 Historical Review

• April 5 May3 Risk Ranking April 5 MaylO Performance Criteria April 12 May17 Verify & Validate

• April 21 May26

• (a)(l) Determination May lOi June14 Training April 1 May6 Self-Assessment.

September 19

.September 19 27 SURRY POWER STATION "Nudea,* Safety First"

Initial Actions.

VIRGINIA POWER

• Initial corrective actions have focused on the issues

. identified at Surry VPAP-0815, Maintenance Rule Program, has been revised based on a detailed review of NUMAR,C 93-01 Per_formance criteria for specific systems have been revised (a)(l) evaluations for specific systems have been completed and goals have been*established e

VPAP-2001, Station Planning and Scheduling, has e

28 been revised to provide additional guidance for on-line maintenance

- ~anagement *instructions have been issued to reinforce the need for Maintenance Rule program compliance

• SURRY POWER STATION "Nueleur Safety First"

Performance Criteria VIRGINIA POWER EEi 97-01-03 Failu,-e to establish adequ~te performance criteria for monito_ring specific systems Actions

• Revised the Maintenance Rule program procedures

• Reviewed performance criteria for specific systems

• Issue supplemental guidelines for administrative procedures

• • Review Performance criteria for all.Maintenance Rule SSCs.

• Compare to actual performance and, if necessary, establish goals and corrective action 29 SURRY POWER STATION "Nuclear Safety Ji'ir.~f" e

e Procedures VIRGINIA POWER EEi 97~01-04

• Inadequate procedural requirements Actions

• Revised Maintenance Rule program procedure

• Issue supplemental guidelines for* administrative e

procedures

• Iss*ue additional guideliries, as necessary i

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30 SURRY POWER STATION "Nucleal" Safety l?il"st"

Historical Review VIRGINIA POWER

• EEi 97-01-05 Failure to accomplish adequate historical reviews Actions

• Established a recovery team

• Issue supplemental guidelines for administrative procedures

• Review and evaluate SSC historical. data.

31 Compare_ to performance criteria and, if necessary,.place in the (a)(l) category

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SURRY POWER STATION "Nm*le'1r Scifefy Ji'irsf" e

e

Goals and Monitoring VIRGINIA POWER EEi 97-01-06

. Goals and monitoring not established for ESW and ESG HV AC systems Actions

• Conducted (a)(l) evaluations and established goals for the ESW system and control room chillers*

• Established goals for ESG room air handlers

• Conduct a historical review of SSC data to ensure any othe~ discrepancies are identified *

• 32 SURRY POWER STATION "Nuclet1r Safety f,'i,-sf" e

Process Improvement VIRGINIA POWER EEi 97-01-07

• Performance criteria changed without approval of the.Working Group, Actions

• Obtained Working Group* approval for RPS performance criteria

• *

• Reinforced management's expectations for str.ict procedural compliance 33 SURRY POWER STATION "Nuelem* Sct(1>fy First" e

I

-~

VIRGINIA. POWER EEi 97-01-08 On-*line Maintenance Management approval not obtained for high risk plant configuration

. Actions

• Issued m~nagement instructions to address this

• issue

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34 SURRY POWER STATION "Nudem* Sn/Hy First" I

e I

e

• Risk Assessment VIRGINIA POWER IFI 97-01-01 Follow.-up licensee actions to strengthen risk assessment for on-line maintenance Actions

• Is~ued. management instructions to reinforce the need for Maintenance Rule program compliance * *

• Provided initial training in PSA insights and.

limitations

• Increased the level of PSA engineering involvement in station planning and scheduling

• Issue supplemental guidelines for risk assessment

• An evaluation of additional tools for on-line maintenance risk assessment is on-going 35 SURRY POWER STATION "Nuelear* Safi.>ty Fir.~I"

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VIRGINIA POWER IFI 97-01-02 Structures Program Follow-up licensee actions to provide performance criteria for structures a/fer industry resolution of the issue Actions

• Issued a structures monitoring plan* for North Anna, similar to Surry's

• • Plan.to modify the program criteria, if necessary, as industry guidance becomes available 36 SURRY POWER STATION "Nudear Scifety Fir.~f"

Conclusions M. R. Kansler

• Vice-President Nuclear Operations m:ai~ *

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SURRY POWER STATION "Nucleur Safely Virsl" j

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• Conclusions**

VIRGINIA POWER

• The intent of the Maintenance Rule is to ensure effe(!tive plant maintenance(t Although our program development and implementation were deficient, the intent of the Maintenance Rul~ was and continues to be met

• Plant safety and performance remain at a high level and will be further improved by full compliance with the Maintenance Rule.

• Our self-assessment was thorough and critical. Our assessment results were consistent with the NRC inspection results 38 SURRY POWER STATION "Nudear Safety Fir.~I" i

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Conclusions VIRGINIA POWER

• The corrective action program is sound. The self-assessment program has been clarified to ensure

_ - de"!)iating conditions are addressed through the corrective a~tion program

• Although w~ considered our Mainte_nance Rule development efforts to be reasonable, we recognize our shortcomings _and a_re committed to achieving and maintaining -fyJ1 compliance with the Maintenance R*ule at both Surry and North Anna

• We will ensure greater management involvement and knowledge in the development of future programs 39 SURRY POWER STATION "N11!'lem* 811.fety First" I

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Closing Comments J. P. O'Hanlon Senior Vice-President Nuclear SURRY POWER STATION "Nuelear Safety Fir.~#"

-~*-*-~--~-

e UNITED STATES NUCLEAR REGULATORY COMMISSION NRC* OPEN PREDECISIONAL ENFORCEMENT CONFERENCE SURRY NUCLEAR PLANT March 11, 1997 ENCLOSURE 3

~----'-- '. ---------------------------------C---

e ENFORCEMENT CONFERENCE AGENDA SURRY MARCH 11, 1997, AT 10:00 *A.M.

NRC REGION II OF~ICE, ATLANTA, GEORGIA I.

OPENING REMARKS AND INTRODUCTIONS L. Reyes, Regional Administrator

• II.

NRC ENFORCEMENT POLICY B. Uryc, Director Enforcement and Investigation Coordination Staff III.

SUMMARY

OF THE ISSUES L. Reyes, Regional Administrator IV.

STATEMEN'X' OF CONCERNS/ APPARENT VIOLATIONS J. Jaudon, Director Division of Reactor Safrty V.

LICENSEE PRESENTATION VI.

BREAK/ NRC CAUCUS VII.

NRC FOLLOW-UP QUESTIONS VIII.

CLOSING REMARKS L. _Reyes, Regional Administrator

~-**

I

~

ISSUES TO BE DISCUSSED A.

FAILURE TO DEMONSTRATE PERFORMANCE OR CONDITION OF STRUCTURES, SYSTEMS, OR COMPONENTS WAS EFFECTIVELY CONTROLLED (10 CFR 50.65):

INADEQUATE PERFORMANCE CRITERIA

• CCW PUMPS

• IA COMPRESSORS EHC SYSTEM BEARING COOLING SYSTEM BORIC ACID TRANSFER PUMPS AUX. BUILDING HVAC C-ROOM EMERGENCY VENTILATION SYSTEM RCS CODE SAFETY VALVES RADIATION MONITORING SYSTEM RPS SYSTEM SIA SYSTEM*.

INADEQUATE PROCEDURE FOR DETERMINING MPFFs.

MFW SYSTEM eves RADIATION MONITORING SYSTEM NOTE:

THE APPARENT VIOLATIONS DISCUSSED IN THIS PREDECISIONAL ENFORCEMENT CONFERENCE*ARE SUBJECT TO FURTHER REVIEW AND ARE SUBJECT TO CHANGE PRIOR TO ANY RESULITNG ENFORCEMENT ACTION.

-~-**-*-=-~----------------------------

e NOTE:

ISSUES TO BE DISCUSSED INADEQUATE HISTORICAL REVIEW OF DATA DC POWER SYSTEM

• EMERGENCY LIGHTING SYSTEM CONDENSATE POLISHING SYSTEM ESG HVAC SYSTEM CHILLERS ESW SYSTEM RADIATION MONITORING SYSTEM GOALS AND MONITORING NOT ESTABLISHED ESW SYSTEM ESG HVAC AHUs FAILURE TO FOLLOW PROCEDURES PERFORMANCE CRITERIA *CHANGED W/0 APPROVAL BY WG MANAGEMENT APPROVAL NOT OBTAINED FOR HIGH RISK.CONFIGURATION THE APPARENT VIOLATIONS DISCUSSED IN THIS PREDECISIONAL ENFORCEMENT CONFERENCE ARE SUBJECT TO FURTHER REVIEW AND ARE SUBJECT TO CHANGE PRIOR TO ANY RESULITNG ENFORCEMENT ACTION.

. ISSUES TO BE DISCUSSED B.

INADEQUATE CORRECTIVE ACTION (10 CFR 50, APPENDIX B, CRITERIA XVI):

.EIGHT SELF-ASSESSMENTS WERE CONDUCTED AND IDENTIFIED DEFICIENCIES *wHICH WERE NOT CORRECTED NOTE:

THE APPARENT VIOLATIONS DISCUSSED IN THIS.

PREDECISIONAL ENFORCEMENT CONFERENCE ARE SUBJECT TO FURTHER REVIEW AND ARE SUBJECT TO*CHANGE PRIOR TO ANY RESULITNG ENFORCEMENT ACTION.