ML20148G919
| ML20148G919 | |
| Person / Time | |
|---|---|
| Site: | Haddam Neck File:Connecticut Yankee Atomic Power Co icon.png |
| Issue date: | 05/30/1997 |
| From: | CONNECTICUT YANKEE ATOMIC POWER CO. |
| To: | |
| Shared Package | |
| ML20148G915 | List: |
| References | |
| PROC-970530, NUDOCS 9706060302 | |
| Download: ML20148G919 (25) | |
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CONNECTICUT YANKEE ATOMIC POWER COMPANY HADDAM NECK PLANT l l
i RADIATION PROTECTION l i
l IMPROVEMENT PLAN i l
1 Revision 0 q7 May 30,1997 Approved by: '
Date: f 9'7 Hea$frihy' sics Manager l
- n Y/ M Date: 5 30-97 Approved by/ " / ~Udit Director l l
Approved by: ei Date: _S-30-47 Direcht of Site 0;&ations and Decommissioning
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9706060302 970530 3 '
DR ADOCK 0500
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RADIATION PROTEC110N IMPROVEMENT PLAN CONTENTS Page 1.0 Introduction i 1.1 Plan Objectives 1 1.2 Plan Implementation 2 2.0 Responsibilities 2 3.0 Source Documents 3 4.0 Root Cause(s) 4 5.0 Improvement Inkiatives 5 6.0 Effectiveness Measures 7 7.0 Schedule 7 Attachment 1 improvement Process Flow Chart And Description Attachment 2 Improvement Initiatives Attachment 3 Corrective Action Matrix (Example)
May 30,1997 Revision 0 i
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RADIATION PROTECTION IMPROVEMENT PLAN
1.0 INTRODUCTION
This plan has been developed as a response to the Confirmatory Action Letter l (CAL No.1-97-007), issued by the Nuclear Regulatory Commission, March 4, ;
1997. Implementation of this improvement plan will result in processes that will i become part of, and be sustained by the execution of, the Radiation Protection ,
Program in support of activities at the Haddam Neck Plant including i decommissioning. j 1.1 Plan Objectives ;
The primary objective of this plan is to institute near and long term permanent !
improvement to the site Radiation Protection Program by establishing processes l
to:
e identify problems, root causes, improvement items / initiatives and associated j corrective actions using site programs and processes; !
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- establish responsibility for corrective action implementation; l
I e prioritize and implement corrective actions using a logic scheme based on the
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potential risk and/or critical facility decommissioning milestones (e.g. reactor coolant system decontamination, major component removal);
i e track, trend and report corrective action implementation using site programs l ,
and processes; l e verify corrective action adequacy and completeness in addressing the initial j improvement initiative through monitoring and feedback; e verify that completion of one or more identified corrective actions resolves the i identified root cause; and e document problem resolution, from identification through corrective action closure using site programs and process.
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- 1.2 Plan Implementation Actions identified in this plan have been prioritized and implementation will be accomplished using a phased approach. In general these phases are defined based on potential risk to workers and the public, need to support plant activities, or the time necessary to thoroughly evaluate and implement those actions. It is expected that improvement progress for the various phases will occur concurrently. For example it is not necessary to complete all actions associated with Phase I activities prior to starting Phase II.
The implementation phases are generally defined as follows:
Phase I inclur'es identified deficiencies which have a potential risk of affecting health and safuy or regulatory compliance. Corrective actions for these deficiencies will receive the highest priority.
Phase II includes actions required to complete implementation of standard industry radiation protection good practices.
Phase III addresses actions necessary for the program to support the implementation of primary system chemical decontamination.
A flow chart depicting the improvement process and description of each of the actions and/or decisions in this flow chart is provided in Attachment 1.
2.0 RESPONSIBILITIES The Director of Site Operations and Decommissioning shall assure that program improvement expectations are conveyed to all site personnel. The Director will l also assure that appropriate communication and cooperation is established among l all site departments and participation from appropriate departments for
" organization and staffing" and " training" corrective actions affecting all site personnel are properly assigned and completed. In addition, the Director is i responsible for the allocation of resources required to support the improvement process commensurate with other decommissioning activities and schedules.
The Unit Director is responsible for management oversight of this plan and ensuring the coordination and integration of the Radiation Protection Improvement Plan with station improvement initiatives and processes. The Unit Director will approve extensions to the due dates for the completion Improvement Initiative Process items.
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t The Health PhysicrdRadiation Protection Manager (IU)M) is responsible for the implementation of the process within the Radiation Protection Department and assuring improvement objectives have been met. The RPM is responsible for categorizing issues and corrective actions with respect to the specific phases of this Improvement Plan. The RPM has the authority for acceptance of proposed corrective actions and is responsible to determine if corrective actions, as implemented, adequately address the identified root causes. The RPM is responsible for identifying resource requirements for plan implementation to the Unit Director. The RPM is responsible for the oversight of schedule adherence, and communication ofimprovement plan implementation status to site management. Corrective action schedule changes that impact completion dates for Improvement Initiative Process Items must be submitted to the RPM. The '
RPM will forward those requests, with his recommendation, to the Unit Director >
for approval.
A Radiation Protection Imnrovement Plan Project Manager will be identified by the RPM. The Project Manager is responsible for detailed tracking of the implementation ofidentified corrective actions and advising the RPM on the application of resources and the adequacy of the corrective actions. The Project Manager is responsible for completeness of all documentation of actions and their associated identified problems, and the integration of this plan into the site improvement plan.
A group leader will be identified for each radiation protection program element and will normally be the CY employee responsible for implementation of that element. Group leaders will be responsible for reviewing and/or developing specific element corrective actions; corrective action implementation, monitoring and assessment of the adequacy of the corrective action implementation; development of performance goals within each functional element; and providing documentation describing corrective action disposition.
3.0 SOURCE DOCUMENTS The conclusions and recommendations presented in the independent assessment report provided by Millennium Services, Inc. have been reviewed and serve as the primary source for the identification of root causes and corrective actions.
Recommendations provided in this report have been evaluated by CY and used to define specific corrective actions orjustification for excluding or modifying the recommendation. Any recommendation change will be documented with appropriatejustification.
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In addition to the results provided in the assessment report, program deficiencies or concerns identified in previous NRC inspection reports, CYAPCO root cause investigation reports such as those resulting from the 11/2/96 and 2/26/97 events, adverse condition reports, and Nuclear Oversight or QA audit results are also used as sources ofidentified problems requiring correction or program enhancement and integrated into this Improvement Plan.
4.0 ROOT CAUSE(S)
The primary root causes used to generate corrective actions are those identified in the independent assessment report. During review and evaluation of additional identified program problems, original root causes will be evaluated to verify continued applicability or modified / enhanced, as necessary.
The root causes of the current program deficiencies have been identified as follows:
Lack of clear definition of responsibilities, authorities, and accountabilities for program elements; Lack of program documents that describe management structure, program commitments, and methods to meet those commitments; Failure to establish rigorous standards for execution and documentation of field radiation protection activities, including surveys, postings, RWPs; Insufficient self assessment by the Radiation Protection Department to identify and correct problems and to reinforce strong performance; Inability to hold people accountable; and Inadequate integration of radiation protection into station work procedures and programs.
As additional information is obtained, reviewed and evaluated, this list may be enhanced to assure that the improvement process focuses on the appropriate underlying causes of program deficiencies.
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l 5.0 IMPROVEMENT INITIATIVES Improvement initiatives have been established to address the root causes identi6ed. These initiatives are comprehensive in nature and will be used to categorize more discrete corrective actions for implementation. It should be noted that these initiatives may be added to or updated, as necessary, as the improvement process progresses. However, modification ofimprovement initiatives will require RPM approval. The improvement initiatives are:
- 1. Develop methods to ensure that organizational roles and management expectations are clearly defined, implemented and communicated to all departmental personnel;
- 2. Improve the quality of the Radiological Controls Manual through development of a Radiation Protection Plan and improvement of implementing procedures;
- 3. Establish a program for self assessment and reinforcement of standards within the Radiation Protection Department;
- 4. Establish radiation protection performance measures and goals that include all site departments; and ,
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- 5. Improve the quality of the Radiation Protection Department training to assure effective implementation of program enhancements.
.%ccific corrective actions will be identified to address each of these improvement j initiatives. The improvement initiatives identified, corrective actions and l effectiveness measures are provided in Attachment 2. The specific corrective actions are tied to the improvement initiative in a tracking database that identifes the action item, source document (s), functional area and/or program element, responsible individual (s) or Group Leader (s), completion date, and the closure mechanism. A matrix typical of the information which will be input in the data base and used to identify all corrective actions associated with a specific program improvement is provided in Attachment 3. The use of the matrix, along with the interface with the site action tracking system, is managed by the Radiation Protection Improvement Plan Project Manager.
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- '.*=a In identifying functional area and program element responsibilities, the relationship between the two are defined as follows:
Functional areas correspond to the major divisions within the organization l and include:
- l. Radiological Operations
- 2. Radiological Engineering
- 3. Radioactive Waste,and
- 4. Radiological Support Services.
Program elements are those basic elements to be addressed in the Radiation Protection Plan and include, for example: ;
- 1. External and Internal Exposure Control ,
- 2. Surveys -
- 3. Posting and Labeling
- 4. Instrumentation ,
- 5. Contamination Control
- 6. Work Control (including planning and scheduling and radiation work permits)
- 7. ALARA
- 8. Respiratory Protection ,
- 9. Radioactive waste shipping and handling
- 10. Radiological Occurrences, including reporting, tracking, trending, root cause analysis, and corrective actions.
I Each functional area within the radiation protection organization is responsible for '
one or more program elements. Implementation initiatives and/or corrective actions which involve organization, staffing and radiation protection personnel training and qualifications are the responsibility of the RPM.
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l 6.0 EFFECTIVENESS MEASURES in addition to radiation protection program effectiveness measures typically tracked, such as person-Rem and contamination events, effectiveness measures have been developed in each of the improvement initiatives areas. Specific action items are assigned to create meaningful measures. Effectiveness measures include items such as performance indicators for activities considered to be precursors to program failures, which are derived from a variety of sources, such as self-assessment and work observation results, ACR causal factor trends as a result of tracking, training effectiveness validation, department survey feedback, and independent program assessments. Performance measures developed as part of this improvement plan will become integral to the Radiation Protection Program and managed as part of the routine program following completion of this improvement plan project. i 1
7.0 SCIIEDULE l
Phase I includes identified deficiencies which have a potential risk of affecting l worker or public health and safety and/or compliance with federal regulations.
Corrective actions for these deficiencies will receive the highest priority.
Examples of specific corrective actions included in Phase I are as follows:
. Evaluate the current radiation protection organization and modify, as 1 necessary, to adequately align resources and responsibilities. Clarify roles and responsibilities and complete transition to the new organization. This should include responsibilities for training oversight and intra-departmental training, I training development and training records maintenance.
- Develop standards and expectations for the conduct of business within each functional area. Ensure proper understanding of procedural adherence is included in the expectations. Some concepts or activities for the development of standards and expectations are as follows:
- 1. Documentation of activities (surveys in particular)
- 2. Communications
- 3. Conservative decision making
- 4. S.T.A.R. (stop, think, act, and review)
- 5. Peer oversight (teamwork)
- 6. Attention to detail
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I e Ensure personnel are knowledgeable of roles, duties, responsibilities, authorities and accountabilities within the newly defined organization.
Items associated with Phase I of the Radiation Program Improvement Plan are
. intended to be completed by July 31,1997 l Phase II includes actions required to implement a program that fully meets or l exceeds standard industry radiation protection good practices. Examples of l
specific corrective actions included in Phase II are as follows:
Develop and implement a self assessment program which includes adequate resource commitment, methods for documentation, and tracking ofidentified deficiencies to closure.
e Develop a Radiation Protection program document to identify program policies, responsibilities and bases. Develop or revise procedures, as necessary, to ensure all program elements are appropriately implemented.
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- Establish departmental goals and performance indicators.
Items associated with Phase II of the Radiation Program Improvement Plan are intended to be completed by September 30,1997.
Phase III addresses actions necessary for the program to support primary system chemical decontamination. Examples of specific corrective actions included in Phase III are as follows:
e Validate program improvements and modify staffing levels to support reactor coolant system chemical decontamination; e Strengthen the exempt personnel training program to include use of outside instruction and on-site seminars; e Strengthen the technician training program; and e Continue program effectiveness validation through self-assessment, work observation and independent assessment. !
Items associated with Phase III of the Radiation Program improvement Plan are intended to be completed by December 31,1997. ;
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RADIATION PROTECTION IMPROVEMENT PLAN ,
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ATTACHMENT 1 i IMPROVEMENT PROCESS i
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IMPROVEMENT PROCESS FLOW CHART DESCRIPTION (PROCESS GUIDANCE)
The following discusses the important aspects of each action or decision in the improvement process flow chart.
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l 1. IDENTIFY ROOT CAUSE - Root cause(s) will typically correspond to those l identified in the independent assessment performed by Millenium Services, Inc. As the process proceeds and additional concerns and/or corrective actions are identified i from sources other than this report, the root cause(s) will be verified to be !
applicable or additional root cause(s) identified, as appropriate.
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- 2. DEVELOP IMPROVEMENT INITIATIVES - Improvement initiatives describe, j in general or broad terms, the actions necessary to resolve the identified root cause. 1 In most cases a single improvement initiative will be defined for a root cause.
However, multiple initiatives may be identified to adequately and completely resolve the problem or address the true cause of program deficiencies. ,
Improvement initiatives will be entered in a tracking system, tied to specific or discrete corrective actions (see 3. below)
- 3. DEVELOP CORRECTIVE ACTIONS & DRAFT EFFECTIVENESS I MEASURES - Specific or discrete corrective actions will be developed to facilitate !
implementation of the improvement initiatives. These actions will define tasks to be completed which can be assigned to responsible program personnel for implementation. Typically, multiple corrective actions will be identified for each i improvement initiative. '
- 4. IDENTIFY AFFECTED PROGRAM ELEMENTS & IMPLEMENT CAs - j Specific or discrete corrective actions may be applicable to multiple (or all) program elements. For instance, " organization and staffing" applies to all program personnel and, obviously, applies to all program elements. Other examples may require implementation from only select program elements or require only partial l implementation. For instance, a corrective action may require the review of site i procedures and revision of those found to be incomplete, inadequate or inaccurate.
l In this case, all elements will be required to review procedures. However, it may
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be found that only a few procedures require revision or a few program element l procedures are in need of improvement. Only when all identified elements have completed corrective action implementation can the action be considered complete and closure acceptable (see 5. below).
- 5. VERIFY CA IMPLEMENTATION WITHIN ALL ELEMENTS - When l corrective actions are applicable to one or more program elements, the CA must be i implemented within these elements. Only when corrective action implementation is l complete within all elements, can the action be considered for closure.
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- 6. IMPLEMENTATION ASSESSMENT REQUIRED? -In many cases a self-assessment or independent assessment of corrective action implementation may be necessary to verify that the discrete action addresses the concern. For instance, corrective actions associated with improvement in performance or knowledge will ,
typically require assessment. For example, an assessment of personnel awareness of roles and responsibilities, as well as authority and accountability may be necessary to measure improvement as a result of corrective actions. However, a corrective action which requires only a procedure revision may not require assessment. In determining the necessity for assessment, care should be taken to 1 assure the improvement initiative is successful. For instance, even though a procedure revision may not warrant an assessment, if the revision was in response to concerns regarding procedure non-compliance, then assessment may be considered an appropriate means for measuring performance improvement or determining alternate or additional corrective actions.
- 7. PERFORM ASSESSMENT - Assessment of correctue action implementation or improved performance may be accomplished in a variety of ways, such as a review and verification of the implementation and documentation of adequacy via memorandum, management observation or through formal processes, which l includes self-assessment and/or independent assessment.
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- 8. DID CA CORRECT PROBLEM? - Whether or not an ass sment of CA implementation is performed, a determination of CA implementation adequacy must be performed which answers the question "Did the CA correct the identified problem?". This must be considered for all program elements which are affected by the CA. ' Additionally, consideration must be given to the inadvertent generation of additional problems as a result of corrective action implementation. If the CA did not adequately address the problem the cause must be evaluated and corrected (see 14. below).
- 9. CLOSE CA - Once it has been determined that the problem is adequately resolved via the corrective action, closure is acceptable.
- 10. VERIFY ALL I.I. CAs IMPLEMENTED & CLOSED - Since multiple ;
corrective actions may be necessary for improvement initiative success, all l associated corrective actions must be verified prior to proceeding. l
- 11. PERFORM ASSESSMENT - A self-assessment and/or independent assessment will be performed for each improvement initiative to verify that corrective action implementation was complete for all initiative associated CAs and adequately addressed all aspects of the improvement (see 12. below). Additional in-progress
! improvement initiative evaluations may also be requested by site management.
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! 12.DID ACTIONS ACHIEVE DESIRED RESULT? - Assessment results will be used to document acceptable program improvement or identify additional actions l which may be necessary to achieve the desired result. If the assessment is positive, I the improvement initiative may be closed. If not, the adequacy or completeness of the corrective actions must be evaluated and revised, if necessary, or the improvement initiative may need further clarification (see 15.).
- 13. IMPLEMENT EFFECTIVENESS MEASURES - Using the corrective actions as a basis, effectiveness measures will be defined, if not already in place, or reviewed and refined, as necessary. These measures will be used to provide continuous !
evaluation of adequate program performance and may also be used to establish j challenging goals for further program improvement.
- 14. WAS CA INADEQUATE - For each specific corrective action, an evaluation will ,
be performed to determine the adequacy of the CA in resolving the associated I problem or concern. If the CA did not adequately address the problem, the cause ;
must be evaluated and corrected. This may require revision of the corrective action 1 to better address the problem or review and evaluate CA implementation.
- 15. REVIEW & MODIFY IMPROVEMENT INITIATIVES OR CORRECTIVE ACTIONS - If the results of all corrective action implementation for an improvement initiative does not achieve the deshed result, the adequacy or completeness of the corrective actions must be evaluated and revised, if necessary, or the improvement initiative may need further clarification.
- 16. CLOSE I.I. - Once it has been determined, through assessment, that the improvement initiative has been adequately implemented and no further refinement is necessary, the I.I. may be closed. i l
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RADIATION PROTECTION IMPROVEMENT PLAN ATTACHMENT 2 IMPROVEMENT INITIATIVES 1
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BADIATION PROTECTION DEPARTMENT NEAR-TERM IMPROVEMENT INITIATIVES l 1 Improvement Initiative 1: Develop methods to ensure that organizational roles and .
management expectations are clearly defined and communicated to all departmental personnel I. Goal: Develop or enhance roles, responsibilities, authorities, and general performance standards and communicate to personnel in order to accomplish uniform, consistent, high personnel performance which reinforces management expectations.
l 11. Process: There have been several events and an independent assessment of the l radiological protection program which have indicated a failure to clearly l define responsibilities, authorities, standards for execution and t
! documentation, and accountability of personnel within the radiological !
controls organization. The following actions are designed to address l this identified deficiency and provide for an organization prepared for a future challenging and changing environment.
Corrective Action (s):
l A. Develop a functionally based organization with clearly identified roles, responsibilities, and authorities. Complete transition to the new organization with l staffing assessment, l
B. Develop standards and expectations for the conduct of business within each functional area. Examples of specific areas where expectations are to be included are proper understanding of procedural adherence, use of effective
, communications, and consistent application of the S.T.A.R. (stop, think, act, and review) concept.
C. Communicate organizational changes including duties, responsibilities authorities and accountabilities, as well as department standards and expectations to department personnel.
l D. Establish a program to promptly and effectively disseminate information to the l HP staff regarding additional program, policy, and procedure changes.
E. Establish a management and supervisory observation /self assessment process t
containing specific observable behaviors by which effective understanding of expectations can be measured.
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l i III. Effectiveness Measurements: l l
a A. Using the ACR process causal factors, establish baseline information, goals, track !
and trend Health Physics Department performance for management expectations.
B. Utilize periodic departmental surveys to determine if program, policy, and l
l procedure changes are being promptly and effectively communicated to l
personnel. The frequency of surveys will be in accordance with or greater than 1 those established in site procedures. j l
l . C. Perform periodic assessments to determine how well management expectations are defined and understood within the department. The frequency of assessments will be in accordance with or greater than those established in site procedures.
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Improvement Initiative 2: Imorove the auality of the Radiolocical Controls Manual
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- through development of a Radiation Protection Plan and improvement ofimnlementing procedures.
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. I. Goal: Radiation Protection technician improved understanding and use of j
- radiological control procedur 's, particularly as the procedures relate to decommissioning activities.
- II. Process
- An independent assessment of the Radiological Protection Program identified many weaknesses in both technical content of some implementing procedures and a general lack of bases understanding by health physics technicians.
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Corrective Action (s):
A. The Radiation Protection Department will generate a Radiation Protection Plan which contains the core bases for the implementing procedures of the !
Radiological Controls Manual.
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B. Improve the technical content ofimplementing procedures for the Radiation Protection Plan through incorporation of weaknesses identified by the Radiation ;
Protection Improvement Plan and ongoing technical review in preparation for i decommissioning activities.
C. Evaluate the reorganization of procedures to better support the Radiation Protection Plan and understanding by technicians for locations of specific procedural guidance.
III. Effectiveness Measurements:
A. Provide for an assessment of procedural improvements upon completion of the l procedural portion of the Radiation Protection Improvement Plan.
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B. Using the ACR process causal factors, establish baseline information, goals, track ,
and trend Radiation Protection Department performance for procedural difficulties.
C. Develop a method for technician identification of procedural problems and recommended improvements. Through tracking and trending of this information I an additional means of measuring procedure improvement is possible.
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Improvement Initiative 3: Establish a nrogram for self assessment and reinforcement of standards within the Radiation Protection Denartment I. Goal: Develop among the Radiation Protection staff a self critical attitude and the ability to continually search for improvemeat in overall Radiation Protection quality and efficiency.
II. Process: The Radiation Protection Improvement Plan should not be the end point in program improvements. Through the use of self assessments and critical review of work performance, the radiation protection staff should continue to improve processes surrounding radiological work.
Corrective Action (s):
A. Reestablish effective self-assessment and work observation processes within the Radiation Protection Department.
B. Develop a method for technician identification of procedural and program problems and recommended improvements.
C. Include as a part of performance expectations the proper attitude toward problem identification and resolution among both the technicians and the exempt staff.
III. Effectiveness Measurements:
A. Track and trend, both number and content, of procedural change i recommendations from department personnel.
B. Utilize qualitative assessments of department's self-critical attitude to be performed by station management or oversight. i l
C. Review of training critique and observation forms will be utilized to qualitatively ;
indicate degree of self-critical attitude. '
D. Track and compare the number of radiation protection program ACRs generated by radiation protection personnel versus those generated by other organizations.
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Improvement Initiative 4: Improve the overall site radiological performance through increased radiological accountability of nersonnel in all site departments. l f
I. Goal: Des clop and enhance an understanding of the overall site support and
, commitment to radiation protection necessary to accomplish activities
! associated with D&D such that exposures are maintained ALARA and work is performed in a compliant, radiologically safe manner.
II. Process: There have been several events and an independent assessment of the radiological controls program which have indicated a failure personnel ;
in other departments to clearly understand their responsibility, authority, ;
and accountability to the radiological controls program. The following actions are designed to address this identified deficiency and provide for a site organization better prepared for a radiologically challenging and changing environment.
Corrective Action (s):
A. Develop a process for establishing exposure goals at an individual department i level. These goals should be for specific majorjobs, phases of decommissioning (i.e., walkdowns for planning), and discrete time frames.
B. Develop individual department initiatives for supervisory observations of radiological work in progress. Develop clear expectations for performance issues to be assessed.
C. Establish a baseline ofinformation for personnel performance issues associated with radiological protection standards from ACR data. Set goals, either department or station wide, for performance improvements.
D. Effect better radiological work performance through integration of radiological '
work controls into individual work packages, improved scheduling of work activities, and effective use of pre-job briefings.
Ill. Effectiveness Measurements:
A. Total exposure estimates to actual exposures, as well as departmental goals compared to departmental actual exposures for specific ALARA tasks will also be used as a measure of effectiveness for this initiative.
B. Trends in radiological performance of workers to be based upon ACR data and l observations of supervisors.
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C. A measure of the effectiveness of the initiative will be the ability of the departments to accomplish the goals set for the departments in the process (A) above.
D. Evaluation of work controls effectiveness based on the number of revisions required to work packages or RWPs due to insufficient planning.
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Improvement Initiative 5: Improve the anality of the Health Physics Department ,
training. f I. Goal: Radiation Protection staffimproved knowledge concerning industry events, better programmatic change management, correction of generic performance deficiencies, and increased professional attitude of the i Radiation Protection staff. !
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- 11. Process: An independent assessment of the Radiation Protection Program and . ,,
several events have indicated a need for improved continuing training l for the Radiation Protection personnel, particularly in light of the many changes as a result of the Radiation Protection Improvement Plan and !
the implementation of decommissioning activities. l Corrective Action (s): i l
A. Establish a program to promptly and effectively disseminate information to .
the Radiation Protection staff regarding program, policy, and procedure changes. i i
B. Establish a responsible individual to coordinate departmental training !
l activities including planning, conduct, and records maintenance. ;
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C. Establish a mechanism to identify topics for both technician continuing training and exempt personnel seminars. Establish specific expectations for.
attendance by personnel, including contractor personnel filling long term
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D. Establish requirements for management participation in the determination of I
training needs, the evaluation of training provided and assessment of the overall value of training compared to desired objectives.
III. Effectiveness Measurements:
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A. Use the training feedback process to determine the applicability of training to the needs of the technicians and exempt staff.
B. Conduct periodic surveys to measure general impressions toward the continuing training program.
C. Track and trend department participation in continuing training classes.
, D. Evaluate ACRs for trends relating to inadequate training.
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ATTACHMENT 3 CORRECTIVE ACTION MATRIX May 30,1997 Revision 0 t
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RADIATION PROTECTION IMPROVEMENT Pt Ad RADIATION PROTECTION IMPROVEMENT PLAN CORRECTIVE ACTION MATRIX IMPR. RECOMMENDATION SOURCE CORREC n sVE ACTION FRASE RESPONSIBLE FUNC. TARGET STATUS INIT. DOC. STEPS M '*F) INDIVIDUAlfS) AREA (S) COMFLETION DATE
- 1. A Develop an organizauon Milleanun I.A.I Establish strawrnao [ RPM / Direct AII 5/16/97 complete based ce functional functional organiration Reports responsibilities. Identify individuals to assune the important roles in the nWor groups within the 4Lucnt.
, Identify resouras and establish a transition plan.
I.A.2 Initial assignment of I RPM / Staff All 5/30/97 names to cach functional area.
I.A.3 Develop draft scope of I Individuals All 6/6/97 responsibilitics included in assigned to cach functionalarea. functional areas 1.A.4 Review /mnunent/ I RPM /Dired All 6/13/97 approve scopes Reports 1 A.5 Identify resource 1 RPM / Direct All 6/6/97 requirements forcxunpletion Reports ofimprovement plast I.A.6 Establish schedule for I RPM All 6/13/97 additional resources 1.A.7 Develop position I Individuals All 6/20/97 descriptions assigned to functional areas 1.A.3 Approve position I RPM All 6/27/97 descriptions.
- l. A.9 Develop transition I RPM All 6/20/97 plan per new functional organiation.
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May 30,1997 I Revision 0 EXAMPLE
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