ML20059C059

SALP Rept 70-1100/88-99 for Jul 1988 - Mar 1990

ML20059C059
Person / Time
Site:	07001100
Issue date:	07/19/1990
From:	NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:
Shared Package
ML20059C058	List: ML20059C054 ML20059C059
References
70-1100-88-99, NUDOCS 9008310022
Download: ML20059C059 (39)

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SYSTEMATIC ASSESSMENT OF LICENSEE PERFORMANCE

-COMBUSTION ENGINEERING, :!NC., WIN 050R, CONNECTICUTE i

e 1.

.lNTR000C110N=

A, Purpose and Overview...................................

3 B. - S ALP Bo a r d Membe r s....................................

C. Background.............................................4!

CRITERIA....-...............................................,6-11.

111.. SUMKARY O F RE S U LT S........................................

7 i

A. Overview..............................................

7 B. Facility Performance Analyses. Summary...................

8 IV. ' PERFORMANCE ANALYSIS A. Facility Operations...................................

9 B, Nucl e a r.C r i t i c al i ty' Sa f e ty............................. 12 C. Safeg.ards............................................ 14

.......................... 16 D. Equipiert Mainterance...

E. Raciciogical Controls............................... 18

......................... 22 F. Emergency Fre:arecress-....

G. Paragem,ert Controis

.......................... 25

......................... 29 i

H. Fire Protect on............

1. Licensing is' sues.................................... 31 V.

SUPPORTING DATA AND SUMv. ARIES 33-A. Investigations anc Allegations SuT.Tary.

.33 B. Escal atec Enf orce ert Action.................

C. Par.agement Cor.ferences............................... 33 1

.V1.

TABLES

1. Enforcement History July 1,1988 to March 31, 1990...

.34

............. 37

2. Enforcement Activity

3. Nor.-Routine Events.................................. 38 r

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I SYSTEMATIC ASSESSMENT OF LICENSEE PERFORMANCE

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COMBUSTION ENGINEERING, WINDSOR, CONNECTICUT I,

INTRODUCTION A,

Purpose and Overview The Systematic Assessment of Licensee Performance (SALP) is an integrated NRC staf f ef fort to evaluate-licensee ptrformance based on The SALP supplements a collection of relevant observations and data, the normal' regulatory process, which is used to en'.ure compliance The SALP is with NRC rules, regulations, and license conditioni, intended to be sufficiently diagnostic to provide meaningful guidance to licensee management to promote quality and safety of f acility operations, SALP evaluations are not typicaliv perforted for nuclear facilities A S~ '- evaluation of Corbustion Ergineering, other than power reactors.

Incorporated, was deemed appropr ute in 1956 in light of the licensee's history of sustained poor perforrrance and the licensee's apparent iracility to identify and correct deficiercies in radiation safety, criticality safety, nuclear material iccountability, transp0rtation, This folicau: SAlp evaluation was nerformec to review 6nd other areas.

tne licersee's performance since the 1935 SALP, An NE SALD Board, composed of the staf f me-:ers listed belca, met on v y 15, 1990, to assess the litersee's :;erfer.mance in accorca ce with a

generic guidance in NRC 'anual Chapter Os}6, " Systematic Assessment of Licensee Performance,".Section 11 of this report summarizes this guicance anc the evaluation criteria used in the assessment'as modified s e:ifically f or tre unique features of fuel f acilities, i

Tnis report is the SALP Board's assessment of the licensee's safety l

performance at the Combustion Engineering, Inc., f acility at Windsor, varch 31, 1990.

Connecticut, f or the period July 1,1953 througn B.

SALP Board Members Chairman:

M. R. Knapp, Director, Division of Radiation Safety and Safeguards '(DRSS)

Members;

.1 W. L. Axelson, Deputy Director, DRSS, NRC Region til J. H. Joyner, Division Project Manager, DRSS R. R. Bellamy, Chief, Facilities Radiological Safety and Safeguards Branch (FRS&SB), DRSS 3

'R. J Bores, Chief, Efflants Radiation Protection Section (ERPS),

FRS&SB, DRSS J. Roth, Project Engineer, ERPS, FRS&SB, DRSS A. R. Blough, Chief, Reactor Projects Branch No.1 Division of Reactor Projects C, Haughney', Chief, Fuel Cycle Safety Branch (FCSB), Of fice of Nuclear Material Safety and Safeguards (SMSS)

G. H Bidinger, Section Leader, Uranium fuel Section, FCSB, NMSS Other Attendees at the SALP Board Meeting M. A, Austin, Radiation Specialist, ERPS, FRS&SB, DRSS P. V. O'Connell, Radiation Specialist, Facilities Radiation Protection Section (FRPS), FRS&SB, DRSS 0, J. Chawaga, Radiation Specialist, FRPS, FRS&SB, DRSS Via Telephone Conference C. E. Gaskins, Senior Safeguards Project Manager, Oc estic Safeguards and Regional Oversight Branch (SG08), sv55 R. L. Jack son, Saf eguards Physical Scientist, SGDB,Av55 R. Castaneira, Pysical Security Specialist, SGDB, Nv55 y, Willia-s, Materia'. Control and Accounting Physica' Scientist, SGDB, NVSS

-C, B a c kg roun_d Conbustier Engireering, Inc., Nuclear Fuel Varuf act. teg, is authori:ed by NRC License No, ShM-1067 to f abricate 'ca-er.ricre: ranium fuel for light water reactors (LWR) and to cornet resea*:a and development activities involving uranium oxide powder.

Fabricat'on activities include f orming f uel pellets, removing volatiles' an: sintering the pellets in electrical furnaces, loading tne pellets ;irto zircalloy cladding, and assembling the sealed rods into fuel assemblies.

Of the 2,500 employees at the Windsor site, apprcximately 250 are involved

-with nuclear fuel fabrication and nuclear fuel research and development; During the current assessment period, the licensee initiated the transfe-of all manufacturing operations involving uranium bearing powder to its Hematite, Missouri, f acility.

Once this transfer and associated decontamination operations are complete, the manufacturing operation at the' Windsor f acility will be simplified, in that only fuel pellet and-fuel rod handling operations will remain, and the potential radiological safety significance of the remaining operation will be less than that associated with past operations, After redeployment of the powder operations to Hematite, operations at Windsor will include pellet drying, pellet stacking, fuel rod loading and fuel assembly f abrication, in addition to the associated product cuality assurance and quality control operations.

Research and develcpment activities will continue to be conducted at the Windsor facility.

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I Confirmatory Action-letter No. 88 23, issued on September 9,1988, requested the licensee to initiate a performance-improvement program and conduct a self-assessment of all f acility safety programs.and '

operations..The licensee's-initial self-assessment was completed by 31, 1989.

The task force that conducted the self-assessment January-then self-initiated the conduct of quarterly-audits to monitor-performance improvement program activities.. initial actions on the performance improvement program were completed on January 31, 1990.

During an October 1989 Management Meeting, NRC' management requestedL that the licensee conduct a re-assessment af ter the performance That re-assessment was improvement program actions were completed.

completed'in March 1990.

During November, 1989, Combustion Engineering, incorporated (CE),

i announced execution of an agreement-in principle to be purchased by a f oreign firm, ABB ( Asea Brown Beveri).

Ibe agreement was approved by the CE Board of Directors, and a stock tender offer was issued to The of f er was accepted by 95 percent of the stockholders.

stockholders.

The ABB accuisition of CE was effe:tive De: ember 14, 1989.

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11. CRITERIA Lic3nsee performance is assessed in selected functional areas that have

. the votential to significantly af f ect nuclear safety, and the environment.

The following evaluation criteria, where appropriate, were used to assess each fusctional area.

1. Assu ance of quality, including management involvement ar.d control 2.' Apprcach to resolution of technical issues irnm a safety standpoint

3. Responsiveness to NRC initiatives-

4. Enfortement history

5. Operat:enal anc construction events

6. Staf fing (including management)

7. Ef fectivene:s of tra tiiing and qualifir.. tion prog. ams Based on the SALP Board assessment, each evaluated functic*al area is Li:e'see performance classified into ore of three performance categories.

in escalated rated te'ow the Ic.est category would have already results:

enf rce ent actiers, which could include modification, sus:ension, or The definitions of the perfor Ance categories revocat on of the license.

i fo'lew.

Category 1

• Lice see caragement attention and involvemeat are readily ew' dent and place emphasis on su:erior performance of nu:' ear safety or sa'eguarcs a:tivities, with the resulting perform.ance su:stant' ally i

Licensee resoure.es are empie and en:eeding re;ulat:ry reavirements.ievel of plant and pe-son'tl perf orrance e"ectively ssed so that a hign d

is beirg acnieved.

Reduced NRC attention may be appropr ite, Categ:ry. 2 - Lice see caragement attention to and involve ent in the I

good.

The perf or-ance of ov: lear saf ety or saf egsards activities art li:erste has atta'ned a level of performance above that rieced to meet Licensee resources are adequate and reasorably; reg;latory requirements.

allocated so that good plant and personnel performance is :eing NRC attention may be maintained at normal leve's.

achieved.

Category 3 - Licensee management attention to and involve ent in. the perfortance of nuclear safety or safeguards activities art not The licensee's performance does not signif t:a-tly exceed sufficient.

Li:etsee resources that needed to meet minimal regulatory requirements.NRC attention should be appear to be strained or not ef f ectively used.

increased above normal levels.

The SALP report may include an appraisal of the performan:e trend in a Licensee performance functional area for use as a predictive indicator.

-during the assessment period was examined by the SALP Boa d to determine A performance trend is indicated only if both a whetner a trend exists.

definite trend is discernable and continuation of the tread may result in a charge in performance rating.

The trend, if used, is defined as:

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p Licensee perf ortrance was detern'ned to be improving _during-E

-Improving:

t the assessf..ent period,

_ Licensee performance was determined to be declining during Declining:

- the assessment period and the licensee had not taken meaningful steps to address this pattern.

111. SU W ARY OF RESULTS i

A.

O__ve rv i ew At the end of the last SALP period, overall licensee performance was marked by inadequate management oversight, slow response to problems identified by the NRC, a lack of objective-quality and safety-related internal audits, significant programmatic and staffing deficiencies-and a generally poor attitude oy plant employees toward safety and Henever, the licersee had ' instituted maragement procedural compliance.

reorgani:ations in several areas and had initiated programs to address The management, saf ety, staf fing and training deficiencies.

reorgani:ations had not been in place long enough to assess, but a

improvements resulting f rom so.e of the other programmatic changes were-noted.

actions taken.by the lice see ::. ring tnis assessment period resulted in some improve ent in all f sr:tional areas assessed, but were most The successful in ecuipment mainte*arce and f acility operations.

licensee improvec staffing i*. se eral areas, developed a'nd implemented new procedures in certain areas and established a system for determining the impact of a change to any ;recedure ca all other protecores.

benever, as of the end of the SALP period the licensee had oeen unable to make the latter system wo*k as designed.

The NRC staf f also noted that the licersee improved its gereral eT loyee anc *adiation worker training programs, developed an excellent preventive and reactive mainte-ance program for prods:tior and safety equipment, made general in the workplace attitude of orkers to safety and pro:ecura' improvement compliance, upgraded emergency preparedness f acilities and the emearency plan, maintained an ef fective safeguards program, and established a Facility Review Group to supplement the' activities of the Nuclear Housekeeping in the facil.ity was improved and fire-Safety Committee.

The licensee protection equipment was well maintained and tested, also maintained its full-time licensing staf f and provided them with additional training in the preparation of license amendment requests.

Overall, these improvements were deemed by the NRC staff to have resulted in a safer workplace.

The licensee's overall performance, however, was marked by a number of actions that were initiated, but still incomplete as of the end of the current assessment period.

For example, program plans init5ated or developed as part of the licensee's Nuclear Fuel Intecrated Improvement Program (NFilP) were not successfully or 7

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-completely implemented in radiological controls, emergency preparedness and licensing. - These deficiencies, combined with others-identified below and in the Performance Analysis that follows, indicate that _.

improvement in management' controls _is also needed..In radiological controls,-program plans continued to be developed th' rough'much of the assessment period, resulting in the continuing need to prepare or

Further,

. revise procedures and the need to train or retrain staff.

the key managetent position established to implement-the day-to-day operation of this program was not filled by a. technically qualified individual at any time during the period.

In emergency preparedness, emergency response organization canagement responsibilities were not-clearly defined and a site-wide exercise had not been conducted.

Procedural inadequacies existed in the fire protection area, where key procedures had not been developed.

Further, while the licensee-used independent -auditors to assist with the NRC-requested self-assessments, and the licensee s first self-assessment task force

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performed cuarterly audits-of NFilP implementation, tFe licensee did not establish a program of routine, periodic, indepercent audits.

The findings of the independent radiological controls _ audit from the initial self-assessment still had not been addressed as of the end-of-this SALP assessient period, nor had many of the prob'em areas identifi+:

in t e previous SALP report, inclucing,for exa ple, the failure to prcvide adewate technical-support to the licensing staff.

B.

Facility Ferfer ance Analyses Symry Ratings for Rat'ngs for Previous C.rrent Functional A<ea Assessment Period Trend Assessment Feriod 1.

Fa:ility Operations 3

Improving 2

2 2.

Nuclear Criticality 2

Safety 2

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3.

Safeguards 2

1 4.

Equiement Pairte a.ce 2

3 5.

Radiological Controls 3

3 6.

Emergency Preparedness 3

Not Rated 7.

Vendor Quality 2

-Assurance 3

Impr:.' ;.

8.

Management Controls 3

2 9.

Fire Protection 2

3 10.

Licensing issues 3

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-4 IV, Performance Aral_ysis A-Facility Operations 1.0 Analysis i

in the previous SALP report Fa:ility Operations was rated SALP Contributing to this rating were the Category 3, Improving.

j licensee-recognized need for censiderable improvement in facili. ties, procedures, training and management and the need for implementation of an effective maintenance prcgram. The Board noted several p'roblem areas' and recommended that the licensee address these l

problems by conducting periodic self-assessments and independent audits of f acility operations and establishing and maintaining _ a performance improvement prograr.

Nine routine irspecticas and o'e special team operations inspe: tion il i

were conducted daring the assessment period and no v o at ons aere identified in this area.

The licensee procured upgraded fuel pellet pressing equipment i

and installed this ec.iprent i' the f acility to cemonstrate peilet

'abrication systems prior to t ansfer of the pellet f abricatica.

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peration to the HeTatite, Vissouri, facility.

A facility and eavipment pruentive ainterar:e program was devised and imp'e ente:

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1 As a result of taese e:vipment changes and the preventive maintena*:

'I rrogram, re'iability cf instal'ed e;uipment was considerably improved.

Overall, d. iring this assess er. period licensee management ma0e' orogress in ad:ressin; the cor: erns icentified in the previous SALP report.

Af ter prompting y the' NRC, the licensee conducted 4

1 two self-assessments of facility cperations and established a Ine first self-assessment and 1

cerformance impr:vement progra,

the performance improsement.pr: gram were cond xted as agreed to

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in Confirmatory Action letter No. CAL 86-23 dated September 9, j

1988.

The second self-assessrent was requested by the NRC during an October 1939 Management Yeeting so that the licensee could

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determine the success of the performance improvement program in j

correcting the safety program ::eficiencies originally identified by the NRC, Both self-assesseents were ef fective in identifying i

major programmatic weaknesses in the licensee's programs and were completed in a timely manrer.

The results of the performance j

improvement program-(designated by the licensee as the Nuclear i

1 Fuel Integrated Improvement Program) are discussed in Section IV G.

As further discussed in Section IV.G, the licensee has not established a program to assure that self-assessments are conducted periodically.

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There were no reportable events associated with manufacturing equipment or facility malfunctions during the assessment period.

However, three nonreportable_ incidents related to loss of off-site power and damage to a natural gas line occurred which necessitated j

shutdown of'the manufacturing _ facility for short periods of time.

Timely and appropr_iate These incidents are described in Table 3.

actions were taken by the licensee in response to these: incidents.

During the assessment period, the I censee twice changed the senior st af f associated with the Nuclear Fuel fanuf acturing f acility, once as a result of a reassignment of the Vice President Nuclear -

Fuel Manufacturing to another Division and once'as-the result of the retirement of the Vice President - Nuclear Fuels (VP-NF) and After each change, implementation the designation of his successor.

of the facility improvement program was modified,.For example, revised program descriptions were to have been issued prior to 31, 1988.

H wever, following the Dece-ber 1933 management-l December Change, issuance was to be withheld until af ter March 31, 1989, j

9 because new senior Tanagement' proposed to redirect the improvement; The lice-see reconsidered and issued the program program.

descriptions, including the i rplementing procec,,res, by February 15, 1939 after beir; recuested to do 50 by tre MC.

The impact of the second orgaai:ational charge, which o:c/ red in October j

1 1959, is discussec in Section IV.G.

The T icensee took aopropriate actions to reduce required: cvertime assigned to cperat*:ns personrel by contra: ting out a cortion of faericatior. eperation.

This action reduced operations f

the pellet staff fatigue and allcaed the licensee to reet :roduct shipping schedules using available staff.

As a result, the use of operations l

staff overtine was appropriately ranaged by tne licensee,

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l The licensee's eroicyee training programs 'mpec.eci during the i

assessment period.

The licensee revised tre Ge*eral Empicyee Training (GET) pro; ram and the Radiation Worker Training and q

were taken by the licensee to assure, with few exceptions, that 1

retraining programs used at the f acility, Appropriate actions ooerations, and engineering personnel who required all management, In addition, the licensee initiated training had been trained.

the use of a quality awareness and improvement program at the facility in order to improve the safety attitude and quality awareness of the employees. Through interviews of licensee operations personnel and observations by the NRC during the assessment period, it was determined that a significant improvement in the attitude of employees toward compliance with regulatory requirements and procedural adherence had occurred

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The training program for the during the assessment period.

operations personnel appeared to be appropriate and effective.

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In summary, performance was impicved during the assessment period, as evidenced by the timely completion of two self-assessments, the use of a quality awareness and. improvement program to improve the safety. attitude of employees, the improved earagement control of overtice using available operations staff, and the implementation-F: wever, effort of.an effective prevertive maintenance progrim.

is needed to establish a program of periodic self-assessments.

2.0 Conclusions Category 2 i

J.0 Board Recommendations None 11 n

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B;

-Nuclear Criticality Safety 1.0 Analysis in the previous assessment period, the licensee's nuclear criticality safety (NCS) program was *ated SALP Category 2.

This conclusion was based on lack of a formal change control system to assure adequate application of criticality safety controls, and concerns about lack of staff dedicated to criticality safety reviews.

During the current assessment period, seven routine inspections and one special inspection of the NCS aspects of the licensee's operations were conducted.

The NRC cited the Itcensee for four Most of these violations violations of NCS requirements.

resulted f rom f ailure of licensee NCS personnel to properly or in some cases completely evaluate al' operations using special nuclear material, or failure of operations personnel to follow Continued posted NCS requirements within the f a:ility.

manage:ent attention is required to assure that the violations do not recur.

Regaroing the assurance of cuality i-tne NCS program, the licenset estaclished the criteria to deterWe the tyce of. f acility or The licensee a'50 equipment changes that must oe eva'.1*.ed.

assigred an incividual who was (n:w's:geable in NCS re%irements reviews to the Nuclear Safety Committee to c:-dJCt irdepend % t H,t.er, because this change was and av:its of the NCS program.

not a:e until late in the assessme**. period, impleirentation of the ircependent -review furction was *0t evaluated by the NRC.

The licensee addressed a prob'eT cei:*ibed in the previous SALP (i.

e., no formal chan;e control syitem) and adopted such a syste-Fe.ever, not all eval.ations coa.du::ed with regard to criticality safety we re well documentec to idertify all limits and controls (e.g., ecaluation of arrays of fuel "d carts' located perpendicull-to each otncr) and not all scenari0s with regard to spacing of materials at all workstit'ons were evaluated (e.g., the sinterabity test' hood and' determination of the appropriate spacing _around This failure to consider the global new pellet storage shelves.)

implications of procedural and equi; ment changes requires attenti:-

Those criticality-safety reviews which addresse:

by the licensee.

all scenarios and which were weil d: umented were of appropriate technical quality, reflected a conservative approach to safety, and represented timely consideratice and resolution of the issues addressed.

There were no significant safety ircidents related to the licensee's NCS program during the c.rrent assessment period.

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L.

p To address the NRC's concern about staffing in this functional area, the licensee added a part-time Senior NCS Specialist to l

the staf f to perform quarterly audits and conduct secondary reviews of-nuclear-safety evaluations. This same individual'was retained by the Nuclear Safety Cormittee to per'6rm the required NCS' audits.

internal audits of the facility NCS program were As a result, increased and suf ficient NCS espertise was considered available, i

However, time constraints resulting from non-NCS duties,_ NCS' involvement in both Windsor ard Hematite, and'use of part-time-personnel may have contributed to the incomplete safety analysis discussed above, and cause the NRC-to conclude that staf fing of the licensee's NCS function may still not be appropriate, j

s The NCS training program for the operations staff was improved During training sessions during the current assessment period.

attended by NRC personnel, the f acility policies, practices and procedu al controls re'ated to nuclear criticality safety were r

reviened and_ strict com;,iance with criticality safety procedures i

Recent NRC inspections of ongoing activities was stressed.

i revealed adequate adherente to and understanding of NCS procedures I

by upe*ating personnel.

In su. ary, the licensee nas taken steps to im;rtve its NCS prograe by ircreasing tre professional NCS expertise wite'n the technical i

support staf f, by upgraf ng -tre worker NCS trair f tg, and by imorovi';

procedaral unceastand'r; and acherence.

However; not all NCS evaluations were well c::uceated to identify all limits and contrp's i h egard to spacing of -ater als at all d

and not all scenarios w t

4 workstations were evaluated.

Continued managemert atter, tion is recuired to assare ache-ence to NCS requirements.

2.0 Conclusions Category 2

.e

.oarc Rec:mmendations B

3.0 Licensee

1.

Implement corrective actions to prevent the recurring instances of failure to perform-complete NCS evaluations.

2.

Provide continued management attention to assure adherence to NCS requirements.

I Evaluate ef fectiveness of NCS safety audits conducted by NRC: the Nuclear Safety Committee.

13

e f [-

I b

t

$afeguards - Material Control and Accounting (MC&A) and Physical.

h C,

)

5ecurity b

1.0 Anal _y si s During the previous assessnent period, the licensee's safeguards t

l program was rated SALP Category 2, based on appropriate planning, L

well defined and impletected written procedures, timely and complete audits, and well maintaired records. The $ ALP Bcard made no

[

recomrrendations,

L!.

During the current assessment period, MC&A inspection responsi-L bilities were transf erred from Region I to the NRC Headquarters Office of. Nuclear Material Safety and Safeguards (NM$$).

A total of five MC&A program inspections were conducted, two by Region !

[

and three by NMS$.

Two physical security inspections of the licensee's program for the physical protection of special nuclear material of low strategic significance were also conducted by Region le No violations of NRC safegsards requirements were identified, f)vring this assessment period thc !icensee's PC&L organization and maragement controls.ere improved anc cere fca d to be effective-n in upgracing the perfecance of the licensee in :enducting MC&A Hedver, tre civision of responsibi'itdes Deteveen activities.

the Marager, Accountability anc Sect.rity, and tre Var ager, Nuclear Yaterials, was not c'early delineated anc occas' anal uf ficulties have resulted For enaPple, proposed revisions *o the Fundamental Nuclear Material Control Plan were suomitted to ve NRC staff for comment by one of tre ennagers without the other ranager I

The frag *ertation of respons4bilit es and occasional i

being aware.

ccwnications lapse cet.een these two pcsitions reecs to be s

aedressed, i

loternal procedures used to implement the NRC*accreved Fundamental Nuclear Material Control Plan (FNMCP) were upgraded and appropriate's issued by the licensee during the assessment period.

However, as described in Section IV.1, lack of appropriate technical review resulted in the need for considerable NRC and li:ensee effort to resolve problems with revisions to the Security plan.

The quality of the licensee's submissions was inadequate and improved management l

oversight is warranted.

Throughout this assessment period, the licensee appropriately planned its activities, established realistic priorities and impleinented the written procedures in the areas of MC&A and physical security without incident.

The licensee's audits were complete, timely and thorough, Additionally, records were complete, well maintaired and easily retrievable.

14

f$g

F 7

~"

y l

i:

E During this assessment period, one operational event was reported P

related to physical Security.

The security alarm system for the warehouse was temporarily disabled when an electrical distribution box was inadvertently damaged by a backhoe during facility renovation..

I Compensatory eeasures were taken promptly and maintained until-mi i

repairs were completed.

i The licensee's c.rrent staffing _and~ training were found to be j

adequate for implerentation and mainterance of the safeguards Expertise is available within the staff to resolve program.

licensee or NRC-identified problems.

For example, the licensee appropriately accressed numerous open NRC inspection issues which f

subsequently were closed during this assessment period, In summary, imolemertation of the MC&A and ' physical security l f'

programs by t*e licensee appeared to be well planned and. appropriate'.

during the assessteet period.

Staffing and training were adequate.1 K

as was response to a security-related incident.

Wo ever, the cuality of the lice *see's revisions to the. security plan was.not' P

always accept,tbie ard the division of responsibilities related i o Y;iA cause: e:casional problets.

t 2.0 Con:1usl:ns Category 2 3.0 Bosed Re:orre*:sticas l

a 5

licensee: Add'tss t*-e Communications / interface p*oblems that hast opa:ted FNMCP and security plan revisions.

NRC: Corcuct a*. ins:ection of the training and staffirg of the liter.see's !a'eguards functions to ensure t*at acequate support of 'ut.re operations is retained.

t i

a e

1 15 i

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.6

.,=

7 D.

E_quipment Maintenance b

1.0 Analysis During the previous assessment period, the licensee's equipment maintenance program was rated SALP Category 2.

Problems were ire.tiiiec with respect to the tradequate mainterance of ventilatica t

systems, fuel' powder containment devices and pellet fabrication

'(

equipment.

Late in th4 previous period, the licensee initiated q

a facility and eQuipm 't upgrade program.

Antiquated pellet i

L fabrication equipt;-

q' replaced with (tate-of the-art equipment.

The SALP Board recommended that the licensee continue emphasis on correcting the problems previously identified in this area.

3 q

Two routine inspections and one special team inspection of the o

licensee's-ecuinment maintenance program were conducted during.

j.

the assessient period.

No violations related to equipment I

maintenance er; identified.

-To im; rove equipment performance, the licensee developed and' t

i implemented a preventhe mainteran:e (;V) program for f acility e wirrent.

This effort continue: the e ohasis_ begun during the Previews assessSent period. T he PV. ;*: gram utilizes a computerize:

re taat 5:re:/ es for mairtenance activities tracki*g. system to enso piece of ecuiptett 6te corsiste*tly tracked and tFat on eact maintenan:e records fer major p'e:es Of equipment are complete,

.}

well raintained, anc astilaDie.

T*.is ::mputerited system has-been effective in ensuring equi ent :perability.

?

Ir addition to the FM program, t*.e li:ersee established a formal system to ersure that eetairs c' e;.,i: ent that support f acility timely fashiori i

operations are properly plannec aed c:

leted in A The status of equiprent repair.4 5 re;;rted and controlled by the use of an Equipment Status Repert (ESR) that is upcated and.

published daily.

This ESR program ertures that the sch-duled repair of safety-related equip <ent is given an appropriate priority compared to prodsct-re'ated 6:vipment, and it confirms that repairs have been completed.. Im:lerentation of the ESR 1

program was. assigned to two Operations Shift Supervisors, who are responsible for coorcinating interactions between licensing, safety and production personnel, and ronitoring the repair and These actions reflect I

maintenance of facility equipeent.

excellent management attention to the assurance of quality in the program.

The licensee identified the key staff positions &r.d cefined the-responsibilities required to support the upgraded equipment maintenance programs implemented durir; the current assessment period. The administration of the PM ;rogram was assigned to the N

a licensea's Manuf acturing Engineering group, which included a full-tima group totaling five engineers and hourly personnel.

This group ef fectively maintained the backlog of open maintenance items at & Icw level during most of the assessment period, although an aggressive ef fort near the end of 1989 was needed to This effort reduce a burgeoning backlog te acceptable levels.

also reflected appropriate management attention to the program.

The individuals who perform repairs on facility equipment are cualified by Mainterance Department supervision. This mar,agement oversight mace a positive contribution to the understanding of work and adherence to procedures, as indicated by few personnel errors.

The redeployment of equipment to the licensee's Hematite facility was initiated dveing the assessrent period, This operational event was well p'anned and coordinated by the licensee.

In summary, the NRC did not identify any concerns in the area of The licensee successfully conceived, eovipment nairte-an:e.

staf fed, imolece ted and has taintained a orogram stat very ef fectively a: essed the pr::' ems that previously existed in this area, 2.0 Co.telusi on s Category 1 3.0 Board Retoe eedations None 17

'I o

E.

Radiological Controls 1.0 Analysis I

'In the previous assessment period, the licen wa's radiological controls program was rated SALP Category 3.

Thu as'sessment was i

based on widespread programmatic weaknesses and ir.acequate Staffing was marginal with' maragement support of the program.

high turnover, health physics training and qualification of both plant operators and health physics staff were minimally acceptable, there was a lack of clear and concise health physics policies,-

procedures and practices and there was a generally negative att_itude An exception to the generally toward safety by plant employees.

poor. program was the environmental sample analysis program, although weaknesses were identified in the licensee's environmental monitorir; and control program. The SALP Board icentified several problem' areas and reccetenced that the licensee take actier to address these problems by: espanding and mair,taining a te:hnically qualifie:.

professional radiation protection staff; reviewing and revising, l

3 1

as necessary, the f acility Radiation Erotection (R&) program; placing high p*icrity on the establishment, conc'etion and.

implementatior of ritten radiation :rotection pre:ecu es; and, r

ey promu'.irg an 'treesec attitude tecard radiatioC safety by plant workers.

There were sin r u ine inspections anc one spec *a' team inspection In the of radiologica' :orttels during the assessment reded.

early part of sne currett assessment period, tre ' espe:tions

.ere conductec peinarily to monitor tre licensee's pre;ress and allow time for c:rrection of deficier:ies iderMfied ir ne previous tae efore, routine insre:tions for cvpliance with sal.P Reocrt; regulatory re:vi e ents did not begir until later in tre assessment i

in Table 1 of this report, the 'en irstections period.

As show e that fo:vsed on regulatory compliance in the area of raciological i

Six of-controls icentifiec nine Severity Lesel IV violat ons.

the cited violations were identified in the last irspe: tion of i

the assessnent period. After the end of the assessment period, the licensee, in its response, contested five of the six violations.

That response is still under NRC review.

Although some improvement was noted, the-overall quality of the i

period was considered RP program during the current assessmentDeficiencies in the licensee's intern minimally acceptable.

audits continued to be observed.

For example, there was no established mechanism to ensure that corrective actions were taken to address deficiencies identified in the monthly audits of the RP progra'n conducted by the Radiological & Industrial U

l:

18 i

?:

l

r Safety (R15) Program Manager.

(The RlS Program Manager is the corporate-level manager who establishes the proper technical bases for the safety programs, whereas the RlS Manager described belew is the plant-level manager who develops tre implementing procedures and is responsible for day-to-day RP activities.) As e

a result, there was a tendency to correct only those deficiencies that were easily resolved and leave the more difficult problems uncorrected.

Also, the licensee's Radiation Deficiency Report (RCR) System was considered weak.

The NRC noted that responses i

to RCRs did not address root causes; criteria had not been establis*e:

for initiating an RDR; and it was uncertain if edserved deficiencies were being consistently recorded by the RDR System.

The licensee made some improvement in the quality of the RP program by developing a formal, written radiation protection program. A hierarchy of documents was established, running from administrative. policy statements at the top level through program doc. tents to implement 4; pr::edures at the 10aest level.

At P e beginnirg of the a?sessment period, the licensee initiated this projet*, to.pgrade its system of C0cumentation by using an existing cor;; rate group of procedure writers. Tre licensee subsecuently Pad difficJty imoletenting t*e rewly ritten Radiation Erete:tica InstrucCors (RPIs) due t: ar ap;arert break::wn in c ce.rication tet.etn *.he RP staf f a*: the or:ce0.re writers, aho were 'tempecier:ed in the licensee's f.ei 'acility ooerations.

A1 5c. tne first ve-s'or of the new R;Is that ere written by the cer:: ate grove :' proce:.re writers c:*tained ;eteral technical infor at'on wa'ch.45 rot needed by t*e RF te:nnicians to perfor* tre :etaile: irr:'ete* ting procedJres.

1.icensee rategerent cecided to p'a:e the genera' technical infor at :-

ir "Frogeat Documents" and retait the deta'le: 'nstructions to te:hriciars in the RPIs.

As a result irr:1 eme* ta t'on of the u:;raded Rfis was significantly ce'a,ed, and ve task of performir; a tajor revision of the ne.ly.ritte* RPIs was reas signed to the esisting R0 staf f traragement.

At the end of t*e asses 5xent perio:.

t*e " Program Docume*.ts" f or each of the f ateti:*al areas of the overall RF program had been comp'.ete:. but the licensee was still in the crecess of identifying ano correcting oefici encies in the implementing RPIs.

The usefulness o' these d;;.Terts could not be ef fectively evaluated by the NRC tecause they had not been ie;1emented for a sufficient tire period.

Relative to the problem of workplace attitude tcward radiation safety, discussions held by inspectors with w:rkers and supervisors during the NRC team inspection in September 1929, and the health pnysics inspection in February 1990, indicated gra $ual improvement in safety attitude throughout the assessment period.

This is an

}

apparent result of the licensee's quality awaeeress program, which is further described in Section IV.G.

I 19

m j 3

~

g The licensee's resolution of technical ' issues gererally was poor.

For example, an independent health physics appraisal, conducted early in the current assessment period by a licensee-ccntracted consultant (Bechtel), revealed technical. deficiencies in the radiological controis program, and the contractor recommended p

corrective actions to address them. A review by the NRC during L

the latter part of the assessment period revealed that.the deficiencies had not been addressed by the licensee.

The NRC also identified technical deficiencies in the licensee's RP prograr*,

3

[

such as inadequate'bicassay evaluations of internal radiation.

exposures and of beta correction factors for external radiation j

These technical deficiencies were not resolved by f

exposures.

the licensee, primarily due to inadequate technical resources ij within the RP staff.

Throughout most'of the assessment period.

the tast of identifying and correcting the technical.dtficiencies D

i in the licensee's RP program was left to the existing professional RP staf f, while they contarrently performed tre caily duties associated with ongoing facility operations.

Trere were no.significant operational events in the area of radiological controls dsring the current assess.ent period.

Throughout the correct assesst*ent, period, theet was a lack of f

licensee fraragtment sucport for an acecuate RE s'.aff.

The licerste ircreased the ratio of litersee employees to cortractcr employees within its RP tecenician acrkforce; nc ever, it # ailed to fecrease tre pr:fessieral RP staff. At the enc of tne previous period, I

the licensee had nly che degreed.raciation safety prcfessional (i.e., heal th ' phy sici st). The previews SALP reprt ncted that the licensee 16cted a tecnnically qualified, tre'essicnal RP staf f, a point also -ace at the beginring of tre corrent assesste**

period by tre noove-tentioned incepencent coesu'tants. By the end of tne current assessment period, the licensee hac failed to l

increase the professional RP staff.

A qualifiec health physicist was reeded for the position of RIS W rager, a key position that was not fillec Dy a technically cualified incividual throughout the assessment period. However, licensee managenent did not aggressively pursue the recruitment of a qualified health physicist until the last few months of the assessment period. As a result of inadequate staf fing, the licensee's RP organization was not effective in its attempt to develop and implerrent technical upgrades to the overall RP program.

The licensee's training and qualification program for the RP staff was poor.

This contributed to a poor understanding of work requirements and occasional procedural violations.

The training program for RP technicians was minimal at the beginning of the assessment period, and the licensee did not begin to 20

m,,.

a 44 0 '

^

s i

s implement'an upgraded training program until mid ay in the period, then allowed it to lapse near the end of the period.. Discussions o

with several RP technicians regarding various aspects of the RP l

F duties indicated additions) training was needed.

For example.

some of the RP technicians did not _know how to properly perform and document beta surveys, or calcu' ate MPC-hour exposures from L

As a result of this failure to develop air sample measurements, the RP staff, there was essentially no change or improvement in the technical capabilities of the RP organization compared to

[

the previous assessment period, and it continued to be poor.

~

b in summary, some improvement was noted in the overall workplace i

attitude toward radiation safety and in the programmatic docu-mentation for the RP functional areas. However, licensee management j

did not provide the professional staf fing resources necessary.to develop and implement tecnnical upgrades needed in the functional h

f areas of tre RP program.

Therefore, technical irorovements plannec by;the licensee were delayed or have not occurred, training and qualifications of the RP staf f was not impreved, technical deficiencies identified by ircependent audits were not promptly addressed er not addressed at all, and the NRC'continved to,

identify aeditional ceficiencies esting the assessment period, 2.0 Conclusiers 7

Category 3 3.0 Recoe endations Lice r.se e : 1, Promptly fill'the Manager, RIS, pcsition with a technically cualifie: individual.

Maintain a technically cualifiec, professional' RP 2.

staff.

(Reeeat recem endation fromLprevious SALP report.)

3.

Establish anc impler.ent an upgraced RP technician training program, 1

4 Address and document actions taken on each of i

Bechtel's recommendations.

5, Continue to improve the workplace safety attitude, i

?

l i

D

C; 4

F.

Emer3enedreparedness 1.0 Analysis During the previous $ ALP period, the licensee's emergency preparedness (EP) program was rated SALP Category 3 based on deficiencies in the Radiological Contingency Plan (RCP), Emergency Action levels, emergency notifications, conduct of drills and esercises, t*sining program, Eme gency Response Organization (ERO) staf fing, and independent audits, The $ ALP Beard noted one problem in particular and recommended'*. hat the licensee address this problem by conducting i site wide demonstration of the RCP which includes of f site support groups.

In the current assessment period, the licensee's EP program was reviewed One violation during four routine insoections and one team inspection.

was issued for failure to perform drills with offsite groups in 1988 required by tne RCP.

Corrective action was adequate and met minimum 45regulatory reavirerents in that a crill of the fuel maavfacturing f acility (Buildings 17 and $) conducted in November 1959 included checks of ccmunication links in lieu of sit,e participation by of f site H0. eve', the licensee did not aporotriately address support grouDs.

the prcblem icertified Dy the previcas $ ALP Ecard, nately to conduct a site. ice exercise, heluding of f-site support gro,ps.

As noted ab0ve, a rajo" coretrn a* Pe beginning of ttis $ ALP period was tne lack of a cor;*ettesi e RCP that icentified aceQuate Fat 49ement v

support of t*e ERO.

bis corcern and ee cefic'e*cies icentified abo,e resulted in crills trat.ere limited in scope arc.ere not ef fecthe tests of the 'icetsee's abil'ty to nanage serious ractation emergencies.

In July 1959, de lice *see submittec a revised RCD to accress these While a.aiting NRC ator: val of the revisec RCP, the licea.ste weauesses.

cevelopec are ao pted, for its exist ng RCP, new orceecures that i

incorporated eletents o' the RCD that had been submitted to NRC.

This resulted in an imeceved prog,am, despite self-icertificatien by the licensee of scPe deficiercies wren the plan was tested in November 19B9 in the licensee's annual EP exercise.

Despite lice *see manage ent's efforts to inprove the cuality of the EP program, some deficiencies still exist.

For exat;1e, audits of the EP program have been performed by senior personnel who had responsibility for implementation of the program.

Deriodic independent reviews by knowledgeable individuals are needed te assure that an effective program is in place, 22 l

l l

I

-.ii,...

p I

w E

c In_ the latter part of the' current assessment period., additional. staffing i

l L

resources were assigned to EP, thus allowing the licensee to more efficiently carry out administrative aspects of the program and to meet the commitment to ensure 24-hour availability of emergency directors l

(ED) and other key responders.. Hewever, the training and qualification F

program for ERO personnel was not well defined.

Training on revised implenenting procedures began past.the midpoi_nt of the period and was incomplete at the time of the NRC's on site review of the EP program.

The onsite training crills did not test the. integrated capability of the RCP, and communications capability with offsite groups was

~'

L, demonstrated during only one of the shifts drilled in the November n

1989 exercise.

The licensee's Independent Task Force (11F) identified several.

q deficiencies in its review of the EP program near the end of the 3

E assessment period.

These ceficiencies might have been identified'

['

scorer if a program of periodic incependert reviews had been establisFed.

The lif findings included the absence of a clear assignment of ERO ma*agement responsibility and a lack of defined ecmmsnications procedures l

anong various onsite and off site support gresps.

Both of these findirgs are similar to= concerns identified by NRC ir t e previous sat.P. The licensee's actions to aedress the ITF's fincin;5 Fac not teen revie.ed

('

by 'AC as cf the end of the assess ent period, b.t tee icentification of t*ese f 4 dings by the liF inc(cates a lac ( o' -aragement attention te the Eo :rogram, t

A'trowgn t*e licensee's resolution of certa'n tecFndcal issues (such as the cefinition of " facility bov*dary" as "at the #4cil~

'ence line" or as "at the site boundary," anc clearly cef 9ed et ency action levels) was delayed, by the midcle of t e period some EP pregram l

er*aacetents, in addition to the RCP enharcete*ts discussed above,

.ere ir. ev dence.

These included upgrade o' e trgeacy response facil't ts i

and initial attempts to develop a closer interf ace with of f site sur; ort Af ter conducting the Nove-ber 1959 drills, improvements (as

,j greurs.

determined by review of licensee crill cHtiave records) were made in employee attitude in carrying out assignec tasts, performance by tr:lant repair and corrective action teams, and mere efficient tests of building evacVations.

In sumary, early in the period, management cc mitment and support to-EP was not evident.

Toward the end of the period, however, the licensee began to focus attention on the actions necessary to attain improved perforcance.

Progress in the program was made in areas of the RCP and implementing procedure development, management and staff involvement, emergency response facilities, and interface with offsite j

However, key licensee commitments either remain support groups.

incomplete or did not receive attention until the latter part of the period, including training and Qualifying of E C personnel on new implementing procedures, conduct of a site wice exercise, and correction of the ITF findings.

L i

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'i 2.0 Conclusions.

a s i Category:3:

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-30 Recommendations" ih U

s Conduct a site-wide demonstration of the' emergency:

4 Licenseef 1.

. plan and include of f site support groups'-(repeat.

p'

~ recommendation).

u

-I J

Enhance operator and ERO training on responses to

' (i.

2.-

fire emergencies.and new implementing procedures.

y,

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,,y NRC: Observe a' demonstration exercise of.the emergency plan..

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G.

FaSagement Controls 1.0 Analysis During the previous assessment period, Management Controls was rated Contributing to.this rating was.little evidence that 7

$ ALP Category 3.

the licensee improved its self-assessment ca; abilities, and ineffective l

management controls that contributed to poor compliance with regulatory The SALP. Board identified several problem areas and

^*

requirements.

recomeerded that the licensee address these problems by improving l

self-assessment capabilities, developing an internal inspection and audit program and increasing the ef fectiveness and meeting frequency of the Nuclear. Safety Committee (NSC).

Five reptine inspections and one special team inspection of management One violatien 3

controis ere condseted during the assessment period.

of regulatory requiretents was icentified with regard to training of operations personnel.

i Overall, during this assess ent period the licensee made progress in An addressing the problets identifiec in the ;tevious SALP report.

inteeral irspection ard ascit pro; ram was ce, eloped ard activities of the NS: initially.ere increasec.

H: wever.. hen the Vice presice*t-% clear Lel (VE-N~) retired in ve lattee eart of 1989, I

the Vice Fresicen', ane Gee.e-al Vanager Nuc* ear Fuel Manufacturing The VF-G", who was (VF GY1 was cesigratec as t*e Acting VF-NF.

rester.Jble for imoleier. tin; P e Ociear F,,el Integrated borove'rert Plar (%; IIP), was not repla:ed.

Following nis elevation to t*e VF-NF i

positier, much of the resorsibility for t*e NFilP.as delegated t0 the Piant Yaeager of the % : lear Fuel Marv acturing facility, an To assist the P' ant inci ic,a1.ith litrited f ael f acility e.pedence.

arege and to helo relieve the NSC of its day-to-day responsibilities, v

v the licensee establisted a :acility Review Group (FRG), and amended its licease to establish the dut es of the group and to specify the i

The licensee retained the NSC to provide d

qualif4 cations of its memoees.

The FRG was charged with the review of safety-related oversight.

practices and trends, emergency planning, the ef fectiveness of the

[

ALARA trogram, inspection and audit reports, abnormal or unusual events and any proposed facility or operational cranges involving criticality i

t Preliminary evaluation by the NRC indicates or radiation safety.

that the members meet only the minimum qualifications specified in

~

the license, and several members have little or no fuel cycle experience s

However, since the FRG was only recently organized, the NRC has not yet assessed its effectiveness.

Two self-assessments of licensed activities were conducted by the licensee, but both were performed only after being prompted to do so by the NRC.

No continuing independent assessments are planned by the 25

e c

e A

licensee. This remains an outstanding issue, with the NRC continuing to believe that an effective self-assessment program must include periodic reviews by technically knowledgeable individuals independent of the Windsor f acility line organization in order to ensure the quality f

of licensed activities, it was noted that, although the licensee established an adequate internal audit program, no independent audits of radiation safety, criticality safety or the emergency planning programs, other than those associated with the self-assessments, have been conducted, Corrective actions have not been addressed and documentee on those programmatic deficiencies identified during independent consultant audits of the radiation safety program conducted as part of the self-assessment performed at the start of the current sat.P period, However, a review of the licensee's self-assessment reports by the NRC indicated that they were comprehensive and effectively l

identified prograwatic weaknetses in the licensee's NRC licensed

~

in the previous SALP report, NRC noted that the licensee

programs, i

did not " apply appropriate sections of the f acility quality assurance c

program to the f acility safety and compliance activities".

During the current SALP period, no evidence was found that the licensee acdressed this problem to any appreciable entent, since audits of f acility crerations or safety crograts have not been conducted by or for f acility Quality Assurance pers;nnel.

Dsring the assess?ent period, the licensee initiated a performaate.

in accoccance.ith the 4;recrents documented in itpreverent prcgram, C a'. SS-23.

Also in accordance witn CAL $5 23, periodic reports on tFe status cf coroletien of tnis increvereet crogram.ere provi0ed in writing and during n,arterly treetings w'th the ARC staf f, The NRC staf f esperienced dif ficulty in s cerstanding how the status e

inferrat on prcvidet by the licensee related to correction of the i

recMers that resultec in iss.,ance of CAL 5B 23, This concern aas 4

ciscussed with various levels of licensee anage ent, inchding the President of the Nuclear p:=er Bustresses Division, but only litited improvement in co-munication occurred.

Further, the licensee reported to the NRC that as of the end of January 1993, the llP essentially was complete.

He.ever, the NRC staff noted that 6

portions of the program related to radiological controls, emergency preparedness and licensing had been either not successfully or not completely implementec, as discussed in these respective sections of this report. This problem, combined with the communication concern discussed above, suggests that the licensee should address ways of improving communication with the NRC, At the start of the assessment period, policy statements with regard to safety were poorly stated or nonexistent and were not distributed However, the licensee revised these policy statements, to the workers.

incorporated them into an employee handbook, and issued it to the Assessment of this handbo0(

workers at the end of the assessrent period.

26

f.

9 4

O e

by hRC indicated that the workers were provided with appropriate policy statements relative to general safety, use of drugs and alcohol, Security, industrial safety, radiological and criticality safety.

In the previous SAlp report, it was noted that the licensee had not established a formal mechanism to assure correction of noncompliance itets or completion of other commitments, and recommended that the liceesee establish a commitment tracking. system to address this problem.

Durirg this assesstent period, program documents were written that F

cescribe a commitment tracking system and the methods used to track tre conmitments made, it was noted that the program documents did net address or establish a single point of responsibility to assure that actions on all commitments were completed, that no mechanism was established to assure that due dates were provided for each tracked issse, and that no mechanism was established (e.g., review or audit rec.trement s) to assure that each commitment was closed and verified.

The licensee established a system to review, investigate and correct att:amal event o:currences during the assessment period.

This system pr,'ded guidance to licensee employees witn regard 10 the conduct of devestigation, t*.e determination of root causes, and the establishment aec' t:rrective acti:n prograts to eliminate identified root causes, i

i*e system apreare: to be ap:ropriate fcr tne rev e* Of abrormal events.

4

':.e.er, d rirg a -eview of tre non-routire events trat occstred during t*e assesstent per'oc, it was cetermined t*at three o' the five esents ces:rited in Table 3 (atta:re:) cire:tly a'f ected coe*ations at the

'.ei manufacturing facility. Ibere as no indicatior that there was ea a;ement invol e ent to ass re that an a::ropriate -azards assessment was corductec prior to the start of work 1: determire if the activity C:,'O af fect the f.el f acility operatier. (e.g., revi a of site plans t

t: ' d e a.t i f y tre ;*esence of.nderground gas lines or electrical c:':uits).

at the start of the assessment period, the position of Manager of 4:'ological and Pdustrial Safety, who is responsible for implementatio-o' tre radiological and industrial saf ety program, was filled by an irdividual who did not have the necessary expertise in these areas.

Inis individual was removed f rom this p0sition about midway through t*e assessment period and the position remained vacant through the e*d of the assesseent period.

Aggressive action to fill this key position is required In general, during the assessment period, the licensee's operator training and retraining program was well defined and implemented for a large portion of the staff. With minor exceptions, the training program was effectively implemented and was considered by NRC to be iPproved since the previous SALP.

However, it was also noted that f0r about six months during the assessment period, operating management i

3 27 l

N o

.w, p; t f'O had been sent lists of personnel in their departments who needed

)

retraining, but little action was'taken to ensure that the listed j

l' personnel were retrained.

The licensee tock action to correct this deficiency after-it was identified by NRC.

j l

t In order to improve the workplace safety attitude the licensee, in-

,f con.bnction with a contractor, developed a quality 4.artness program.

~

i Training associated with this. program'wa5 provided to all individuals working in the Nuclear Fuel Panuf acturing - Windsor eeganization.

There were positive indications, based on discussions with workers l

and supervisors, and observation of improved adterence to-safety p

procedures, that the attitude of workers toward safety and procedural

4 compliance was improved.

oj' In suenary, during this assessment period, _maragement improved controls related to the review of abnormal events, training of operations E

personnel and the establishment of' a cuality a.areness program to A commitment tracking system

-improve,the workplace safety attitude.

No was established, but guidance for implementation was incomplete.

program for continuing indeperdent assessments was established, and-corrective actions on program deficiencies icenti_fted during contractor

'aucits of the raddo'ogical protection and Nelear criticality safety program ere not accressed.

The NEllE wH re:orted t: NRC as corpleted, 4

but' the licensee exper'eacec cif ficulty coavicating the results to NRC in an effective matree, and NRC ena'sation in otrer fu ctional n

areas svg;ests that aeditional work retains.

An ina:eauntely Qualified inciviosal had been assig ed by the idceasee to a key plant safety marage ent position, and af ter his removal the pcsition remained vacant through the end of the SALP period.

The qualificatio*s;of the FRG re-bers aere minital.

In addition, tre licensee die rot adcress a previously icentified problem involvirg the f ailure : apply ar;ropriau u

se:tions of the f acility quality assurarce program t: the facility safety anc ccmpliance activities.

[

2.0 Conclusions Category 3, improving 3.0 Board Re.ommendations Licensee: 1.

Apply appropriate sections of the facility quality assurance program to the facility safety and compliance activities (repeat recommendation.)

F 2.

Establish a mechanism to assure that a hazards assessment of site maintenance activities that could affect facility operation is conducted prior to the start of work, h

NRC: Evaluate the effectiveness of the FRG.

1 28 m.

y~.

1 H.-

Fire Protection 1.0 Analysis In tre previous assessment period, the licensee's fire protection program was_ rated SALP Category 2 based on the licensee's lack of e

responsiveness to an assessment conducted early in the period.

Ho.ever, the licensee'$ subsequent corrective actions included upgrading of ecuipment,- training of persennel and testing of equipment. The SALP Board made no recemeerdations.

There was one inspection of the licensee's fire protection program,.

No violations l

which was conducted at the end of the assessment period.

1 l

were identified.

The licensee's f acility equipeent inspections were generally adequate l

and performance data were generally cc-plete and well maintained.

l Equipeent systems tests anc/or inspections were condu:ted..as appropriate.

.eekly, monthly, quarterly, semi annually and annually on fire-suppressi:*

system preaction valves, cressure regulators, heat cete: tors, sprinkler i

system alarms, post incicator valves, gate valves and. et and dry

.sorirkler systems as rec:t enced by Natier.al Fire Prote: tion Association (N pA) coces.

~Ya'agerent rade some pec;ress in the resciution of te:hnical ard safety

[

l increased earagement attentio* as directed tc. arc the centrol

issues, of combustib'e materia's througbcut the fuel ennufact. ring facility,'

f and-housekeeping pract'ces.ere significantly improved.

Fire extinguish s

.ere relocated to apprcp inte locatiors tnrougneut -tne 'acility, j

Also, these extinguishers were routine'y inspected as reccnmee.ded by l"

NicA fire safety codes.

A " program de:grent".45 written that describes t*e everall fire pr:tect'on program.. Oetailed ieplerenting procecures

.ere still under develep ent at the enc of the curr&nt assessment

[

period, although the p*evious SALP ree:rt roted they.ere scheduled for completion by mid-1939.

The licersee also f ailed to develop a written fire pre-plan as part of these implementing procedures to.

address such technical issues as the use of' water on fires in areas cor.taining fissile caterial.

There were no other significant NRC concern, requiring licensee response identified in the fire protection

+

area during the current assessment period.

However, the licensee continued to address concerns identified by the NRC in the Operational Sciety Assessment conducted in August 1986.

There was one operational incident related to the fire protection program during the current assessment period.

A natural gas pipeline-7 The leak was ruptured while remcving tree stumps near the facility.

was isolated, the facility was evacuated, and the local fire company was called to the site as a precaution while the leak was repaired.

The licensee's response to this incident was appropriate.

29

)

4 v

w

r

+

l Licensee management has provided adequate staffing and en,pertise in the area of fire protection. The licensee established a new position, entitled " Industrial Safety Specialist," to focus more attention on in the latter part of the period, an the fire protection program, appropriately qualified and experienced individual was assigned to the position and given the responsibility of developing implementing procedsres for the fire protection program.

In sumary, the licensee increased management attention to the fire protection program during the current assessment period, provided additional staffing, and properly maintained the upgraded equipment installed late in the previous assessment period, but had not established or implemented a fire protection pre-plan.

2.0 Conclusions Category 2 3.0 Beard Recommendations Lice *see: Develo a written fire pre-plan for the fuel cansfacturing

facility, MC : Ccaduct a 5:ecial inspection of the licersee's fire protection program.

30

L e,,

p.

~

E

.,A 1,

licensing issues i

1.0 Analysis in the previous assessment period, the licensee's administration of This determination F

the licensing process was rated SALP Category 3.

was based upon observations that the licensee submitted atendment applications that required numerous revisions, some of.which conflicted with previous applications, did not adequately confer with NY$$ prior L.

to submittal, and did not nake proper use of applicable Regulatory e

L Guides.

However, durdng the latter part of the previous assessment

~

period, improvements were recognized as the licensee assigned a dedicatec staf f to the licensing function and began to address the NRC's suggestions for improving the clarity of its license submittals, The SALP Board identified several potential problems and recommended that the licensee address the problems by continuing the use of a dedicated staff, assurin; L

that the dedicated _ licensing staf f is trained in the ; reparation of Part 70 license modification submittals, and provici*; adequate technica*

i:

support for the licensing staff,

_ During the curreet assessment period, the licensing %nction.

occasionally suffere: f rcm inef fective rena;ement c:*t ols, During a 3:e:ial terr irspectice conducted 'n September 1969, the NRC (dentified l'

eat tne interf aces ::etween tre piant staf f, the te:**ical suppnrt staf f, and the ruc* ear licensing staf f had not been c*early cefinsd by ransgement or written in an ace nistrative procec.re. This absent-of policy atd cirecticn contriouted to lack of ccorc' ration between tFese. separate licea.see staf f s, and decreased the c,e*all ef fectiveness of tne licensin; function.

An eranole of this occut ed during this t

assessment perio een tFe licensee submitted a cet;'ete revision to its security p'an for NRC review and approval, The revisien required extensive anc repeated ccmnsnication tet.een the l'ceasee and the NRC cver an ertended period to resolve discrepancies,

• • e Quality of the r

licensee's ef f crt csring this security plan' revisier eeflected a' lack of.communicaticn bet.een the licensee's operational and licensing-staf f s, and therefore, better maeagement oversight a:cears warranted, An administrative procedure for the licensing funct en was_ being writter d

by the licensee at the end of the assessment period, Dut it had not been reviewed, approved or issued, In addition, dif ficulty in the resolution of technical issues in safety licensing submittels was a significant f act,or in the issuance of license Of the eight safety amendment applications submitted by j

t amendments.

the licensee to NRC, two containec significant technical inadequacies

'c and several others contained at least some technical inadequacies, For example, the licensee's submittals did not always provide limits f

a and controls to prevent all postulated criticality accident scenarios.

This issue occurred consistently throughout the assessment period, l

g l

l t

31

e u

$of !

..L

!p c.

l i

Resolution of these inadequacies of ten recaired extensive cc%unications between the NRC and the licensee, causing-celays that largely could j

li have been avoided if the applicationt. bad received adequate technical l

J review prior to submission to NRC.

?

Staffing for the licensing function was adequate during the current-

. assessment period.

The licensee utili:ed a full time licensing staff, l

h: wever, the Windsor technical support staff (which assists-the licensin; l

staf f) also provided assistance to the licenfirg activities.at the licensee's Hetatite site, and this increased workload apparently had a detrimental ef fect on the'overall-technical adequacy of the licensee's

.l submittals during the assessment period.

Lack of acequate technical h

support to the licensee's licensing staf f is believed by.the NRC to

'[

be a continuing problem that requires management attention.

Dsring the course of the current assess ert period. the licensing staf f acquirec r:re experience ar: be:6 e Fore c;alified in the pee;aration of license sut:mittals. -Ey the end of tre period, the.

licensing staf f rad demonstrated an im;*cied u derstancing of. Part 70 l

r licensing.

.}

i h s' mmary, t*e ' ice see had an 4:eQ, ate :entf eg 5*,4f f curing ;the assessrent' :erict, but cordnued to es:er ance cif f':ui ies receiving:

d t

ade:, ate te: vical support for li:ensie; 'is'.es.

TH s resulted in 1

the need f o" f re:,,ent corrsnicatd:ns ndte *RC to res:1ve. technical rttee improvement in discrepancies ir license n' enomert rea.e5*l.

s this area is warranted.

2.0 Con:1usions

'l Category 3 Rec:weneat oes d

3.0 Provice ade4Vate technical 5,:p;et 10 the liten$ing staff

(

licensee: (repeat recommendation f rc,m pre,dous SALP report,)

-p i

W 32 i

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V.

$_vyporting Data __and Summaries A..

Investigations and Allegations Suwary i

A total.of 35 allegations were received by.the Region 1 of fice during l

the assessnent period.

Of this total, 25 allegations were made by two different allegers, and 8 of these allegations were $1milar. By the end of.the assesseent period, the NRC had closed 30 of the allegattors.

Fifteen of the 30 allegations were substantiated.. Corrective actions l

were initiated or completed by the licensee on. the ider.tified issues.

.B.

Escalated Enforcement Action L

As a result of programmatic deficiencies identified during the previous assessment period, Confirmatory Action Letter No. CAL 88-23 was. issued

.on September 9,1988, at the t'.ghning of the current assessment Period.

6 That confirtatory action letter eequired' the licensee to 1) establish.

'a Perfortarce Impresenent Program (FIP), 2) :enduct a self-assessment

[

of all licensed activities. 3) rett with Region 1 persennel to present E

plans for the PIP, c) update the PIP on the easis of irformation generate:

during the self-assessment, at ; (5) provide NRC witr a monthly status '

The report on tre PIP and scre:,ie stat,$ reetir;5 cuarte*1y.

self-assessrent was ccmpleted Of Ja*.ary 31, 1959 an: tre PIP was completec by Jansary 31, 1990, Shse: vent to complet :n of-the P!P l

i tFe licensee initiate: concuct of a secced self-assess ent at the re:tuest of the NRC.

The se:or: sel'-assessient was c:?pleted by March 31, 1990.

The. licensee ':entifiec or:;rarsati: :eficiencies in L

tre areas of criticality safety, ra:iological contre's and licensing.

C.

Parace-ent C n'ererces Two raragecent ecnferences were hel: daring the assess ent period in accor:ance

~

cther then the q,arterly PIP status meetings condu:te:

with the Ccrfirmatory Action Letter.

The p;P-status teetings ere held on Jarsary 17, June 27, a*d October 5,19B9, ar: on January 4, 1990.

1 A managerent conference was ccaducted by the NRC at the licensee's site on October 26, 1938 to provide the licensee wit

• the results of the SALP assessment for the period July 1, 1986 to J ne 30, 1988, These results were provided in SALP Report No. 70-1100/86-99.- A second management conference was conducted in Region 1 on February 16, 1989, at the request of the NRC, to discuss the licensee's reasons for not issuing Radiological Protection Instructions by Dece-ter 31, 1989, as required by the schedule provided in the facility PIP.

33 l.

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=

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m a

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'g ABB Combustion _ Engineering. Incorporated E

e V

Enforcenent History July 1.1988'to Present j

.1990 Inspection Report No.- 070-1100/90-03: Six violations in. Radiological Safety.

St.4 Failure to evaluate adequacy of beta measurements.

.5L4 Failure to issue termination reports.

r

. Failure to issue proper. dosimeters.

SL4

'$L4.

Failure to train HP techs.

t SL4-Failure to evaluate representativeness of stack samp1ing.

I Failute to evaluate sa ple representativeness of inp' art general air.

I L

$L4

-l samplers.

After the end of the assessmer.t period, the' licensee i*c'cated that (Note:

additional pertirent infortation.as availaMe and requested re::esideration'

'of five of the six violations fr:. Irs;e:ti:. Report No. 070-11:0/90-03.)

i f

itat re;uest is under consicerat'en b the NRC staff.

Inspe: tion Report No. 070-1100/9:-02: One violation in Cri ica'ity safety.

t lL 5L4 Failure to maintain re:ords of criticality safety eva'.ations.

a Inspe: tion Report No. 070-1100/9;-01: Ma age. tent Conferen:e. N: violations.

i 1959-Inspection Report No. 070-1100/E3-07: Two violations in Radio'egical and.

u Criticality $afety. The violation in Radi0 logical Safety was r:n-cited.

j I

SL4 Failure to maintain twenty-foot; spacing between two 'a rays of shipping containers.

f SLS Failure to post a "seatainer" on all four sides with (NCV)( ) Cau' ion-Radioactive Materials signs.

t 9

-(

Inspections-conducted at the beginning of the assessment period were conducted to monitor the licensee's progress toward correcting program?$ tic deficiencies, rather than to focas on regulatory compliance, inerefore, l

severity level 5 violations were treated as Non-Cited Violatters (NCV.)

34 l

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l Irspection Report No.;070-1100'/89 06:.No violations in Radiological Safety.

j L

?i.

Inspection-Report No. 070-Il00/B9-80 (Mid-$ ALP Review): Two violations in i

Yanagement Control.and Criticality $afety.

j t

F

$L4 Failure to estaolish and post required criticality safety controls for the Sintersoility Test Hood, p

$L4 Failure to assure that-all-production and salaried personnel are-retrained annsally.

.l inspection Report No.'070-1100/89-05:

No violations in security.

lespection Report No '070-Il00/B9-04: One violat, ion in E: ergency Planning.

$L4 Failure to coaduct an annual emergency drill iraelvin; of f site agencies.

.irspe:tien Report Nc. 070-1 00 39-03:

Cre violatier in Re:1o4;ical Safety.

h SL4' Failure to a:ea.,ately e.aivate cicassay'results.

l t

inspection Report No. 070 ID0/B9-02:

Two violations in :iadiolcgical and

\\

Criti:ality Safety. The viciation in criticality safety.as nor-cited.

SL4 -

Failure to felicw all requirements'of an RWF'anc hase a written procedure to :over dilstion of liquic wastes.

t ei

$LS Failure to assign meassred L'-235 content and errichtert values to j

l (NCV)(

' packages in a tirrely ma%ner,

'l t

inspection Report No. 070 1100/B9-01:

Seven violations in Radiological and Criticality Safety.

Five of the violations were non-cited.

'SL4 Failure to seal shipping containers prior to outside storage.

SLA Failure of the Nuclear Safety Committee to review and approve $NM

' license amendments af fecting nuclear criticality safety.

SL5 Failure to maintain a sixty-inch exclusion zone around new pellet (NCV) storage shelves.

35 a

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,TI s t[

.! 1 -

'I pli:

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SL5

. Failure to ' adhere to a posted nuclear. criticality safety sign..

!t (NCV)

Failure to assure that water could not enter the fuel-rod box' storage R

$l$

(NCV) facility.

5

l SLS.

Failure to maintain the face velocity on two Chemistry Laboratory-

. (NCV).

hoods.

LFailure to adequately measure releases from the FA-3 ventilation

'. 5L5

.(NCV) system stack.

'.i

n I

. inspection Report No. 070-1100/89-202: No violations in Material Control..and

^

Accounting.

T Irspection Repert No, 070-1100/$9-201:

No-violations in Vaterial-Control and Accounting..

- i r

f lesoe: tion Report No. 070-1100/89-200: N: violations in Vaterial Control and j

i. ;

A::o6nting.

4 1968 Irspe: tion Report No,' 070-1100/BB-10: One non-citec violation in Criticality Safety.

' ~

8 SL5 Incorrect stacking of f uel rods in' a f uel ' roc teay.

(NCV) lnspe: tion Report No. 070-1100/8B-09:

No violations.in hterial Control and

[

accounting.

a Inspection Report No. 070-1100/8B-08: No violations in Radiological'and.

[

Criticality-Safety.

i inspection Report No. 070-1100/83-07:

No violations in Material Control and-Accounting and Security.

l r

k.

36 vr -

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17; 7 55

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yw z,

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TABLE 2 k

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g 6

ENFORCEMENT ACTIVITY' 4"'

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hNCT10NAL.

NO.:0F VIOLATIONS IN EACH SE'VDTfiELEVEL -

3

~

. AREA Vi IV 111 l11' '

I TiOTAL i:

f

. (:

, Facility Operations.

~

ii

/

s 1

4-51 i

y W Nuclear' Criticality 4

r,-"

J._ %

i$4fety-'

M i

'i E L$afeguards?

2 u

p.:

, Ge'neral Ecuipre*t p

F Maintenance-

. 9

(;

9 Jadiological

-g

. Con. trol s '

1 k'

E4ergency-1 1-f.

Frepare:ress y

laragement 1

1 controls

~

FireProtectIor.

Lra v

tic e_n s' i ng 1

?

JActivi. ties g

e' in,-

(TOTAL" 15 15-1 N (..

R Notesi 1.

After the end'of the assessment period, the licensee indi:sted that additional pertinent inforn'ation w85 available and y ;.

-requested reconsideration.of five of= six: Radiological Cottrol ~

-e' violations from Inspection Report No. 070-1100/90-03, s

I

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TABLE 3 o-L Non-Routine Events Ouring Assessment Period Date-De sc ri p t'i on -

t 8/12/88 The. Combustion Engineering Windsor, Connecticut f acilities lost of f site' electrical power as a result of 4. power loss in the entire Windsor area. Dr./ations in the Nuclear Fuel Manufacturing Facility were terminated and the facility emergency power: system was started and operated as, required.-

All-monitoring systems ieportant to safety were switched to emergency power and no movement of fuel oc:urred mtil of f site power wa$' restored.

B/2$/8B

'The Nuclear het MaNf acturing Facility-lost of f site

- i" electricar pcotr when a tree, which was being trimed, broke

{

and-fell =across the. electrical wires. leading into the facility.

Only the fuel fabrication _ facilities were affected.

Operations in the N,,: lear Fuel Manufacturing Facility were

~]

termirated and the 'acility e erger.cy ::.er system was started All rtoni orieg systets irrportant to and operated as re:,, ire:.

t safety werel5.itc*e: te e eegency ;c.er and no m:vement of fuel o:curreo until offs'te ::.er was rest: red.

10/12/SB Wnile unica:ir; sir:ere: cellets f ro.? ! shipping container in.

l tne Pellet She; Aratx. a wheel on a.trarsfer cart trote.

About 70 kilegrams of uraaiut exide pellets spillec onto the fleer, The Anrex was irrme:a ately evacuated.

Aralysis of breathing

ene air samplers #:e :ersonnel working in the-area indicated I

that no airborre 4:t v'ty was released..Tne licensee cleared i

up'the area, alicwt ;tisonnel to're-te.ter and initiated-t I

actions to examine 19e steuctural integrity of all other-transfer carts-use ir tne facility.

f 12/9/88-Workers at the Wincsor, Connecticut site broke a lh-inch natural gas pipeli*e while removing. tree stumps from a clearing adjacent to the Fuei Fanufacturing Facility.

The licensee was preparing the area to extend the facility parking lot.

The gas

.y leak was promptly isolated, The Nuclear Fuel Manufacturing Facility was evacuated and the local fire company was called to the site as a precaution. Gas company personnel were o

-immediately dispatc*.ed to the site to repair the leak, t

38 y

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- a s_ s - x

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1. ,1 TABLE 3 (Continued);

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ste.

. Description S i An:electricaldist'ributionboxcontainibg.conduitforthe~

, y m p g/39-l facility; warehouse security. alarm system was damaged when,a'-

f

>, i?

backhee. inadvertently struck, the box during renovation of'the.

h, s

west end.of.the Nuclear. Fuel Manufacturing Facilit'y Cold Shep..

As 4. result of;this datage; the warehouse secur'#v alarms were :

o

e. t.

c.

p..

' disarmed.. Compensatory measures were immediatei nstitete: and >

J were maintained until'the. alarm = system wa's repate.e 3.

P e

.....w Y$. '

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,2 4

$?

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