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UNITED STATES t
NUCLEAR REGULATORY COMMISSION i
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REGION 1 5
t 476 ALLENDALE ROAD
.f KING OF PRUSSIA, PENNSYLVANIA 19406
'O 8 J UL 1988 MEMORANDUM FOR:
Robert M. Bernero, Deputy Director Office of Nuclear Material Safety and Safeguards FROM:
James M. Allan, Deputy Regional Administrator, RI
SUBJECT:
DRAFT REGION I NATIONAL PROGRAM REVIEW REPORT We have reviewed the subject draft report provided with your memorandum dated June 20, 1988.
Specific comments on the report are enclosed.
Along with the the comments are offered suggestions for improving the manner in which the report portrays Region I efforts in the fuels, safeguards and materials areas. The paragraph numbers in the enclosure are keyed to the draft report.
The specific comments point out ways in which the report organization, focus and analysis in support of conclusions could be improved.
Frequent repetition of the same facts makes the report confusing and gives undue significance to certain of the findings (e.g., the report notes five separate times that the currently recommended field notes were not being used in the materials area, a minor finding, we believe, and that each materials inspector was not accompanied by a supervisor).
Also, the repeated information is sometimes inconsistent or contradictory.
We believe the draft report could more accurately present the extent of the problems caused by our inability to obtain approval to fill key administrative vacancies in the Nuclear Materials Safety Branch, and to the actions taken to compensate for those problems.
We also believe that the report could more accurately describe the impact that 3M or Radiation Technology had on the regional materials program.
Each of these coments is more fully explained in the enclosure.
An area that we believe requires further comunication between Region I and NMSS involves the physical security inspection program at UNC-Naval Products.
The detailed information provided in the enclosure to this letter (1) indicates a need for an early technical level discussion to resolve the is. sue of inspection frequency and resource expenditures for this facility, particularly as a function of licensee performance and regional staffing levels, and (2) suggests the recommendations in this area be reconsidered. We also suggest that NMSS management / staff participate in the next scheduled inspection of the UNC facility, planned for August 1988.
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Robert M. Bernero 2
We believe that the National Program Review could have been improved by combining the safeguards and transportation visits with the materials visit.
A combined review could have facilitated coordination of the findings, some of which were not communicated to regional management until the draft report was received.
It is suggested that this issue be resolved in the final report.
We appreciate the opportunity to comment on the draft report.
We trust our comments will be incorporated into the final report and thereby improve its usefulness to NMSS and Region I in assessing the adequacy of our collective efforts in the areas reviewed.
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/y ames M. Allan
,/ Deputy Regional Administrator
Enclosure:
As stated cc w/ encl:
H. Thompson, NMSS R. Burnett, NMSS R. Cunningham, NMSS M. Knapp, NMSS V. Miller, NMSS
i REGION I COMMENTS ON DRAFT NATIONAL PROGRAM REVIEW REPORT SECTION 2.1 - MATERIALS LICENSING The statement that casework adjustments were made to allow for non-budgeted, labor-intensive cases such as 3M and Radiation Technology is incorrect.
The adjustments were made solely on the basis of lower than estimated receipts during the first four months of FY 88 (491 received versus 671 in.the original forecast).
We suggest the statement in the report about the adjustment be modified as follows:
Adjustments were made to decrease casework completions from the budgeted figures. The adjustments were necessary because application receipts during the first four months of the year were significantly lower than forecast.
Staff allocations were not reduced to allow for non-budgeted, labor-intensive efforts such as 3M and Radiation Technology.
Although the footnote in this section takes note that the licensing program was impacted by agency hiring restrictions, the reader of the report is unlikely to understand the full reason for the shortfall in completions and related lengthening of turnaround times.
Therefore, we suggest insertion of the following paragraph to replace the footnote:
During the period covered by this review, Region I lost critical clerical staff assigned to support the materials licensing program.
The net deficit was 1.3 staff years of clerical support.
Due to the agency's overall overage of staff-on-board, the Region was for a period under an absolute hiring freeze and later under strict limitations.
The licensing staff compensated for this situation by (1) soliciting and receiving four staff weeks of clerical support from NMSS, (2) using overtime for available staff, and (3) diverting direct staff to cover essential clerical and administrative duties.
The diversion of approximately one staff-year of direct staff to administrative duties was largely responsible for the failure to complete licensing casework on schedule. Also, the necessity of training and rotating staff through temporary assignments resulted in some inefficiencies and delays in the administrative processing of cases.
However, by taking these compensating measures, Region I was able to docket all incoming licensing casework and to complete priority cases in a timely manner.
It is not clear to the Region I staff what finding was made regarding the technical adequacy and accuracy of completed licensing actions.
The phrase "no significant problems noted" may be interpreted variously as condemnation or praise.
Region I and Agency management deserve a more definitive evaluation of performance.
ENCLOSURE
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2 SECTION 2.2 - MATERIALS INSPECTIONS This section of the draf t report states that Region I completed 1049 material inspection reports and notices of violation (NOV) in FY87 compared with an Operating Plan goal of 1010 inspections.
t This statement is confusing and misleading.
We did conduct 1049 inspections in FY87. Of the 1049 inspections, violations were identified in 307.
However, since inspection reports are issued for only a small fraction of the inspections (field notes are usually used) and several inspections (i.e,
inspections of several licenses held by a single licensee) are often documented on the same 591 or letter, we suggest, " Region 1 completed 1049 inspections in FY87.
This is 104 per cent of the Operating Plan goal of 1010.
Violations were identified in 307 inspections."
If you wish more specific data about the results of the inspections, we will attempt to supply it.
The report notes that the inspection reports and NOVs included 322 inspections in Transportation and 118 inspections in Low Level Waste.
In order to clarify the intent of this comment, we suggest the following:
"Of the 1049 inspections completed, 322 included a review of Transportation and 118 reviewed Low Level Waste." There were few, if any, inspections where these were the only subjects covered. We assume these data are included for general information only, since there are no Regional goals or NMSS requirements in these areas.
The following statement is included in the report:
"On the average, inspection reports and NOVs were issued in 67 days compared to a goal of 20 days.
Delays were apparently a result of clerical understaffing." This brief comment provides little information about the problem.
While clerical shortages mainly affected completion of the licensing program in FY87, our comments in Section 2.1 also apply here.
In early FY88 the time to issue NOV's increased significantly due to the clerical shortage.
The report states that several special inspections were performed of Radiation Technology, Inc. during FY87 and FY88.
In fact there were 22 inspections of Radiation Technology, Inc. during FY87 and three inspections in FY88 (through February 25, 1988.)
A number of factors influence er ability to complete routine inspections at the established nominal frequency.
Several examples are given on page 8.
Considering the number of non-routine and/or unbudgeted activities in which we were involved, we are particularly sensitive to the statement in the report that, since there were 10 overdue inspections among licensees in Priorities 1, 2 and 3, this indicated that management was not closely tracking overdue, high priority inspections.
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3 Region 1 has 105 licenses in Priority 1,179 in Priority 2 and 942 in Priority 3.
We suggest that a more proper conclusion is that "of the more than 500 inspections associated with licenses in Priorities 1, 2 and 3, less than four percent were conducted outside the established nominal frequencies.
Nevertheless, as part of a recent realignment of the materials program, Region I has directed that close attention be given to assuring that all inspections in Priorities 1, 2 and 3 are completed in the nominal frequencies.
Similarly, the report correctly notes there were 16 " overdue" inspections for priorities 5, 6, and 7, and suggests the telephone contact questionnaire could have been used. We do not believe that failure to conduct 16 inspections (out of approximately 500 inspections) within the nominal frequencies in these priorities is particularly significant. We did not employ the telephone questionnaires for'this purpose because we believe that all such inspections can be completed, even though somewhat beyond the nominal frequency.
On several occasions the report notes that the three Section Leaders each accompanied three inspectors, and that most junior inspectors were not i
accompanied. We believe that these accompaniments did focus on junior inspectors. However, we have committed to accompanying all inspectors during FY88 and subsequent years.
With regard to the comment on the region's continued use of the 1982 version of the field notes, we have begun the conversion to the standard field notes.
This will be completed by September 1, 1988. Additional comments on this issue are provided on page 7.
SECTION 2.4 - FUEL CYCLE AND MATERIALS SAFETY 'NITIATIVES Each of the initiatives described is associated only with the Materials Program.
We suggest the section be renamed, " Regional Initiatives."
SECTION 2.5 - RECOMMENDATIONS FOR ACTION Several of the recommendations are appropriate actions to take, but do not appear to specifically address any deficiency noted in the report.
The presence of a reconnendation normally implies a deficiency or weakness.
If the recommendation does not address a deficiency or weakness, then the issue could have generic implications and should be covered in a policy document.
The report contains a recommendation that the region continue to track licensing and inspection turnaround times and notify HQ if recent actions do not improve the situation.
Further it notes that particular attention should be paid to the timeliness of clerical support.
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While we plan to carefully monitor all actions which affect turnaround times and attempt to improve them, we suggest this recomendation be dropped. NMSS was fully aware of the clerical problem when it occurred and even helped overcome the impact. Although we would promptly inform NMSS if the situation should recur, including the recomendation implies that notification was not made.
Another recommendation contained in the report addresses the need to recruit to fill staff vacancies.
Does this recommendation respond to an identified deficiency? We believe we have been quite conscientious about filling vacancies when allowed.
The sixth recomendation proposes that the region surface any problem regarding interactions with Headquarters prior to the National Program Review visits.
This seems to imply that we have not done this in the review period.
Does it refer to a specific problem?
If so, it should be discussed and resolved with us.
If not, the recommendation should be dropped.
If it is associated with the matter described later in Section 2.6, the connection should be clarified.
SECTION 3.1 - SAFEGUARDS LICENSING PROGRAM With regard to the Safeguards Licensing Program and case reviews being perfonned " generally consistent with Headquarters' policy and guidance", we i
were not informed of any inconsistencies during the Program Office review and are at a loss to understand the coment. We suggest dropping the word i
" generally" from this statement.
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SECTION 3.2 - SAFEGUARDS INSPECTION PROGRAM i
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l While there was only one routine security inspection conducted at UNC-Naval Products in FY-87 (87-05; 6/15-18/87, 28 hours3.240741e-4 days <br />0.00778 hours <br />4.62963e-5 weeks <br />1.0654e-5 months <br />), independent inspection effort was expended during two MC&A inspections (87-02; 3/16-20/87, 3 hours3.472222e-5 days <br />8.333333e-4 hours <br />4.960317e-6 weeks <br />1.1415e-6 months <br /> and 87-07; 9/21-25/87, 4 hours4.62963e-5 days <br />0.00111 hours <br />6.613757e-6 weeks <br />1.522e-6 months <br />) to review facility visitor access controls.
Similarly,12 hours1.388889e-4 days <br />0.00333 hours <br />1.984127e-5 weeks <br />4.566e-6 months <br /> of independent inspection effort were expended during an MC&A inspection conducted 9/15-19/86 (86-10), just 11 days prior to the start of FY 87, to review facility vehicle access controls.
In addition, one special security inspection (87-09) was conducted 11/16-17/87 to review night firing qualifications (9 hours1.041667e-4 days <br />0.0025 hours <br />1.488095e-5 weeks <br />3.4245e-6 months <br />). Therefore, a total of 44 hours5.092593e-4 days <br />0.0122 hours <br />7.275132e-5 weeks <br />1.6742e-5 months <br /> of security inspections were expended during CY 87 at UNC-Naval Products.
Region I had notified NMSS & IE several times since 1985 (via the semi-annual Region I Perfonnance Report) that the security FTE's for UNC-Naval Products 'were excessive.
No reallocation occurred, and coments were not made until this report.
Prior to the 3/14-18/88 routine security inspection at UNC-Naval Products (88-03), the last violation cited was in 1983 and involved a minor records problem in the area of training and qualifications (T&Q) (a T&O violation was also cited in 88-03.)
Based on that enforcement history and the licensee's performance, the region did not consider UNC a high priority for expending inspection resources during a time of inadequate staff resources, as described below.
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The security inspector assigned to UNC was on light duty for about one and one-half years, including most of FY-87, and had applied for disability retirement, which was granted and taken in 12/87.
There was also a shortage of 1-2 security inspectors during that year, despite seyeral attempts to fill the vacancies.
The reasons for not filling those vacancies were not discussed with Region I during the Program Office review; therefore, it appears inappropriate for the Program Office to compare them with other regions and state the circumstances were the same. The back-up security inspector for fuel facilities was engaged in higher priority inspections at nuclear power plants and licensing activities at the time, and because of scheduling changes, only one inspection was conducted at UNC-Naval Products.
It was not an overt decision to deviate fro;n the Manual Chapter requirements as is stated in the draft National Program Review Report, but one brought about by circumstances.
With regard to refresher training for qualified inspectors, the Program Office should be aware that the availability of meaningful training courses for either qualified or new security inspectors is extremely limited.
Several inspectors who were sent to available courses in the past considered them a waste of time and we discontinued enrollments in those courses.
Recently we became aware of several excellent technical courses provided at the Norfolk Naval Shipyard and we have sent, and will continue to send, inspectors to those courses, new inspectors first. We are also sending our inspectors to the Sandia Coarse, which is specifically designed for NRC security inspectors.
Therefore, while Manual Chapter 1245 calls for refresher training, the Program Office should look into the availability of meaningful training for security inspectors before it states that Region I is not following the MC. We cannot waste funds on frivolous training.
SECTION 3.4 RECOMMENDATIONS FOR ACTION With regard to the first recommendation, we suggest that the Program Office assess the inspection program requirements at UNC-Naval Products.
ith regard to the second recommendation, we find no basis to suggest that inspection modules were net performed in a comprehensive manner.
With regard to the third recommendation, it is accepted.
SECTION 4.0 - TRANSPORTATION SAFETY AND SAFEGUARDS INSPECTION PROGRAMS The followina is provided as comment and clarification:
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6 Section 4.1.1 Materials Licensees It is not correct to say that 1,049 of the 3,020 active licenses administered by Region I were inspected in FY 87 because of the following.
First, in FY 87, about 17 general and non-licensees were inspected.
Second, 41 licensees were inspected more than once. <For example, Radiation Technology, Incorporated was inspected 22 times in this period due to escalated enforcement action at the Rockaway facility. Other licensees were inspected between two and seven times in this period due to regional concerns with program performance or the fact that a Priority 1 licensee may be routinely inspected twice in the same fiscal year.
In addition, we are unsure why this is discussed in the section on transportation.
If such sumary infonnation is useful, it would be better placed in Section 2.2.
The statement, "As of March 1988 Region I had a backlog of about 35 inspections that were overdue", in this section of the report implies that the subject is related to transportation inspections.
Such implication is incorrect. The 35 overdue inspections related to the total number of inspections in all program areas, not to inspections within this particular program area.
Further, we are uncertain of the significance to be attributed to this statement since it appears unrelated to the context of this section and repeats information provided in Section 2.2 We take exception to the implication of the statement, " Regional staff was neither aware of nor could they offer a rationale as to the apparent lower number of violations uncovered during an apparent substantially larger number of inspections."
Earlier, in this same section, it was stated that " Regional staff attributed the increase (in the number of inspections, i.e.,180 in FY 86 compared to 322 in FY 87) to better compliance by staff in the method of preparing Fonn 766."
As we attempted to explain to the NPR team, in FY 87 we enhanced the copies of Form 766 used by our staff by incorporating a direct reference to Module 86740.
Combined with explicit instructions to all personnel, such action increased the likelihood that inspections of this program area would be properly documented on Form 766.
It is our belief that the differences in numbers of inspections completed in this program area between FY 86 and FY 87 is largely a result of increased capturing of the information on the Form 766, and not really the result of substantially more inspection effort.
Obviously we were " aware" of this data since we supplied it to the NPR Team, and did offer this " rationale" in explanation.
Notwithstanding this clarification, the statement represents defective 1
reasoning by implying that more inspections of a specific program area l
must necessarily yield proportionately more violations. Further, we are uncertain as to the significance of the matter in any case. We request these statements be deleted, as there are no criteria for the " appropriate" number of violations per inspection.
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Relative to the comment pertaining to our use of " obsolete" field notes, we recognize that the difference between the forms specified in Manual Chapter 87100 and the forms we are currently using is generally one of format.
In most cases, the information that is documented is general.ly the same, and both formats perform identical functions with equal utility. We do not believe our use of the earlier version < implies any problem with the quality of the inspections, nor do we believe NMSS intended to imply this. However, we believe this should be more specifically stated in the report so that the intent is clear.
Regardless, to be consistent with the program guidance, we intend to implement the Manual Chapter 87100 version by September 1,1988.
This section states, "About 16 files of completed field notes were reviewed for thoroughness of completion. A number on those observed were only partially completed"; as compared to Section 5.1 which states, "Of the 16 files selected, most were found to be adequately completed."
While these statements are not mutually exclusive, both lack precision.
It is not evident if the finding represents that some elements of the field notes were not applicable, and therefore not completed, or required elements were not completed.
Perspective of the finding would be enhanced if quantitative, descriptive information was used, such as stating what number of files reviewed were incomplete; and the reasons that the files were considered as incomplete.
This section of the report, as well as Section 5.1, discusses inspector accompaniments, each indicating that eight of the 23 inspectors were accompanied by section chiefs in FY 87.
In fact, nine accompaniments were performed, as previously stated in Section 2.2.
Regardless of this inconsistency, we are uncertain as to why it is restated so often.
It is suggested that this be done in one place in the report.
SECTION 5.0 - LOW-LEVEL WASTE INSPECTION PROGRAM (10 CFR 61)
No significant information is presented by this portion of the report as applicable to the materials program.
Section 5.1 restates, however, in the same unfocused manner, the identical " findings" as previously mentioned in Section 4.1.1.
For example:
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Once again "a backlog of 30-40 overdue routine inspections" is mentioned. The relation of this backlog to this particular program area is unexplained and should be deleted, since it is better covered in the materials section.
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The review of the "16 files" is again restated and should be deleted.
3.
It was again pointed out that the field note format was " outdated" and inconsistent with Manual Chapter 87100. This should be covered in the materials section only.
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We are reminded that only eight (actually nine) of the 23 inspectors were accompanied by section chiefs during FY 87. This minor inaccuracy should be corrected and covered in the materials section.
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SECTION 7 - FTE AND PROGRAM SUPPORT FUNDS UTILIZATION Region I finds this section confusing and believes that it may mislead Agency management in their evaluation of the management of,NMSS programs in Region I.
The RITS data may be sorted, sliced and interpreted in many ways.
The fact that NMSS and Region L cannot come to the same conclusion as to whether staffing levels exceed or fall short of budgeted levels should be evaluated and resolved.
It appears that the NMSS figures account for almost all regular and non-regular hours expended by staff assigned to these functions.
Region I analyses are usually based upon hours charged to direct labor codes.
FTE expenditures are then calculated by dividing direct labor by 0.72 for NMSS programs.
In other words, we assume, as we believe the budget does, that only 72% of an individual's time is available for direct labor.
A finding not noted in the report is that for the Region I materials program, the ratio of direct hours to total hours expended is closer to 0.66 than the budgeted or assumed 0.72.
The report fails to note, evaluate or comment on this fact. There are various reasons for this discrepancy which involve management initiatives and decisions.
A part of the NPR report should be an evaluation of whether priorities were correctly set when such decisions were made.
Examples of indirect expenditures which diverted direct staff from licensing and inspection were:
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Higher than normal training expenditures due to:
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Hiring five new entry level staff during the first months of the review period, b.
Arranging several specialized training sessions for new and existing staff during the review period.
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Assignment of direct staff to plan and conduct special seminars or lectures for target groups of licensees (broad scope licensees, irradiators, and nuclear nedicine technologists).
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Assignment of direct staff to perform essential clerical duties when all other alternatives were exhausted.
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