ML20133D484

Staff Evaluation of State of Co PSC Plans to Enhance Mgt of Fort St Vrain Activities

ML20133D484
Person / Time
Site:	Fort Saint Vrain
Issue date:	10/03/1985
From:	NRC
To:
Shared Package
ML20133D471	List: ML20133D467 ML20133D484
References
TAC-60566, NUDOCS 8510090074
Download: ML20133D484 (50)

Text

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t ENCLOSURE D

k STAFF EVALUATION OF PSC PLANS TO ENHANCE THE MANAGEMENT

- s OF FORT ST. VRAIN ACTIVITIES t

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. s TABLE OF CONTENTS I. INTRODUCTION II. EVALUATION II.1 PSC Responsiveness to NRC Assessment Report 11.1 PSC Responsiveness to Third-Party Management Review III. SCHEDULE IV. CONCLUSIONS IV.1 Additional Information to Respond to NRC Assessment Report IV.2 Additional Information to Respond to Third-Party Management Review IV.3 Additional Information on Scope of PEP

,V . REFERENCES 1

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. s LIST OF TABLES Table Title 1 NRC Assessment Report Findings 2 Cross-References Between NRC Findings, Consultant's Report, and Licensee Submittals 3 PSC Responsiveness to Third-Party Management Review 4 Performance Enhancement Program Sunmary Schedule 5 PSC PEP Responsibilities W -

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. 1 I. INTRODUCTION .

In October of 1984, the NRC staff issued a preliminary report (Reference 1) th'at documented the results of a special assessment of operations at the Fort St. Vrain Nuclear Generating Station (FSV). The special assessment was requested by the Director of the Office of Nuclear Reactor Regulation as a result of several operating problems that had occurred at FSV. Based on the assessment, the staff concluded that the plant should not be restarted until the licensee had completed several actions, one of which was the performance of an independent, third-party review of management structure and practices related to the operation of F5V.

In November and December of 1984, the NUS Operating Services Corporation (NUS0SC) performed an independent study of nuclear-related activities within

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the Public Service Company of Colorado (PSC). The results of the study are documented in a report dated January 30, 1985 (Reference 2). The report contains the following listed five sections, with each section containing NUS0SC recommendations for consideration by PSC:

A. Conduct of Operations / Management (11 recommendations)

B. Work Control System / Procedures (8 recommendations)

C. Commitment Control (3 recommendations)

D. Training / Retraining (6 recommendations)

E. Organization and Staffing (6 recommendations)

PSC responded to the NUSOSC recommendations by letter dated February 28, 1985 (Reference 3). PSC submitted additional information by letters dated March 29 and June 25, 1985 (References 4 and 5).

II. EVALUATION The staff has evaluated References 3 through 5 for responsiveness to the NRC assessment report (Reference 1) and to the third-party management review (Reference 2). The primary documents used during the evaluation were

• 1 Regulatory Guide 1.8 (Reference 6), Regulatory Guide 1.33 (Reference 7), ANSI N18.1-1971 (Reference 8), ANSI N18.7-1972 (Reference 9), the Fort St. Vrain Updated FSAR (Reference 10), the Fort St. Vrain Quality Assurance Program (Reference 11), and Title 10 of the Code of Federal Regulations (Reference 12). References 6 through 9 are currently applicable to Fort St.

Vrain. Secondary documents used for additional regulatory guidance were NUREG-0731 (Reference 13), NUREG-0737 (Reference 14), the Standard Review Plan (Reference 15), the final Policy Statement on Training and Qu'alifications of Nuclear Power Plant Personnel (Reference 16), Generic Letter 83-28 (Reference 17), ANSI N18.7-1976/ANS-3.2 (Reference 18), and ANSI /ANS-3.2-1982 (Reference 19).

1. PSC Responsiveness to NRC Assessment Report The scope of this task is limited to Section 4 (Conduct of Plant Operations) of the NRC assessment report. Although the report contains observations that can be construed as weaknesses in the licensee's conduct of operations, these observations are not listed as specific staff findings, but are embedded in the text of the report. To facilitate comparison of the PSC submittals with the assessment report, the staff has developed the list of 26 specific " findings" shown in Table 1. The Table includes cross-references to the subsections of the assessment report wherein the findings are expressed.

The staff then compared the third-party consultant's report (Ref. 2) and the PSC submittals (References 3 through 5) with the assessment report findings to determine how responsive the licensee has been to the assessment report. The results of the comparison are shown in Table 2.

Each assessment report finding from Table 1 is listed in Column 1 of Table 2; cross references to corresponding subsections in the third-party consultant's report and the initial PSC response to that report (Ref. 3) are listed in Column 2; cross-references to corresponding subparts of the PSC Performance Enhancement Program

(References 4 and 5) are listed in Column 3; and explanatory notes are listed in Column 4. Column 3 is separate from Column 2 because the numbering system used in the Performance Enhancement Program is different from the numbering system used in the consultant's report.

Table 2 is sufficiently detailed to enable the reader to determine how responsive PSC has been to each finding. The Table includes the staff position (found in Notes 1-26), including basis, on each item. In sumary, PSC has been fully responsive to 15 of the 26 findings.

Follow-up actions to more fully address the remaining 11 findings are discussed below in Section IV of this staff evaluation.

2. PSC Responsiveness to Third-Party Management Review As a separate task, the staff evaluated the responsiveness of the PSC submittals (References 3 through 5) to the third-party consultant's report (Ref. 2). Sections A through E of Table 3 contain the full text of all 34 of the consultant's recomendations, with each recomendation imediately followed by the staff position (including the basis for the position) on the PSC response.

In sumary, PSC has been fully responsive to 32 of the 34 recommendations. Follow-up actions to more fully address the remaining two recomendations are discussed below in Section IV of this staff evaluation.

III. SCHEDULE The adequacy of the PEP schedule has also been evaluated.

There are six PEP projects, each of which is divided into from three to nine subprojects. There are a total of 34 subprojects. The titles of the projects and subprojects, and a timetable for their completion, are given in Table 4 (extracted from Reference 5).

F Based on the scheduled start dates in Table 4, all PEP subprojects have begun.

Nineteen subprojects are scheduled to be completed in 1985 and 15 are scheduled to be completed in 1986. Of the 15 subprojects scheduled for completion in 1986, 11 of them are scheduled to have their initial phases completed in 1985 (e.g., initial schedule, initial definition, or initial The staff assessment), with final implementation proceeding into 1986.

It is not too compressed for a concludes that this is a reasonable schedule.

program as ambitious as the PEP, yet the scheduled end date is not too far into the future; and the more extensive projects are given a longer time frame.

Based on the personnel assignments shown in Table 4, direct responsibility for the 34 subprojects is spread among 15 individuals, with six individuals A separate listing of the

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responsible for three or more subprojects.

subprojects assigned to each of the 15 individuals is shown in Table 5.

Although it appears that multiple assignments have been made in order to k subprojects of a similar nature under the same individual (for example, the six subprojects under employee Fuller are all closely related to day-to-day activities at the plant site), the number of estimated working hours allotted Therefore, the licensee should supply to each subproject is not given.

additional information on the scope of each subproject to show that adequate staff has been assigned to supervise and implement the PEP concurrent with normal duties. .

IV. CONCLUSIONS In general, the staff finds the PSC submittals to be responsive The to the NR assessment report and to the consultant's independent recomendations.

PSC Performance Enhancement Program should materially strengthen the c As discussed below, however, there are some of operations at Fort St. Vrain.

findings and recommendations for which PSC should supply additional .

information.

1. Additional Information to Respond to NRC Assessment Report Finding 4-2 The licensee should supply details of the plant tour program.

Finding 4-9: The licensee should submit a more complete description of procedure ENG-3 for further review by the staff.

Finding 4-10: The licensee should verify to the staff that the functional acceptability of equipment being returned to service will be checked and/or verified by the Shift Supervisor regardless of the reason for having removed the equipment from service (e.g., surveillance testing, inspection, maintenance, modification,etc.).

- Finding 4-13: The licensee should commit to develop a shift turnover procedure.

Finding 4-14: The licensee should commit to develop a procedural requirement for licensed operators to read and review operating logs upon return to the Control Room after an extended absence.

Finding 4-15: The licensee should supply details of the plant tour program (the same information is needed to close out Finding 4-2).

Finding 4-16: The licensee should submit a more complete description f of procedure ENG-3 for further review by the staff (the

! same information is needed to close out Finding 4-9).

Finding 4-17: The licensee should commit to improve the control of system operating procedures in use at local control panels.

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Finding 4-19: The licensee should take steps to improve access to the Control Room from the Shift Supervisor's office, or provide additional explanation of why their current

, arrangement is acceptable.

Finding 4-20: The licensee should verify that PEP subproject VI.2 will encompass the verification of the correct l performance of operating activities.

Finding 4-24: The licensee should describe hcw the " safety-related" designation is used in their parts management system.

2. Additional Information to Respond to Third-Party Management Review Recommendation A.4: The licensee should describe how their Master Planning and Scheduling System will address surveillance testing in general and "surveillances requiring shutdown" in particular.

Recommendation A.6: The licensee should clarify how they plan to f

analyze for the root cavse of procedure compliance i failures.

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3. Additional Information on Scope of PEP i

The licensee should supply additional information on the scope of each f PEP subproject to show that adequate staff has been assigned to supervise and implement the PEP concurrent with normal duties (refer to discussion in Section III above).

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V. REFERENCES

1. Letter from H. R. Denton (NRC) to R. F. Walker (PSC) transmitting the

" Preliminary Report Related to the Restart and Continued Operation of Fort St. Vrain Nuclear Generating Station," October 16, 1984.

2. NUS Operating Services Corporation, "An Analysis and Evaluation of the Management of Nuclear-Related Activities of the Public Service Company of Colorado," January 30, 1985.

3. Letter from O. R. Lee (PSC) to R. D. Martin (NRC), "Public Service Company of Colorado's Response to the NUS Operating Services

• Corporation's Management Assessment of January 30, 1985," February 28, 1985.

4. Letter from O. R. Lee (PSC) to R. D. Martin (NRC), "PSC Perfomance Enhancement Program," March 29, 1985.

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5. Public Service Company of Colorado presentation to NRC staff,

" Systematic Assessment of Licensee Perfomance," May 29, 1985.

6. U.S. Nuclear Regulatory Comission, Regulatory Guide 1.8, " Personnel Selection and Training," Revision 1-R, September 1975.

7. U.S. Nuclear Regulatory Comission, Regulatory Guide 1.33. " Quality Assurance Program Requirements (Operation)," November 3, 1972.

8. ANSI N18.1-1971, " Selection and Training of Nuclear Power Plant Personnel."

9. ANSI N18.7-1972, " Administrative Controls for Nuclear Power Plants."

10. Letter from 0. R. Lee (PSC) to Director of Nuclear Reactor Regulation (NRC), " Fort St. Vrain Updated FSAR," Revision 2," July 20, 1984.

11. Letter from O. R. Lee (PSC) to Director of Nuclear Reactor Regulation l (NRC), " Fort St. Vrain Updated FSAR, Revision 2, Appendix B,"

September 28, 1984.

12. Code of Federal Regulation, Title 10, Parts 0 to 199, " Energy," revised as of January 1,1985.

.13. U.S. Nuclear Regulatory Commission, NUREG-0731, " Guidelines for Utility Management Structure and Technical Resources (Draft Report for Interim l Use and Coment)," September 1980.

14. U.S. Nuclear Regulatory Comission, NUREG-0737, " Clarification of TMI

Action Plan Requirements," November 1980.

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15. U.S. Nuclear Regulatory Commission, NUREG-0800 " Standard Review Plan,"

Chapter 13, Revision 2, July 1981.

16. U.S. Nuclear Regulatory Commission, 50 FR 11147, " Commission Policy Statement on Training and Qualification of Nuclear Power Plant Personnel," March 20, 1985.

17. U.S. Nuclear Regulatory Commission, Generic Letter 83-28, " Required Actions Based on Generic Implications of Salem ATWS Events,"

July 8, 1983.

18. ANSI N18.7-1976/ANS-3.2, " Administrative Controls and Quality Assurance for the Operational Phase of Nuclear Power Plants."

19. ANSI /ANS-3.2-1982, " Administrative Controls and Quality Assurance for the Operational Phase of Nuclear Power Plants."

TABLE 1 ,

NRC ASSESSMENT REPORT FINDINGS NRC CROSS-FEFCtENCE ASSESSMENT REPORT, TO PERTINENT CONDUCT OF OPERATIONS SUBSECTION OF NRC FINDINGS (NOTE 1) DESCRIPTION ASSESSMENT REPORT 4-1 Failure to follow established procedures. This covers 4.2.1, 4.2.2 operations procedures, maintenance procedures, surveillance procedures, and QA procedures.

4-2 Poor housekeeping at the plant. 4.2.1, 4.2.6 4-3 Improperly written procedures. Some maintenance 4.2.1, 4.2.2, procedures are not precise. Surveillance pro- 4.2.6 cedures need improvement.

4-4 There is s. significant backlog of safety-related 4.2.2 maintenance actions.

4-5 More management attention is required on surveillance 4.2.2 activities.

4-6 PSC has a tendency to take the position that new NRC 4.2.2 requirements apply to LWRs, but not to HTGRs.

4-7 PSC does not have a central point of contact for 4.2.2 licensing matters.

4-8 Tfiere are weaknesses in the control of purchased material. 4.2.2 4-9 Modified systems have been returned to service without a 4.2.2 comprehensive effort to update associated documentation.

4-10 Modified systems have been returned to service without 4.2.2, 4.2.6 verification by the Shift Supervisor of cold checkout or functional testing. In general, there is no comprehensive -

provision for post-maintenance testing.

4-11 In some cases, superficial management response to NRC 4.2.2 initiatives has required excessive NRC follow-up.

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MRC ., CROSS-REFERENCE ASSESSMENT REPORT, TO PERTINENT .

CONDUCT OF OPERATIONS SUBSECTION OF NRC .

DESCRIPTION ASSESSMENT REPORT FINDINGS (NOTE 1) _

4-12 PSC has stated that an FSV vendor interface program 4.2.3 (re: Generic Letter 83-28) is not needed because FSV is a one-of-a-kind design. This indicates an incomplete understanding of what is intended by a vendor interface program, and indicates that the " qualified life" issue has not been addressed.

4-13 There is no shift turnover procedure. 4.2.5 4-14 There is no procedural requirement for a licensed operator 4.2.5 to read and review operating logs upon return to Control Room duties after an extended absence (e.g., training, vacation,sickleave).

4-15 There is no procedural requirement for Shift Supervisors 4.2.5 or for the Operations Superintendent to conduct periodic plant tours.

4-16 Not all drawings available for operator use are controlled. 4.2.5 4-17 System operating procedures at local control panels are 4.2.5 not identified to show which panel they apply to.

4-18 Several examples of lax tagging practices have been 4.2.5 identified.

4-19 The Shift Supervisor has an office outside the inmediate 4.2.5 Control Room area and a card key is needed for access. .

Access could be delayed by an inoperable card reader.

4-20 There is only a limited program for the verification of 4.2.5 the correct perfomance of operating activities.

4-21 There is no formalized priority system for maintenance and 4.2.6 I&C work.

4-22 The licensee's preventive maintenance program is static 4.2.6 and nontechnical rather than dynamic and technology based.

4-23 There is no shelf-life program for spare parts. 4.2.6

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NRC CROSS-FEFERENCE ASSESSMENT REPORT, TO PEFTINENT .

d CONDUCT OF OPERATIONS SUBSECTION OF NRC .

FINDINGS (NOTE 1) DESCRIPTION ASSESSMENT REPORT 4-24 PSC uses the term " quality-related" to apply to items 4.2.6 associated with the Technical Specifications. There is no special designation for safety-related items.

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, 4-25 There is no means to display the status of maintenance 4.2.6 backlog items to management.

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4-26 PSC needs to strengthen overall management control in 4.3 order to improve plant operations. A third-party consulting organization should assess the root causes of operational problems and identify broad-ranged corrective measures.

NOTE 1: Chapter 4 of the NRC preliminary assessment report (Reference 1) discusses the staff's 1984 review of the conduct of operations at Fort St. Vrain based on operating history, operational activities, and maintenance.

Although several weaknesses were identified, they were not explicitly identified as findings nor were they listed in any kind of numerical order. This Table is an attempt to enumerate the NRC assessment findings in Chapter 4 and cross-reference them to the third-party consultant's management audit and to various follow-up submittals from Public Service of Colorado.

TABLE 2 ,

CROSS-REFERENCES LETWEEN NRC FINDINGS, CONSULTANT'S REPORT, AND LICENSEE SUBMITTALS Cross-References to Cross-References to PSC NRC Consultant's Report (Ref. 2) Performance Enhancement Program Findings (Ref. 1) and Initial PSC Response (Ref. 3) (Refs. 4 and 5) Notes 4-1 A.6 IV.5 1 4-2 A.8 VI.1 2 4-3 A 6, B.1, B.3, B.6, B.7. D.4 III.2, IV.I. IV.5, V.3, V.4, 3 V.5, V.6, V.7 4-4 A.4, B.2, B.3, B.8 11.2 III.1, III.2 4 4-5 A.2, A.7, A.9, A.11 1.3, II.1, II.3 5 4-6 C.2, C.3 IV.3, IV.4 6 4-7 A.6, E.2 I.1, IV.5 7 4-8 B.5 IV.6, VI.6, VI.7 8 4-9 B.6 - 9 4-10 B.4 III.3, VI.3 10 4-11 A.6, A.7, A.9, A.11, E.1, I.1, I.3 I.4, I.6, IV.5 11 E.2, E.3 .

4-12 B.5 IV.6, VI.6, VI.7 12 4-13 A.6 IV.5 13 4-14 A.6 IV.5 14 4-15 A.8 VI.1 15 4-16 B.6 - 16 4-17 A.6 IV.5 17

TABLE 2 (Continued)

Cross-References to Cross-References to PSC ~

Consultant's Report (Ref. 2) Performance Enhancement Program NRC and Initial PSC Response (Ref. 3) (Refs. 4 and 5) Notes Find!ngs (Ref. 1) 4-18 VI.4 18

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VI.2 20 4-20 -

A.4, B.2, B.3, B.4 II.2 III.1, III.2, III.3 21 4-21 III.3 22 4-22 B.4 VI.7 23 4-23 -

- 24 4-24 -

A.2, A.4 II.1, II.2 II.3 25 4-25 References 4 & 5 26 4-26 References 2 & 3

NOTES: ,

1. Section 12.3 of the licensee's FSAR, Rev. 2, states that the FSV

" procedure' system meets the requirements and intent of ANSI N18.7-1972." With respect to procedure adherence, Section 5.1.2 of ANSI N18.7-1972 simply requires that procedures be followed and that requirements for the use of procedures be prescribed in writing.

The PEP includes a comprehensive program to upgrade and standardize procedures and to improve compliance with procedures. The Quality Assurance Division is spending time on procedure reviews and training to eliminate root causes for failures to follow procedures. The licensee's actions are consistent with their FSAR comitment.

2. Regulatory Guide 1.39, which endorses ANSI N45.2.3-1973, provides guidance on housekeeping requirements during plant operation. A

" General Housekeeping Program" for Fort St. Vrain was established in June 1984. The licensee claims that housekeeping problems have been resolved and a program is in place to maintain the plant at a level of cleanliness intended to r u pce abnormal degradation of plant equipment and reduce personnel safety hazards. Procedures have been implemented to document corrective actions taken in response to plant tours.

The licensee has also comitted to develop a formal plant tour program, which includes general housekeeping as part of the PEP. At the time of their latest presentation to the staff (Reference 5), they had not made-a final determination of exactly who should perform the tours and had not finalized the details of a tour program. The licensee should supply details when available.

3. Section B.5.5.1 of Appendix B to the licensee's FSAR (Rev. 2) states that the FSV procedure system conforms to the intent of Regulatory Guide 1.33 November 1972, and ANSI N18.7-1972. Section 5.3.1 of ANSI N18.7-1972 requires operating and maintenance procedures to be sufficiently detailed for a qualified individual to perform the required function without direct supervision; Section 5.3.2 offers guidance on acceptable procedure content; Sections 5.3.3 through 5.3.9 give detailed guidance for particular procedure categories (e.g.,

system procedures, maintenance procedures, etc.).

The licensee has incorporated plans to improve procedures in several areas. Those items in the consultant's report and the licensee's responses that specifically mention procedure enhancements have been listed in this Table. Several_other items will probably also lead to ,

procedure changes to improve the conduct of activities associated with Fort St. Vrain. The licensee's actions are consistent with their FSAR commitment.

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4. The licensee's FSAR does not address the timeliness of maintenance activities; however, the staff has long considered it good practice to avoid a backlog of safety-related maintenance actions.

The licensee has responded to the NRC assessment report by initiating a master planning and scheduling function for nuclear activities. A maintenance planning group will be established to coordinate maintenance activities, and up-to-date planning and scheduling principles will be applied to the existing preventive maintenance system. The licensee's plans are expected to improve their control of maintenance actions.

5. Section 3.2 of ANSI N18.7-1972 requires that lines of authority and responsibility be established from the highest management level through intennediate levels to the plant manager and the on-site operating organization. Additional guidance on management control in general and control of surveillance testing in general is contained in Sections 3.2 and 5.2.8 of ANSI N18.7-1976/ANS-3.2. Section B5 of Appendix B to the FSAR, Rev. 2 (Quality Assurance Program for Plant Operation), also states that the Vice President-Electric Production is assigned the authority and responsibility for all activities associated with engineering, procurement, operation, maintenance, modification, and quality assurance at FSV.

Although the NRC assessment report finding addresses management attention to surveillance activities only, the Table lists cross-references to several items that should enhance management attention in general (including surveillance activities).

6. Section 3.2 of ANSI N18.7-1972 requires that the highest management level recognizes that the plant must be operated under well formulated and detailed control to assure safety and efficiency. Although this requirement does not specifically address the review of generic NRC issuances, the Maff considers such review to be a routine function at

! a nuclear utility. To assure safety and efficiency, the nuclear organization must be knowledgeable about industry activities, including regulatory activities, in general.

l The licensee's PEP is responsive to the NRC finding. A method of reviewing regulatory documents to identify items applicable to FSV is being established.

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7. ANSI N18.1-1971 and ANSI N18.7-1972 give general guidance pertaining to organizational structures appropriate for the operation and technical support of nuclear power plants. Although-the referenced standards do not require a central point of contact for licensing matters, the staff's interactions over the years with numerous licensees have shown j that a single point of contact is very important for accurate and efficient communications.

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3 The licensee's PEP is responsive to the NRC finding. The new Licensing and Fiela Division separates the licensing and fuels activities from 1

the Nuclear Engineering Division, thus providing for a stronger licensing function and a central point of contact with the NRC.

8. Section B.S.7 of Appendix B to the FSAR, Rev. 2, establishes PSC quality assurance requirements for the control of purchased material, equipment and services. Section 5.3.C of ANSI N18.7-1972 requires procedures for the proper procurement, documentation and control of materials and components necessary for plant maintenance and ,

. modification.

The licensee's PEP is responsive to the NRC finding. They are 1 assessing the scope and adequacy of their current procurement process and plan to improve their parts management system. A component shelf-life program is also being developed.

9. Section B.5.3.7 of Appendix B to the FSAR, Rev.2 establishes PSC quality assurance requirements for processing changes to design

- documents. Although ANSI N18.7-1972 does not specifically address document revisions, Section 5.2.15 of ANSI N18.7-1976/ANS-3.2 does contain guidance on the control of documents (instructions, procedures, drawings and engineering requirements) to preclude the possibility of use of outdated or inappropriate versions.

On page 26 of the Attachment to their letter dated February 28, 1985 (Reference 3), the licensee states that current drawing control

!. practices are effective and that Engineering Procedure ENG-3 establishes formal practices for handling, distributing, numbering, and storing design documents so that personnel have access to proper and ,

current documents at all times. Based on the correspondence used in 4

this review (References 1-5), the staff is unable to close the NRC finding. PSC is requested to submit a more complete description of ,

what is in procedure ENG-3 together with an explanation of how it assures that system modifications are documented prior to return of the j systems to operation.

10. Section 6.5 of ANSI N18.7-1972 requires that tests or inspections be perfomed following plant modifications or significant changes in

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procedures to confirm that the modifications or changes reasonably l produce expected results and do not reduce safety. Although i Section 5.1.5 (Equipment Control Procedures) of ANSI N18.7-1972 does s not address the return of equipment to service, a later version of the standard (ANSI N18.7-1976/ANS-3.2, Section 5.2.6, Equipment Control) i does state that, when equipment is ready to be returned to service, i

operating personnel shall place the equipment in operation and verify and document its functional acceptability. Item I.C.6 of NUREG-0737 also requires that the authority to release systems and equipment for maintenance or surveillance testing or return-to-service may be

delegated to an on-shift SRO, provided the Shift Supervisor is kept <

fully informed of system status.

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r The licensee's PEP is responsive to the NRC finding. A procedure is being developed to define the responsibilities of Nuclear Production Division supervisors. A comprehensive preventive maintenance program is being developed that will include post-maintenance testing. The licensee should confirm to the staff that the functional acceptability of equipment being returned to service will be checked and/or verified by the Shift Supervisor regardless of the reason for having removed the equipment from service (e.g., surveillance testing, inspection, maintenance, modification,etc.).

11. The Systematic Assessment of Licensee Performance (SALP) process includes an evaluation of licensee responsiveness to NRC initiatives.

In an effort to improve responsiveness, PSC has implemented or initiated several PEP subprojects. All the listed cross-references have some bearing on the need for PSC to focus management attention on FSV operations and maintenance.

12. The PSC position on Generic Letter 83-28 is being evaluated by the staff along with the rest of the industry responses to that letter; however, PSC has included in the PEP an assessment of parts management and shelf-life needs.

13. Section 5.1.3 of ANSI N18.7-1972 requires a mechanism for disseminating instructions of general and continuing applicability to the conduct of business, such as instructions that deal with job turnover and relief.

More detailed guidance is contained in Section 5.2.1.4 of ANSI /ANS-3.2-1982. Item I.C.2 of NUREG-0737 requires licensees to have procedures for shift relief and turnover to ensure that each oncoming shift is made aware of critical plant status information and system availability.

The licensee's responses commit to a comprehensive procedure review; however, there is no specific commitment to develop a shift turnover procedure. The licensee should make such a commitment.

14. Section 5.1.1(6) of ANSI N18.7-1972 makes the plant staff responsible for reviewing routine operating data to assure safe operation. More detailed guidance is contained in Section 5.2.1.4 of ANSI /ANS-3.2-1982.

The licensee's responses commit to a comprehensive procedure review; however, there is no specific commitment to develop a procedural requirement for licensed operators to read and review operating logs upon return to the Control Room after an extended absence. The licensee should make such a commitment.

15. Same as Note 2.

16. Section B.5.6 of Appendix B to the FSAR, Rev. 2, establishes quality assurance requirements for the control of documents. Additional guidance is contained in Section 5.1 of ANSI N18.7-1972 and in Section 5.2.15 of ANSI N18.7-1976/ANS-3.2.

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On page 26 of the Attachment to their letter of February 28, 1985 (Reference 3), the licensee states that Engineering Procedure ENG-3 establishes guidelines for document control and that the current system for controlling drawings is effective. Based or the correspondence used in this review (Reference 1-5, the staff is baable to close the NRC finding. PSC is requested to submit a more complete description of what is in procedure ENG-3 together with an explanation of how use of the procedure assures that only controlled drawings are available for use of plant personnel.

17. Section 5.1.2 of ANSI N18.7-1972 establishes requirements for procedural adherence.

l The licensee's responses commit to a comprehensiva procedure review; however, there is no specific commitment to better identify system operating procedures in use at local control panels. The licensee should make such a commitment.

18. Section B.S.14 of Appendix B to the FSAR, Rev. 2, addresses quality assurance requirements for the status tagging of plant systems and equipment. Section 5.1.5 of ANSI N18.7-1972 establishes requirements for equipment control proceriures, such as locking or tagging to secure and identify equipment in a controlled status.

The above-referenced section of the FSAR states that the FSV Administrative Procedures Manual establishes requirements for tagging, logging, and displaying the status of plant equipment and systems. PEP subproject VI.4 also appears to encompass tagging practices.

19. Section 5.1.1 of ANSI N18.7-1972 defines and establishes the general responsibilities and authorities of the plant staff. Additional guidance on the authority and responsibilities of the Shift Supervisor I is contained in Section 5.2.1.3 of ANSI /ANS-3.2-1982. Additional requirements pertaining to operator staffing are contained in 10 CFR i

50.54(m)(1).

! Although the Shift Supervisor's office is not necessarily a part of the Control Room area, the staff considers it a good operating practice for l the Shift Supervisor to have unobstructed access to the Control Room area whenever he is in the office. The licensee should take steps to improve access to the Control Room from the Shift Supervisor's office, or provide additional explanation of why their current arrangement is acceptable.

20. Section 5.1.5 of ANSI N18.7-1972 requires independent verification, where appropriate, to ensure that necessary equipment control measures, such as tagging equipment, are implemented correctly.Section I.C.6 of NUREG-0737 contains additional guidance on procedures for verifying the correct performance of operating activities.

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The licensee should verify that PEP subproject VI.2, " Revise Conduct of Operations," will encompass the verification of the correct performance of operating activities.

21. Section 5.1.6 of ANSI N18.7-1972 requires a maintenance program to

' maintain safety-related equipment at the quality required for it to i perform its intended function. A preventive maintenance schedule should be established and maintained which describes the frequency and type of maintenance to be performed. .

The licensee's PEP includes several subprojects designed to improve the

, maintenance function. The intended result is a major upgrade of the .

licensee's ability to plan, schedule and accomplish nuclear-related work, with particular emphasis on preventive / predictive maintenance.

22. Same as Note 21.

23. Same as Note 8.

24. 10 CFR 50, Appendix A, General Design Criterion 1 " Quality Standards and Records," requires that structures, systems, and components important to safety steall be designed, fabricated, erected, and tested to quality standerds commensurate with the importance of the safety functions to be parformed. 10 CFR 50, Appendix B VIII requires that measures be established for the identification and control of materials, parts and components of safety-related structures, systems and components. Section B.S.2.7 of Appendix B to the FSAR, Rev. 2, defines the FSV safety-related items to which the QA Program applies.

Based on the correspondence used in this review (References 1-5), the staff cannot conclude that the licensee's parts management controls

1. meet the requirements of the regulations. The licensee should describe how the " quality-related" treatment of parts meets the requirements of the regulations for " safety-related" items.

25. Same as Note 21.

26. Section 3.2 of ANSI N18.7-1972 requires proper administrative and procedural controls to ensure recognition at the highest management level of a utility organization that a nuclear plant shall be operated under well formulated and cetailed control to assure safety and efficiency.

In an effort to strengthen overall management control and improve the operation of the Fort St. Vrain plant, PSC has had a third-party consulting organization perform "An Analysis and Evaluation of the Management of Nuclear-Related Activities of the Public Service Company PSC subsequently initiated the Performance of Colorado" (Reference 2).

Enhancement Program (References 4 and 5) to strengthen its overall conduct of operations.

b

TABLE 3 PSC RESPONSIVENESS TO THIRD-PARTY MANAGEMENT REVIEW SECTION A Conduct of Operations / Management A.1 Mission and Function Statements Recomendation:

"The PSC nuclear organization should require that detailed mission and function statements (charters) be developed for each senior manager's group. These statements should be reviewed and agreed upon by the

/ appropriate. senior manager and then approved by the senior nuclear executive. The statements should be developed in such a manner as to be able to serve as guidance for the development of similar statements at the departmental and supervisory level. The statements, after approval, should become part of the nuclear policies and procedures manual for the senior nuclear executive." ,

The licensee has agreed to complete mission statements for each nuclear division and its subunits. Other relevant documents, e.g., " Administrative Procedure APM Q-1 (Organization and Responsibilities) " and the Updated FSAR, will be reworked as necessary. The existing Nuclear Policies and Guidelines Manual will be revised to reflect organizational changes and changes in position responsibilities.

The licensee's response conforms with Sections 3.1 and 3.2 of ANSI N18.7-1972. Section 3.1 requires that " relations!.ips within an organization that operates cne or more nuclear power plants be clearly defined."

Section 3.2 requires that organizational relationships be " documented and updated, as appropriate, in the fonn of organizational charts, functional descriptions of departmental responsibilities and relationships, and job descriptions for key positions of personnel having direct operating, support, or audit respon'.ibility within the organization or in equivalent fonns of documentation." The staff finds the licensee's response acceptable.

A.2 - Management Planning System l Recommendation:

"The PSC nuclear organization should develop and implement an effective management planning system that encompasses the following basic elements:

• Define the overall management objectives (results to be achieved) for the conduct of nuclear activities.

• Identify the work that must be accomplished in order to achieve the objectives (referred to as critical performance areas).

L' - ------

Group and assign work responsibilities to individual organizational units within the nuclear organization.

• Select critical objectives for each manager and prepare detailed and measurable action plans for achieving each of the critical objectives."

The licensee has agreed to establish a master nuclear planning and scheduling system that will incorporate state-of-the-art planning and scheduling techniques. The system will support the identification, coordination, and ,

monitoring of individual tasks and their relationships to nuclear objectives.

Although the licensee's response does not directly address all of the basic elements in the consultant's reconsnendation (e.g., " critical performance areas," " critical objectives for each manager," etc.), their plan to use

' " state-of-the-art planning and scheduling techniques" indicates a meaningful effort to upgrade management planning.

Although ANSI N18.7-1972 does not contain specific guidance on management planning systems, Section 3.2 of the Standard does state that "a requirement for proper administrative and procedural controls is recognition at the highest management level of the organization that the plant shall be operated under well-formulated and detailed control to assure safety and efficiency."

The staff considers it a good management practice to have a planning system of the general type proposed by the licensee because it will help upper management achieve the degree of control anticipated by the Standard. The staff finds the licensee's response acceptable.

A.3 - Management Skills Program Recommendation:

"The PSC nuclear organization should implement a management skills development program."

The licensee has agreed to develop a Management Skills Program containing the following elements:

program scope program policy statement

• identify participants (key members of nuclear staff) identify strengths and weaknesses of participants identify available training courses design individual training programs for participants

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The Management Skills Program will focus on nuclear management skills and should enhance the licensee's existing program for management skills development at the supervisory, department / division, and executive levels.

Although ANSI N18.1-1971 and ANSI N18.7-1972 do not contain specific guidance on programs to develop management skills, it is generally recognized throughout the industry that a person needs a high degree of managerial skill in order to administer the complex organization associated with the operation and technical support of a nuclear power plant. The staff considers it a good management practice to have a management skills development program of the general type proposed by the licensee. The staff finds the licensee's response acceptable.

A.4 - Annual and Long-Range Schedules Recomendation:

"The nuclear organization should develop and maintain a program of annual and long-range schedules. The scheduling program should include,

- as a minimum, planned plant modifications, plant surveillances requiring shutdown, major maintenance activities, and. plant outages."

The licensee's response to the recommendation covers the scheduling of Performance Enhancement Program projects, Action Plan projects, planned refuelings, outage activities, major regulatory commitments, major design changes, major construction activities, and maintenance; however, it does not specifically mention "surveillances requiring shutdown." We assume that such surveillance is encompassed by the term " outage activities," but this should be confimed by the licensee.

Otherwise, the licensee notes that scheduling and planning efforts for maintenance and outages / modifications are being improved and will be integrated with the master nuclear planning and scheduling system (see Recommendation A.2). A computer-based Power Plant Maintenance Information System (PPMIS) has been implemented at FSV, and an outage coordinating committee has been established. Consulting assistance has been retained for procurement / warehousing activities, maintenance control, and critical-path-method (CPM) scheduling.

The licensee's response conforms with Section 5.1.6 of ANSI N18.7-1972, which requires a maintenance program to maintain safety-related equipment at the quality required for it to perform its intended function; however, Recommendation A.4 remains an open item pending clarification by the licensee of how they plan to address surveillance testing in general and "surveillances requiring shutdowns" in particular. Surveillance testing requirements are given in Section 5.1.7 of ANSI N18.7-1972.

A.5 - Criteria for Change Notices Recommendation:

" Criteria for evaluation and prioritization of change notices should be developed. The combination of priority and scheduled start should be used by all nuclear groups involved to coordinate the preparation for construction of change notices. The criteria should specify one individual or position who has safety and design control authority for Fort St. Vrain. The work control group should function as an advisory body to this individual."

The licensee has agreed to develop criteria for the evaluation and prioritization of change notices. This will be done in conjunction with their development of a master nuclear planning and scheduling system (see Recommendation A.2).

The licensee's response to the recomendation implies that the Manager-Nuclear Engineering has primary design control authority, although several other individuals are closely involved with the design change process at FSV. For example, the Manager-Nuclear Production has final authority on whether a proposed design change will actually be implemented. The Nuclear Licensing unit performs a safety design review of each change notice, and the

'QA Division approves all design changes from a quality standpoint. The licensee also considers design control authority to be separate from safety authority. In matters relating to safety, the Vice President - Electric Production has final authority. There is also a Work Review Committee that serves as a link between engineering and operations during implementation of design changes.

The licensee's response conforms with Section B.S.3 of Appendix B to the FSA9, Rev. 2, and with Sections 3.2 and 5.1.6.4 of ANSI N18.7-1972. FSAR Section B.5.3 establishes FSV quality assurance requirements for controlling design activities (primarily design modifications) during the operational phase. Section 3.2 of the Standard establishes general requirements for administrative management controls (i.e., planning and scheduling), and Section 5.1.6.4 establishes requirements for plant modifications. The staff finds the licensee's response acceptable.

A.6 - Review of Procedures Recomendation:

"A thorough and comprehensive review of procedures should be initiated as soon as possible. Their review should be geared to identifying and

correcting procedural deficiencies, overlaps, and omissions. In addition, a detailed analysis of procedures which do not get followed, should be conducted and the root causes for failure to follow procedures identified. Verbatim _ procedure compliance should be enforced."

. . . ._ _ ~ _ . _ _ _ _ . _ _ . _ . _ _ . - _ _ _ _ _ _ _ _ _ _ _ . - _ . _ . _ _

o Section B.5.5.1 of Appendix B to the FSAR, Rev. 2, states that the FSV procedure system conforms to the intent of Regulatory Guide 1.33, November 1972, and ANSI N18.7-1972. Section 5.1.2 of the Standard requires that procedures be followed and that requirements for the use of procedures be prescribed in writing; Section 5.3.2 offers guidance on acceptable procedure content; and Sections 5.3.3 through 5.3.9 give detailed guidance for particular procedure categories (e.g., system procedures, maintenance procedures,etc.).

The licensee has agreed to perform a comprehensive review of procedures. The policy and procedure process within the nuclear organization will be analyzed to determine how policies and procedures are written, reviewed, authorized, implemented, and monitored for compliance.

The licensee's response to the recommendation generally conforms with the FSV QA Program and with ANSI N18.7-1972; however, the PEP does not explicitly address the analysis of procedures that do not get followed. Although page 5 of the cover letter submitting the PEP (see Reference 4) states that the purpose of PEP Project VI is, in part, to correct the root causes of various NRC observations, none of the subproject discussions explains how this will be done. Recommendation A.6 will remain an open item pending clarification .

) of the licensee's position with respect to the analysis of procedure compliance failures.

A.7 - Quality Assurance Management Attention l' Reconnendation:

"The Quality Assurance organization should be given additional emphasis and management attention."

The licensee's response to this recommendation refers to a reorganization that was designed to improve the management oversight of FSV activities.

Under the reorganization Quality Assurance was identified as a staff function rather than a line function. The intent was to enhance the capability of the QA organization to monitor the line divisions and to direct executive attention toward finding and eliminating the root causes of problems. The Manager Quality Assurance continues to report to the Vice President-Electric Production, who is the senior executive responsible for nuclear activities. Under the reorganization, the Vice President -

Electric Production reports to the President and Chief Executive Officer. In addition, QA concerns will become a separate agenda item at the biweekly staff meetings held by the Vice President - Electric Production.

l The licensee's response conforms with Section 3.2 of ANSI N18.7-1972 which i

establishes management authority and responsibility for safe and efficient '

plant operation, including off-site technical support and audit activities (more specific guidance on the quality assurance function is contained in ANSI

' N18.7-1976/ANS-3.2). The licensee's response also conforms with guidance on l

acceptable off-site organizations contained in Section 13.1.1 of the Standard Review Plan (SRP) and Section II.B.1 of NUREG-0731. The staff finds the licensee's response acceptable. The Manager, Quality Assurance has direct i

I

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access to responsible corporate management at a level where appropriate action can be taken (the level of the Vice President - Electric Production) and has a regular means of reporting on the effectiveness of the QA program (at the biweekly staff meetings).

A.8 - Establish Effective Tour Program

. Recommendation:

"An effective tour program should be established. Problems found during tours should be summarized by type and location and a periodic report provided to all tour participants in order to increase visibility of .

plant problems to all levels cf supervision and management."

The licensee has agreed to issue and implement procedures to enhance the existing plant tour program.

The licensee's response to the recommendation points out that general

~

housekeeping, which is part of the overall plant tour program, was addressed in June 1984 by establishing a General Housekeeping Program at Fort St. Vrain. The program involves all levels of plant management and is intended to increase the visibility of housekeeping deficiencies so they can be more promptly corrected.

The licensee's response conforms with Section 5.1.4 of ANSI N18.7-1972.

Although ANSI N18.7-1972 does not address housekeeping directly, Section 5.1.4 does require an administrative mechanism for issuing management instructions that require dissemination; such instructions, sometines referred to as special orders, should encompass housekeeping. Additional 9uidance on housekeeping is found in Section 5.2.10 of ANSI N18.7-1976/ANS-3.2. The staff finds the licensee's response acceptable.

A.9 - Policy on Staff Meetings Recommendation:

" Policies should be developed which require regular and frequent division, department, and group meetings."

The licensee has agreed to develop a policy for transferring information and communication throughout the nuclear organization. The policy will formalize the use of meetings and will be incorporated in the Nuclear Policy and Guidelines Manual.

The licensee's response to the recommendation also points out that, although current procedures such meetings dooccurring have been not formally (address the subject of staff meetings,and For example, the Vice President - Electric Production has biweekly staff meetings, periodic division-level meetings, monthly interdivisional coordination meetings, and periodic lower-level staff meetings.

Although ANSI N18.7-1972 contains guidance on the management and administrative control of nuclear power plants, it does not contain specific requirements on staff meetings. It is the staff's judgment that the licensee's policy on staff meetings is adequate. The staff finds the licensee's response acceptable.

A.10 - Industry Group Participation Recommendation:

"PSC should take steps to allow its personnel to increase their awareness of events external to PSC. These steps could include increasing enrollment and attendance with industry groups, as well as subscribing to information services.

The licensee is assembling a listing of industry groups and professional societies in which FSV management and professional staff participate. The licensee plans to examine the degree of employee participation in industry groups and to consider increasing, participation in standards committees, if warranted.

Although ANSI N18.7-1972 contains guidance on the management and administrative control of nuclear power plants, it does not contain specific requirements on utility participation in industry groups. It is the staff's judgment that such participation is useful and that the licensee plans to take adequate steps to examine their degree of participation. The staff finds the licensee's response acceptable.

A.11 - Visibility of Senior Personnel Recommendation:

" Visibility of senior personnel should be increased through plant visits, plant tours and attendance at staff meetings at all levels."

The licensee's response to the recommendation contends that recent organizational changes (see Recommendation E.2) and staff additions will increase the visibility of the President and Chief Executivt Officer, the Vice President - Electric Production, and senior management at the Division level.

, The licensee's response conforms with Section 3.2 of ANSI N18.7-1972, which l states that " lines of authority and responsibility shall be established from the highest management level through intermediate levels (including off-site technical support and audit activities) to the plant m6 nager and the on-site operating organization." Although the Standard does not specifically address

" management visibility," it is the staff's judgmert that strong day-to-day participation in nuclear activities by all levels v7 management is very important in achieving safety and efficiency. The staff finds the licensee's response acceptable.

SEL. ION B Work Control Systems / Procedures B.1 - Streamline the Modification Process Recommendation:

" Review the modification process, from initial request to final installation and test. Provide for the elimination of redundant reviews and approvals. Change the work procedures to make them as simple as possible."

The licensee has agreed to establish a task force responsible for reviewing the FSV modification process and simplifying the procedures. The task force may visit other nuclear facilities to gather information about their modification processes.

The licensee's response conforms with Sections 3.1 and 5.1.6.4 of ANSI N18.7-1972. Section 3.1 of the Standard contains general requirements for the administrative control of nuclear power plants; Section 5.1.6.4 contains requirements pertaining to plant modifications. The staff concurs with the licensee's plans to streamline their modification process. The licensee's response is acceptable.

B.2 - Planning Group for Maintenance Recommendation:

" Establish a planning group to prepare jobs for work before their release to maintenance. Assign job coordination responsibilities to superintendents in charge of specific maintenance disciplines."

The licensee has agreed to implement this recommendation. Improvements in maintenance planning will be coordinated with the planning and scheduling efforts described in the responses to Recommendations A.2 and A.4.

The licensee's response conforms with Section 5.1.6 of ANSI N18.7-1972, which requires a maintenance program to maintain safety-related equipment at the quality required for it to perform its intended function. A preventive maintenance schedule should be established and maintained which describes the frequency and type of maintenance to be performed. The staff finds the licensee's response acceptable.

B.3 - Planning and Scheduling Qualifications Recommendation:

" Policies and procedures should be developed and implemented that establish the qualifications of planning and scheduling personnel and

i. . . .

the required guidelines and criteria for planning and scheduling activities. Personnel currently involved in the planning and scheduling function should be upgraded through training and experience to the required criteria. Consideration should be given to the hiring of a qualified and experienced planning and scheduling manager."

The licensee has agreed to develop and implement guidelines for the qualification, responsibility, and authority of planning and scheduling personnel.

The licensee's response to the reconsnendation notes that several actions have already been taken in this area, some of which include establishing an independent planning and scheduling authority at FSV and filling the position of Supervisor-Planning and Scheduling (in December 1984). See Recommendations A.2, A.4, and B.2 for additional infonnation related to planning and scheduling.

The licensee's response meets the intent of Sections 3.3 and 4.6.2 of ANSI N18.1-1971. Section 3.3 of the Standard establishes functional levels and

- responsibilities for technical support personnel; Section 4.6.2 establishes qualification requirements for staff specialists (such as planning and scheduling personnel). The licensee should ensure that their final qualification guidelines for planning and scheduling personnel satisfy the

' Standard. The staff finds the licensee's response acceptable.

B.4 - Preventive Maintenance Program Recommendation:

" Develop a complete preventive maintenance program including engineering analysis and feedback. Routinely specify and conduct postmaintenance tests which ensure that the system or component meets its design intent."

The licensee has agreed to develop and i.?plement a comprehensive preventive maintenance program to control maintenance activities associated with equipment deemed essential for reliable plant operation. Some of the things the program will cover are:

• list of "significant components"

• independent verification of correct operating activities

• maintenance procedures training and qualifications historical data file

• failure trend analysis l

system for acting on identified deficiencies engineering analysis and evaluation f

maintenance scheduling, tracking, and feedback post-maintenance testing The licensee's response conforms with Sections 5.1.6 and 6.5 of ANSI N18.7-1972. Section 5.1.6 of the Standard requires a maintenance program, including preventive maintenance, to maintain safety-related equipment at the quality required for it to perform its intended function; Section 6.5 requires that tests or inspections be performed following plant modifications or significant changes in procedures to confirm that the modifications or changes reasonably produce expected results and do not reduce safety. The staff finds the licensee's response acceptable.

B.5 - Material Access Exclusion List Recommendation:

"The exclusion list at FSV governing material access to the site must be reviewed and corrected."

The licensee has agreed to review and evaluate the FSV " exclusion list" governing material access to the site and to possibly incorporate it into the FSV Administrative Procedures Manual.

Section 5.3.9 of ANSI N18.7-1972 requires procedures for the proper procurement, documentation, and control of those materials and components necessary for plant maintenance and modification; however, there are no specific requirements pertaining to the use of an " exclusion list" governing material access to the site. It is the staff's judgment that the licensee's plans to review and evaluate the FSV exclusion list are adequate. The staff finds the licensee's response acceptable.

B.6 - Revision and Control of Drawings Recommendation:

" Policies and procedures should be developed and implemented to improve the revision and control of drawings to support plant operations and maintenance."

The licensee's response to this recommendation states that FSV has new equipment that will allow on-site reproduction of drawings. This will result in quick turnaround and distribution of revised drawings. Otherwise, the licensee feels that existing policies and procedures are sufficient to maintain design documents up to date, and no further action is planned.

Section B.5.3.3.7 of Appendix B to the FSAR, Rev. 2, establishes PSC quality assurance requirements for processing changes to design documents. Although ANSI N18.7-1972 does not specifically address document revisions, Section 5.2.15 of ANSI N18.7-1976/ANS-3.2 does contain guidance un the control of documents (instructions, procedures, drawings and engineering requirements) to preclude the possibility of use of outdated cr inappropriate versions. The staff finds the licensee's response acceptable.

B.7 - Procedures for 10 CFR 50.59 Recommendation:

" Develop more explicit procedures and criteria for performing safety evaluations to meet 10 CFR 50.59."

The licensee considers the current Design Control System (Administrative Procedure APM Q-3) to be adequate and responsive to 10 CFR 50.59. However, the computerized licensing-document data base will be expanded and training

.on the performance of safety evaluations will be enhanced to ensure that licensing personnel know the procedure and the data base.

Although the term " safety evaluation" is not used and 10 CFR 50.59 is not cited, Section 5.1 of ANSI N18.7-1972 requires written administrative policies to control the issuance of documents, including changes, that prescribe activities affecting safety-related structures, systems, and components; these policies shall assure that documents are reviewed for adequacy and approved for release. In addition Section 5.1.6.1 requires that safety-related maintenance or modifications be performed in a manner to assure quality at least equivalent to that specified in applicable codes, bases, standards, design requirements, and Section 5.4 requires plant management to arrange for review of proposed changes to procedures having i safety significance. Sections 5.2.7 and 5.2.15 of ANSI N18.7-1976/ANS-3.2 I contain additional guidance on those subjects. It is the staff's judgment that the licensee's plans to expand the licensing document data base and enhance training on the performance of safety evaluations conform with the above referenced Standards. The staff finds the licensee's response acceptable.

B.8 - Separate System for Corrective Action Requests (CARS)

Recommendation:

" Establish a separate system for CARS so that only significant items are called CARS, and give them proper management attention. The system should address priorities, schedules, reviews, etc. Other items presently carried as CARS can be handled in a similar system, if desired."

4 D

12-k The licensee has agreed to establish internal controls to provide for a Quality Assurance Division appraisal of the significance of potential Corrective Action Requests (CARS). The purpose will be to ensure that only significant findings are recordec' as CARS. The licensee considers NRC "open items" and " unresolved items" to be significant and intends to continue recording them as CARS.

Although ANSI N18.7-1972 does not have a section devoted to corrective actions, Section 5.2.11 of ANSI N18.7-1976/ANS-3.2 does discuss the use of a corrective action program to ensure that conditions adverse to plant safety are promptly identified and corrected. The staff finds the licensee's response, which discusses the FSV Corrective Action Request (CAR) system, -

acceptable.

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SECTION C Commitment Control C.1 - Comitment Control Program Recomendation:

" Develop and implement policy regarding comitment control. Consider the following points as a minimum: accountability, measurable performance goals, requirements, priorities, and analysis."

The licensee has agreed to issue written policy to cover the existing comitment control program. The policy will define the program scopa and purposes, the identification of a comitment, the assignment and acknowledgement of responsibilities, the tracking and closure of comitments, and the organization responsible for overall program management. The program will be reviewed periodically by executive level management, and regular analyses will be performed to determine program effectiveness and to identify areas for possible improvement.

Section 3.1 of ANSI N18.7-1972 requires that proper administrative controls be in effect to cssure that decisions are made at the proper level of responsibility and with the necessary technical advice; Section 3.2 requires that the highest management level recognize that the plant must be operated under well formulated and detailed control to assure safety and efficiency.

Although these requirements do not specifically address comitment control or the review of regulatory correspondence and other documents, the staff considers such activities to be routine functions at a nuclear utility. To assure safety and efficiency, the nuclear organization must be knowledgeable about plant comitments and regulatory correspondence and documents. The staff concurs with the licensee's plans to improve these areas of administration and finds the response acceptable.

C.2 - Regulatory Correspondence Review flecomendation:

"The methods used for internal review of regulatory correspondence should be improved and standardized with procedural guidance developed regarding use, basis, uniformity, and distribution."

The licensee has agreed to develop and implement procedures for the review of regulatory correspondence. The procedures will include criteria for identifying comitments in regulatory correspondence and will define how such correspondence is to be distributed for management / staff action. The licensee plans to incorporate the review of regulatory correspondence into the Commitment Control Program (see Recomendation C.1).

5ection 3.1 of ANSI N18.7-1972 requires that proper administrative controls be in effect to assure that decisions are made at the proper level of responsibility and with the necessary technical advice; Section 3.2 requires that the highest management level recognize that the plant must be operated under well formulated and detailed control to assure safety and efficiency.

Although these requirements do not specifically address commitment control or the review of regulatory correspondence and other documents, the staff considers such activities to be routine functions at a nuclear utility. To assure safety and efficiency, the nuclear organization must be knowledgeable about plant comitments and regulatory correspondence and documents. The staff concurs with the licensee's plans to improve these areas of administration and finds the response acceptable.

C.3 - Regulatory Documents Review Recommendation:

" Reviews of regulatory documents must be undertaken on a conceptual basis to determine whether installed equipment, which is often different from that described by the NRC, might fall under the requirements or intent of a regulatory directive."

The licensee has agreed to implement a systematic, continuing review of essential regulatory documents to identify obligations that apply to FSV.

Obligations for all nuclear activities (e.g., equipment, engineering, operations, maintenance, quality assurance, management, etc.) will be cataloged and distributed to responsible managament and unit level personnel.

The licensee plans to expand the duties of the existing Licensing Coordinator position to include the development of a system for acknowledging and controlling ongoing obligations.

Section 3.1 of ANSI N18.7-1972 requires that proper administrative controls

- be in eff ct to assure that decisions are made at the proper level of responsibility and with the necessary technical advice; Section 3.2 requires that the highest management level recognize that the plant must be operated under well formulated and detailed control to assure safety and efficiency.

Although these requirements do not specifically address commitment control or the review of regulatory correspondence and other documents, the s.taff considers such activities to be routine functions at a nuclear utility. To assure safety and efficiency, the nuclear organization must be knowledgeable about plant commitments and regulatory correspondence and documents. The staff concurs with the licensee's plans to improve these areas of administration and finds the response acceptable.

4 SECTION D Training / Retraining D.1 - Resource Requirement for Training Recommendation:

"A detailed manpower study should be performed to determine the resource requirements needed to thoroughly accredit the nuclear organization training."

The licensee has completed a study of the resources needed to achieve accreditation of the ten training programs covered by the INPO accreditation process. As a result of the study, the licensee's staff has received management approval to add 12 people to the Nuclear Production Division to help meet INP0 accreditation requirements and has identified several changes that are needed in the training organization.

- The licensee's response conforms with the general requirements of Section 5.1 of ANSI N18.1-1971, and it also conforms with the Policy Statement on Training and Qualifications of Nuclear Power Plant Personnel (50 FR 11147).

The Standard requires that the training program be such that fully trained and qualified operating, maintenance, professional, and technical support personnel are available in the necessary numbers at the time required. The Policy Statement endorses the INP0-managed Training Accreditation Program, which encompasses the following ten site-related training programs:

nonlicensed operator control room operator senior control room operator / shift supervisor shift technical advisor instrument and control technician electrical maintenance personnel mechanical maintenance personnel radiological protection technician chemistry technician

• on-site technical staff and managers The staff finds the licensee's response acceptable.

l D.2 - Nuclear Training Program 4

Recommendation:

"A training program should be developed for all personnel involved in nuclear-related activities at Fort St. Vrain. The training program should be structured against a job and task analysis conducted for the various positions."

i The licensee has agreed to develop training programs for all positions within the scope of the INPO accreditation program (see Recommendation D.I.) These programs will be based on job / task analyses.

The licensee also plans to address the training of FSV nuclear groups that fall outside the INPO accreditation program, e.g., Nuclear Engineering, Nuclear Licensing and Fuels, and Quality Assurance. Training for these groups will be based on available INP0 technical guidance.

The licensee's response goes beyond the scope of the Policy Statement on Training and Qualifications of Nuclear Power Plant Personnel (50 FR 11147) and is acceptable.

D.3 - Formal Training for Entry Into New Positions Recommendation:

"A formal evaluation should be performed to determine what training is required for a candidate prior to entry into a new job position. Each employee should be thoroughly trained and prepared for entry into the company through a comprehensive, introductory orientation program. The program should include job-specific requirements, departmental responsibilities and goals, and the nuclear organization."

The licensee has agreed to develop training programs for all nuclear-related divisions (Nuclear Production, Nuclear Engineering, Licensing and Fuels, and QualityAssurance). The programs will include orientation programs, general employee training, and procedure training. They will be comprehensive programs designed to give employees the basic knowledge needed to perform assigned tasks.

.The licensee's response conforms with the general requirements of Section 5 of ANSI N18.1-1971 and goes beyond the scope of the Policy Statement on Training and Qualifications of Nuclear Power Plant Personnel (50 FR 11147).

-The staff finds the licensee's response acceptable.

l

D.4 - Individual Training Requirements Recommendation:

" Training policies, procedures and methodologies should be developed that address the assessment of individual performance, the identification of individual training needs, and successful completion of training requirements."

1 The licensee has agreed to develop training programs for all nuclear-related divisions (Nuclear Production, Nuclear Engineering, Licensing and Fuels, and l Quality Assurance). The programs will include orientation programs, general l employee training, and procedure training. They will be comprehensive programs designed to give employees the basic knowledge needed to perform assigned tasks.

The licensee's response conforms with the general requirements of Section 5 of ANSI N18.1-1971 and goes beyond the scope of the Policy Statement on Training and Qualifications of Nuclear Power Plant Personnel (50 FR 11147).

The staff finds the licensee's response acceptable.

D.5 - Consolidated Site Training Recommendation:

"All site training activities should be consolidated under one person who will be responsible for all site-related training."

The licensee has agreed to consolidate Nuclear Production Division training responsibilities in the Nuclear Production Training Department. Except for management-related training, all Nuclear Production Division training activities will be the responsibility of the Support Services Manager.

Section 13.1.2 of NUREG-0800 (Standard Review Plan) and Section II.A of NUREG-0731 contain guidance on the organization of site training activities.

The licensee's response indicates that Nuclear Production Division training is a distinct functional area under the Superintendent-Training, who reports to the Manager-Nuclear Production through the Support Services Manager. The staff finds the licensee's response acceptable.

D.6 - Retraining of Licensed Personnel Recommendation:

"The retraining program for licensed personnel should be modified to accommodate team training and incorporate training needs identified by on-shift performance and/or evaluation."

e The licensee's response to the recommendation states that, although the current FSV Licensed Operator Retraining Program is considered to be adequate, the INP0 accreditation process will incorporate team training and the evaluation of on-shift performance.

Although ANSI N18.1-1971 does not address the use of team training or the incorporation of training needs identified by on-shift performance, recent trends in nuclear training support these concepts. For example, the Policy Statement on Training and Qualifications of Nuclear Power Plant Personnel (50 FR 11147) endorses the INP0-managed Training Accreditation Program in that The staffit encompasses the elements of effective performance-based training.

also agrees with the use of simulators or other methods to promote

• team-building among on-shift crew members. The staff finds the licensee's response acceptable.

i SECTION E Organization / Staffing E.1 - Aucaent Nuclear Staff Recommendation:

"PSC should augment the nuclear staff with trained personnel having experience in licensing, maintenance, scheduling, training, and planning."

PSC has approved the addition of 79 new personnel to the nuclear organization. A. major commitment has been made to nuclear training; licensing people with LWR experience are being added t6 help relate NRC regulations to HTGR technology; additional plant engineering staff will help l increase attention on preventive maintenance and engineering analysis; additional design engineering staff will help improve control and coordination of design changes and plant , support; a new Master Planning and Scheduling function will help man'agem?nt prioritize and direct nuclear activities; and the QA staff is being : creased to allow greater coverage of

. audits, training, and inspections. The staff finds that the licensee's organizational plans conform with the Standard Review Plan and are acceptable.

E.2 - Vice President, Electric Production (Span of Control)

Recommendation:

"It is recommended that PSC consolidate all nuclear-related operations l under one senior nuclear executive whose responsibilities would be limited to nuclear activities. The consolidation should bring together all groups involved with operations, maintenance and support of the Fort St. Vrain Nuclear Power Station.

I

The senior nuclear executive position should be provided with full l

authority and management support to conduct nuclear-related business and l

operations.

t The placement of this position should be such that it is l

organizationally capable of executing such authority. Consideration should be given to placing the senior nuclear executive under the President PSC."

l l The licensee recently reorganized to strengthen nuclear management. The key '

l changes are:

I

• The Vice President-Eleccric Production now reports directly to the President and Chief Executive Officer.

I

The span of control of the Vice President-Electric Production has been modified by consolidating all fossil production under a new position entitled General Manager-Fossil Production.

• Nuclear acthities have been concentrated under three division managers; The Manager-Nuclear Production, the Manager-Nuclear Engineering, and the Manager-Nuclear Licensing and Fuels.

U1e iluclear Licensing and Fuels Division will have the senior management communication link to the NRC.

The Quality Assurance Division now has a staff (rather than line) function with direct acctss to the Vice President-Electric Production (see Recomendation A.7).

Although the senior executive responsible for nuclear activities (the Vice President-Electric Production) alco has responsibility for fossil production activities, the craation of the new General Manager-Fossil Production position is a step in the right direction. The licensee should carefully l monitor the new orga'11zation, with particular emphasis on the span of control of the Vice President-Electric Production and the possible need to consolidate nuclear a .tivities under a single executive with no non-nuclear responsibilities.

l The staff finds that tie licensee's organizational plans conform with the

! Standard Review Plan and are acceptable.

E.3 - Manage Licensing / Nuclear Fuels from Site l Recommendation:

"The present makeup of the licensing and nuclear fuels group (Office of the Executive Staff Assistant) and the QA/QC group appears adequate from l

an organizational standpoint. However, it is the recommendation of the Review Team that these groups be managed from the FSV site."

l The licensee has agreed to perform a study to determine whether the Nuclear Licensing and Fuels Division should be managed from the FSV site. The l

licensee's response to the recommendation also notes that the Quality

! Assurance Division is currently managed from the site, and that a site licensing group was established in the Fall of 1984.

The exact location of a nuclear utility's licensing organization is not prescribed by the regulations. It is the staff's judgment that the guidelines of NUREG-0731 and the Standard Review Plan should be followed when organizing the various administrative and technical support functions. The staff finds the licensee's response acceptable.

E.4 - Combined Engineering Functions Recommendation:

"It is recommended that all engineering and documentation functions be combined into one organization managed from the FSV site. Functional areas in ' Nuclear Engineering' would include:

Site Engineering (including Nuclear Design)

• Nuclear Engineering Records (and Nuclear Documentation Control)

• Nuclear Betterment Engineering (excluding I&C Maintenance Functions)

Technical Advisors The engineering group at FSV should be organized such that they may handle all small and medium projects (< $1,000,000). All major projects should be handled by the Systems Engineering Division."

The licensee has agreed to perform a study to determine whether all functions of the Nuclear Engineering Division should be managed from the FIV site (Site Engineering and Nuclear Engineering Records are currently managed from the site).

The licensee's response to the recommendation also points out that their nuclear organization has sufficient engineering support to accommodate present needs, including major projects.

Except for the Independent Safety Engineering Group (ISEG) described in Section 13.4 of the Standard Review Plan (SRP), the exact location of a nuclear utility's engineering organization is not prescribed. It is the staff's judgment that the guidelines of NUREG-0731 and the SRP should be followed when organizing the various administrative and technical support functions. The staff finds the licensee's response acceptable.

E.5 - Nuclear Production Organization Changes Recommendation:

"It is recommended that the Station Manager's organization be modified to absorb I&C maintenrace work activities while relinquishing the engineering functions of Nuclear Betterment to ' Nuclear Engineering' as discussed in the pr'. ceding paragraph. Further, the ' Shift Supervisor-Trcini.g' position should be transferred to the training organization. This arrangement will result in an ' Operations &

Maintenance' group devoted solely to the objective of operating and maintaining the plant. Functional areas in ' Station Operations and Maintenance' will include:

4

Operations Maintenance

- Electrical

- Mechanical Instrumentation & Control Scheduling F!anning" The licensee's response states that the recommended reorganization would be detrimental to commitments made since September 1984 and could undermine general morale at FSV. The staff tends to agree that a major reorganization at the station level is not advisable at this time. The licensee should be given time to get used to the recent upper-level reorganization and to start working on the many commitments they have made. However, at some point in the future, the consultant's recomendation should be reconsidered; additional organizational improvements may become evident as the Performance Enhancement Program is implemented.

The staff finds the licensee's response acceptable; however, the licensee

'should reconsider the recommendation periodically during implementation of the Performance Enhancement Program.

E.6 - Reorganize Technical / Administrative Department Recomendation:

"The Review Team concluded that the functions of the Technical /

Administrative Department are redundant to those of other organizations.

Based on expanding ' Nuclear Engineer' [ sic] to include all engineering and documentation, it reduces this group to only security and computer services. Recomendations are to transfer these activities to ' Support Services' and entirely dissolve the Technical / Administrative Department.

" Support Services" would therefore be responsible for:

i Health Physics Chemistry Training Security Computer Services" i

The licensee's response to this recomendation, and the staff's evaluation of the licensee's response, are basically the same as the response and evaluation under Recommendation E.5.

l l The staff finds the licensee's response acceptable; however, the licensee should reconsider the recomendation periodically during implementation of the Performance Enhancement Program.

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TABLE 5 PSC PEP RESPONSIBILITIES Name Subproject Responsibilities D. M. Picard, I.I Formalize reorganization & PEP PEP Manager I.2 Document charters & mission statements II.1 Establish planning / scheduling function II.3 Implement planning / scheduling methods M. Zachary I.3 Document comunication policy C. Gaudreau. I.4 Evaluate staffing Production Services Coordinator J. Gahm, I.5 Complete organizational changes Manager-Nuclear '

Production D. W. Warembourg, I.6 Evaluate relocation of engineering / licensing Manager-Nuclear to the site IV.5 Revise nuclear engineering procedures V.5 Improve nuclear engineering training C. N. Fuller, II.2 Develcp schedules FSV Station Manager IV.5 Revise nuclear production procedures VI.1 Formalize plant tour procedures VI.2 Revise " Conduct of Operations" procedure VI.3 Document supervisor responsibilities VI.4 Implementplantsignage,(labels, signs,etc.)

program D. Miller III.1 Establish maintenance planning group III.2 Define maintenance planning function F. J. Novachek, III.3 Develop preventive maintenance program Technical / VI.5 Study facility needs at the site Administrative Services Manager J. Reesy IV.1 Revise design change process VI.6 Improve parts management VI.7 Establish shelf-life program M. H. Holmes, IV.2 Implement commitment control program Nuclear Licensing IV.3 Develop procedure for reviewing regulatory Manager correspondence IV.4 Review essential regulatory documents V.3 Improve 10 CFR 50.59 training

c._

M. J. Ferris, IV.6 Revise exclusion list Quality Assurance Operations Manager McNulty V.1 Upgrade management skills H. L. Grey, V.2 Review membership in industry groups Manager-Nuclear V.6 Improve licensing and fuels training Licensing & Fuals L. W. Singleton, V.4 Improve QA training Manager-Quality Assurance F. J. Borst, V.7 Develop nuclear production training Support Services V.8 Consolidate site training V.9 Retrain licensed personnel 1

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