ML20149L512
| ML20149L512 | |
| Person / Time | |
|---|---|
| Site: | Crane  |
| Issue date: | 07/24/1997 |
| From: | Langenbach J GENERAL PUBLIC UTILITIES CORP. |
| To: | NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
| References | |
| 50-289-97-04, 50-289-97-4, 6710-97-2296, NUDOCS 9708010262 | |
| Download: ML20149L512 (10) | |
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GPU Nuclear, Inc.
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Route 441 South l
NUCLEAR Post Office Box 480 bddletown, PA 17057-0480 Tel 717 944-7621 July 24,1997 6710-97-2296 U.S. Nuclear Regulatory Commission Attn: Document Control Desk Washington, DC 20555 i
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Subject:
Three Mile Island Nuclear Station, Unit 1 (TMI-1) i Operating License No. DPR-50 l
Docket No. 50-289 J
Reply to Notices of Violation 97-04-01,97-04-03, and 97-04-04
Dear Sirs:
l Attached is the GPU Nuclear reply to the Notices of Violation, 97-04-01,97-04-03, and 97-04-04, transmitted as an Enclosure in NRC Inspection Report No. 50-289/97-04, Sincerely, 4%IQ h vp James W. Langenbach Vice President and Director, TMI AWM
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TMI-l Senior Resident inspector j
j TMI-l Senior Project Manager 4!RC Pqumiluiuunu,i,mer;4h.gion1
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ATTACHMENT I l
6710-97-2296
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Page 1 of 9 a
NOTICES OF VIOLATION 04-01. 97-04-03. and 97-04-04 1
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During an NRC in',pection conducted 'on May 12 through May 15,1997, violations of NRC requirements
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were identified.. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement
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. Actions," NUREG-1600, the violations are listed below:
1 A.
10 CFR 50.54(q) requires, in part, "A licensee authorized to possess and operate a nuclear power reactor shall follow and maintain in effect emergency plans which meet the standards in 50.47(b) and the requirements in Appendix E of this part."
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10 CFR 50.47(b)(9) requires adequate methods for assessing actual or potential offsite j
consequences of a radiological emergency condition as part of the licensee offsite emergency response plans. The licensee's Technical Specifications, Section 6.8.1 states, in part " Written procedures shall be established, implemented and maintained covering the items referenced below:
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...f. Emergency Plan Implementation."
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Contrary to the above, from April,1995 to May 15,1997, the licensee had no documentation for the continuous on-line assessment and quick calculation computer codes used for dose projection calculations, nor written procedures to perform those calculations.
This is a Severity Level IV violation,97-04-01 (Supplement Vill).
B.
10 CFR 50.54(q) requires, in part, "A licensee authorized to possess and operate a nuclear power reactor shall follow and maintain in effect emergency plans which meet the standards in 50.47(b) and the requirements in Appendix E of this part."
10 CFR 50.47(b)(15) requires, in part, " Emergency response plans fbr nuclear power reactors must meet the following standard: Radiological mergency response training is provided to those j
who may be called on to assist in an emergency The licensee's Emergency Plan, Section 8.2.1, " Training," states "GPU Nuclear station and station support organization personnel assigned to the emergency organization with specific Emergency Plan duties and responsibilities are required to attend specific EP training. The training is designed to prepare these essential personnel to perform their assigned duties in accordance with the E-Plan and Implementing Documents." It also states " essential personnel reverify their assigned emergency preparedness training preferable every 12 months but at least every 15 months."
ATTACHMENT I 6710-97-2296 Page 2 of 9 Procedure TEP-ADM-1300.02, Emergency Preparedness Training," Section 4.0, Exnibit 1, states, in part, "On-Shift Emergency Organization, Initial Response Emergency Organization and Emergency Support Organization must... satisfactorily complete and maintain EP training program requirements for the position assigned....For personnel responding onsite....must satisfactorily maintain respirator qualifications and General Employee Radiation Worker Training (Category II) and must be active in the dosimetry system."
Contrary to the above, from about September 1994 to May 15,1997 the licensee repeatedly had unqualified individuals listed on the response roster as part of their emergency response organization. The licensee's audit reports indicated that in 1994 a number of ERO personnel on duty had allowed their qualifications to lapse; in 1995, nine personnel allowed their qualifications to lapse, of which four were on duty; and in 1996, 10 personnel allowed their qualifications to lapse, of which three were on duty.
Specifically, individuals did not complete required respirator training or whole body counts necessary to be active in the dosimetry system.
This is a Severity Level IV violation,97-04-03 (Supplement VIII).
C, 10 CFR 50.54(t) se is, in part, a nuclear power reactor licensee "shall provide for a review ofits emergency preparedness program at least every 12 months by oersons who have no direct responsibility for implementmion of the emergency preparedi.,ss program."
The licensee's Technical Specifications, Section 6.5.3.1.e, states that audits of the Emergency Plan and Implementing Procedures shall be performed in accordance with the TMI-l Operational Quality Assurance Plan.
The GPU Nuclear Operational Quality Assurance Plan, section 9.1, states in part, "a comprehensive and documented audit system shall be established, implemented and maintained to ensure that....correctise action systems and management reviews provide for timely completion of requisite action for identified deficiencies....and effective identification and prevention of recurrent and/or significant program nonconformances." Section 2.4.3 states, "for audits, the program requirements of ANSI N45.2.12 shall be satisfied." ANSI /ASME N45.2.12-1977 Standard, Section 4.3.2.4, states "when a nonconformance or quality assurance program deficiency is identified as a result of an audit, further investigation shall be conducted by the audited organization in an effort to identify the cause and effect and to determine the extent of the corrective action required."
A quality deficiency is defined in Procedure 1000-ADM-7215.02, "GPUN Quality Deficiency Reports" as "a deficiency in charactenstic, documentation, or procedure which renders the qualify of an activity unacceptable or indeterminate" and a quality deficiency is documented in a quality deficiency report. Section 4.4.2 of said procedure, states, in part, "the corrective action response shall address the following areas: The cause(s) and extent of the deficient condition (s); actions that will be taken to correct the deficient condition; and action which will prevent the deficient condition from recurring " Section 4.5 states "upon receipt of the corrective action resporse, NSA shall review the response to ensure
ATTACHMENT 1 6710-97-2296 Page 3 of 9 l
that the root cause of the problem has been determined ano appropriate actions to correct and prevent recurrence of the problem have been established."
Contrary to the above, froat September,1994 to September 13,1996 the licensee did not: 1) provide effective prevention of the recurring lapses iri ERO qualifications identified during the 1994,1995 and 1996 audits; 2) trend deficiencies to be able to monitor recurrence, such as outdated procedures or E-Plan changes found in the emergency facilities during the 1995 and 1996 audits; 3) perform a review in order to determine the adequacy of the corrective actions.
Additionally, the characterization of findings was negotiated with the EP staff, obviating the independence of the findings.
This is a Severity Level IV violation,97-04-04 (Supplement VIII).
GPU NUCLEAR RESPONSE TO NOV 97-04-01 1
l Reason for the Violation The violation as stated was caused by poor implementation practices relative to development of the continuous on-line and manual emergency preparedness dose assessment codes used at TMI. In short, computer software changes were made by Emergency Preparedness personnel without appropriately J
I documenting the charises in approved station procedure 6610-PLN 4200.02, "The TMI Emergency Dose Calculation Manual (EDCM)". As stated in this procedure, the contents of the EDCM shall be used as the basis for the computations performed in the Emergency Plan RAC computer programs. Additionally, the software user's manual last updated in 1996 was not updated to reflect recent changes. As a result, the i
documentation associated with the TMI emergency dose assessment codes was found to be less than I
adequate.
Corrective Steps Taken and Results Achieved Several short-term corrective steps have been taken to correct the deficiency noted. On 5/29/97, Quality Deficiency Report (QDR #972025) was issued relative to this deficiency as a means to assure that corrective actions are tracked through completion. Radiological Engineering has prepared a listing of the iodine reduction factors used by the dose assessment codes but not currently documented in the EDCM.
This information has been provided to the dose assessment code users as an interim step until the EDCM is I
' appropriately updated. The dose assessment performance by the TMI staff demcastrated in the May 13, 1997 Remedial Exercisc. and the Unusual Event declared on June 21,1997 provide evidence that the formal j
training provided to the dose assessment code users in conjunction with the interim stsps taken are effective.
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6710-97-2296
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Page 4 of 9 Corrective Steps to be Taken to Avoid Further Violations As addressed in QDR #972025, a comparison is underway between the EDCM and the dose assessment codes. This comparison will provide the necessary detail to support a complete update of the EDCM.
Additionally, as part of this comparison, a formal verification of the dose assessment codes will be performed and documented. These actions will be complete by 1/1/98. To support training of users in the future, the dose assessment user's manual will be revised by 3/31/98. This will support the next training t
cycle for the dose assessment personnel.
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A dose assessment conunittee headed by the Manager Radiological Engineering has been established to i
provide a formal means of approving all future changes to the dose assessment codes. This process will prevent modification of this software without the formal documentation and testing of the changes as
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required by station procedures.
Date when Full Compliance will be Achieved Full compliance will be achieved by 3/31/98.
GPU NUCLEAR RESPONSE TO NOV N-04-03 i
Background
GPUN agrees that the information contained in this notice of violation is accurate; however, the violation as written does not completely document the conditions related to the violation. Quality Deficiency Report (QDR) 942005 was issued on 7-6-94 to document failure to ensure ERO personnel maintained their required qualifications. (Qualifications expired for five individuals on duty in a four month timeframe.) A QDR is a GPU Nuclear approved 10CFR50 Appendix B, Criterion 16 corrective action mechanism. This QDR remained open until 2-6-96 to track long term corrective actions, and to ensure interim corrective actions remained in place until the long term actions were completed. Since the implementation of the corrective actions specified in the response to QDR 942005 (2-6-96), only two personnel have been on ERO duty with an expired qualification. The first individual was identified in the second quarter 1996, and he served in an ERO position for two days prior to requalifying. The second individual was identified in April 1997 and he served in a position on the ERO for six hours prior to requalifying. The conective actions associated with QDR 942005 have been determined to be effective in correcting the 1994 identified adverse trend of failing to maintain ERO qualifications for on duty personnel. This determination of acceptability is based on the less than one percent failure rate observed after the close-out of the QDR, and the expeditious correction of he two occurrences of personnel with expired qualifications. The referenced t
audits acknowledged the existence and status of QDR 942005 but did not repeat actions or oversight already tracked by the QDR.
i ATTACHMENT 1 6710-97-2296 Page 5 of 9 Reason for the Violation As stated in QDR 942005, the cause of the deficiency was a lack of an adequate management tracking system and lack of knowledge in the u se of the existing tracking system were the prime contributors.
Corrective Steos that Have Been Taken and Results Achieved As stated in QDR 942005, a qualification tracking system was verified to be operational on February 6, 1996. E-Mail messages are being automatically sent to selected clerks and administrators notifying them of personnel qualifications coming due. Implementation of this tracking system was supplemented by the continued use of a previous tracking system, and a monthly check by the Emergency Preparedness department. Since February 6,1996 only two personnel have been on ERO duty with an expired qualification. Therefore, the corrective actions of QDR 942005 have been effective, in that a recurrence of the programmatic breakdown in maintaining ERO qualifications has not recurred.
Date when Full Compliance will be Achieved Full compliance was achieved on February 6,1996. GPUN plans no further action on this violation.
GPU NUCLEAR RESPONSE TO NOV 97-04-04 Basis for Disputing the Violation GPUN disputes the violation in that the information presented in inspection report 97-04 is not complete.
Regarding item (1), the inspection report states:
"The licensee's Emergency Plan, Section 8.2.1, required essential personnel to reverify their assigned EP training every 12 to 15 months to maintain current qualifications. A QDR, number 942005 was issued to the EP Department as a result of a 1994 EP program audit for a number ofindividuals on the ERO duty roster with incomplete training. As a result of this deficiency, the EP stafTimplemented a computerizedif?
l qualification tracking system in late 1994 to monitor training qualification records. Ilowever, during the 1995 EP progrwn audit, nine individuals were identified with expired qualifications, four of which were on duty. The aud.t report indicated that an additional computerized tracking system was being implemented and scheduled tbr completion by September 1,1995 and QDR 942005 remained open.
In Tedruary 1996, the QDR was closed by memorandum fmm the EP Manager to the Director, Radiation IIcalth and
!,afety, st ig that the EP Department continued to monitti EP qualifications and a new tracking system was in place. Ilowever, during the 1996 EP program audit, an EP stafimemix.r stated that over a six-month period, ten ERO personnel had their qualifications lapse, three of which were on duty. The report stated, "since the actual error rate for expired qualifications while on duty is very low it will be considered a minor deficiency."
The NSA Audit Program Procedure 1110-ADM-7218.10 defines a minor deliciency as one not being programmatic, not generic, does not compromise quality, is not potentially reportable, and/or corrective action would not be extensive. The independent safety reviewer who evaluated the 1996 audit stated that
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o ATTACHMENT 1 6710-97-2296 Page 6 of 9 "no signiGcant safety conditions were identified, all findings were properly characterized as QDRs or minor deficiencies and no undetected trends were identified by this review." The inspector disagreed with the decision to downgrade the QDR to a minor deficiency and the determination that no trends were identified
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since ERO qualification problems had been identified in the past three audits (one individuars 1
qualifications had lapsed as recently as March,1997). The audit team leader stated that the EP staff identified the individuals and removed them from the ERO upon discovery. Since the EP stafT was addressing the ERO qualification problem, NSA decided that a QDR was not necessary. Also, the auditor stated that NSA did not do an independent assessment during the 1996 audit to verify that all memtwrs of the ERO were qualified at that time."
Initially, our fmdings were considered to be significant conditions adverse to quality. Accordingly, a Quality Deficiency Report was issued and corrective actions were taken to address the cause and program weaknesses identified. Subsequent to the completion of those corrective actions to the program, lapses in qualifications were identified; however, these lapses, we believe, are not indications of a fimdamental program problem.
There was an apparent misunderstanding between the NRC Inspector and the NSA Audit Team Leader. The NSA Audit Team Leader did not have the information or the involvement with all the issues discussed in this inspection and Notice of Violation. A specific, detailed history follows.
Quality Deficiency Report (QDR) 932010 was issued on 5-13-93 to document the failure to ensure personnel assigned to the ERO maintained their qualifications current. The corrective action to this QDR was the creation and implementation of a computer based qualification tracking system.
The QDR was closed on 1-28-94 when the QDR initiator verified all corrective actions had been completed. On 7-6-94 QDR 942005 was issued to document the continuco failure to ensure personnel on the ERO maintained their qualifications current. This QDR identified the trend of failed ERO qualifications and the long term ineffectiveness of the corrective actions associated with QDR 932010. The corrective action response to QDR 942005 identified and offered a solution to a weakness identified in the corrective action to QDR 932010. The qualification tracking system created to resolve QDR 932010 provided access to individuals to their qualification due dates. The proposed system upgrade in response to QDR 942005 would allow plant managers and their administrators to access the qualification tracking database for all of their personnel. The new system would also send computer generated reminders, two months in advance, to personnel whose qualifications were coming due.
Neither QDR 932010 nor QDR 942005 were written as a result of an Emergency Preparedness Audit. These QDR's were issued as a result of oversight personnel external to the audit teams trending deficiencies related to maintaining ERO qualifications. Both QDR's were closed after the initiator verified all corrective actions were completed. This verification included observing the operation of the tracking database systems. Neither QDR was closed based on the initiation of a memorandum. As discussed in response to NOV 97-04-03, QDR 942005 remained open until 2 96. Since the closing of that QDR only two personnel have been assigned duty on the ERO when their qualifications had expired. One individual was expired for two days, and the other individual was expired for six hours.
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i ATTACHMENT 1 6710-97-2296 Page 7 of 9 l
The 1996 Emergency Preparedness Audit, S-TM1-96-08, correctly classified the failure to maintain ERO qualifications as a minor deficiency. The audit referenced the number ofindividuals who allowed their qualifications to expire in a six month time period. Most of those deficiencies occurred while QDR 942005 was still open. Since an approved corrective action mechanism was tracking and correcting those deficiencies an additional QDR was not written. As discussed in response to NOV 97-04-03, the corrective actions of QDR 942005 have been found to be effective in resolving this deficiency. Issuing another QDR as a result of the 1996 Emergency Preparedness Audit would have been repetitious, and would not have resulted in a corrective action different S om the corrective actions of QDR 942005. NSA did not perform an independent assessment of ERO qualification status during the 1996 Emergency Preparedness Audit since the interim sorrective action for QDR 942005 was for Emergency Preparedness personnel to perform a j
monthly self assessment of those individuals whose qualifications were coming due each month.
The Emergency Preparedness stafTealls all individuals who have not requalified by the last few days of the month to ensure these personnel are aware of their need to requalify. This action continues, since it has been effective in ensuring ERO personnel maintain their qualifications.
1 Regarding item (2), the inspection report states.
" Discussions with the EP Manager about this matter indicated that the problem was not only poor tracking systeras but also the lack of management expectations regarding ERO personnel maintaining their qualifications current, and the consequences for not doing so.
While reviewing the audit reports, the inspector noted other " minor deficiencies" that were similar in nature in the 1995 and 1996 reports. For example, copies of EPIPs, the Emergency Plan, and operating procedures and drawings located in various ERFs were found to be out of date.
In 1996 it was identified tl at the equipment kits were insutlicient and kit inventories were not being properly conducted. Sinve these issues were corrected during the audit, the licensee included them as findings, but did not assess them as deficiencies. The NSA did not trend these similar findings and therefore had no historical reference of the EP Department's performance in this area for identifying recurring issues.
In 1995 it was identified that Lancaster County oflicials were concerned about the handling of false siren soundings.
l The EP staffinformed the auditors that only a few sirens had been inadvertently activated and a system upgrade was expensive. The EP stafTcommitted to evaluate the siren system. 'lhe 1996 audit stated "there is gili a problem with false siren soundings" and that EP is getting contract bids for installation of a system to identify faulty sirens and give feedback directly to the counties. Although this was a repeat item, it was not made a deficiency in the 1996 audit report. The QA team leader stated that since the EP staff had been reviewing this concern for the past two years, and was in the process of making additional corrective action decisions, the issue did not warrant a deficiency. The licensee appeared to characterize the repeat audit finding as insignificant due to the EP stafTs' commitment to continue to review the issue. The NSA was nonconservative in its characterization of findmgs as conditions adverse to quality."
The following are responses to item (2) in the order of the issues raised.
Personal accountability for the maintaining of current qualifications has been addressed in QDR 972029, issued 6-16-97. This QDR documented an adverse trend in maintaining a number of qualifications.
Although not specifically written to solely address ERO qualifications, these qualifications will be addressed in this QDR. The QDR has been issued to the Director - TMI, and his proposed corrective actions include the formulation, documentation, and issuance of a directive to all TMl personnel concerning
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1 ATTACHMENT 1 6710-97-2296 l
Page 8 of 9 his management expectations for the maintaining of current qualifications. This directive will include the consequences of failing to maintain qualifications, including ERO qualifications, current. TMI is also creating a qualification tracking database which track all qualifications held by all personnel at TMI.
Minor deficiencies relating to out of date procedures and documents were identified in the 1995 and 1996 Emergency Preparedness Audits. The recurrence of these minor deficiencies has been trended by the Nuclear Safety Assessment (NSA) Department. A Quality Assurance Monitoring Report (QAMR) was -
l conducted and issued in December,1996. This QAMR,9600053, was specifically conducted to review the i
current status of procedures and documents at the Emergency OfTsite Facility (EOF) to determine if a significant condition adverse to quality existed. The QAMR identified or e procedure which required i
updating. Because the error rate was judged to be very small, NSA concluded that the issue should l
continue to be trended, but a significant condition adverse to quality does not exist. Tbc referenced audit reports and QAMR have been distributed to management to ensure they are cognizant of the status of this
- trending, Contrary to the inspection report, the Audit did assess the Emergency Equipment Kits / Lockers not being properly stocked and maintained as a deficiency. Based on a review ofinventory records and NSA Auditor l
observations of the kit / locker contents, a trend was identified and determined to be a significant condition adverse to quality, QDR 962013, issued 8-16-96, documents this deficiency, We believe that how occasional siren false alarms are handled, as discussed in the EP audits, is not considered to be a condition adverse to quality, Frequent siren false alarms or inuances of sirens failing to J
alarm would be considered conditions adverse to quality. The audit team documented their discussions I
with counties, including the suggestions for enhancement of the siren system. The suggested improvements j
to the siren system are properly documented as possible enhancements in the audit report. The enhancement of the siren system that the EP staff was pursuing was completed in January 1997.
Regarding item (3), the inspection report states:
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Conclusions The inspector detennined that the audits covered many areas of review but that they appeared to be narrowly focused on compliance rather than substance. The short-term corrective actions taken by the EP statithat were identified during the audit were considered acceptable even though an in-depth review for determuung the adequacy of the corrective actions was not perfor.ned. Characterization of audit findings appeared to be negotiated with the EP sta1Tand minor deficiencies were not trended for detennination of recurrence. Cverall, the inspector assessed the NSA audit of the EP program to be perfunctory.
The licensee's Technical Specifications, Section 6.5.3.1, states, in part, " audits shall be performed in accordance with the TMI-1 Operational Quality Assurance Plan." The Operational Quality Assurance Plan requires that the audit system provide for corrective action systems and management reviews for timely j
correction of identified deficiencies and prevention of recurrent nonconformances. The licemce did not j
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provide efTective prevention oficcurring deficiencies nor review corrective actions for deficiencies to 1
determine their adequacy. This is a violation (VIO 50-289/97-04-04)."
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s ATTACilMENT 1 6710-97-2296 Page 9 of 9 We consider auditing for compliance to our procedures and regulations to be a fundamental aspect of the audit program. An audit matrix, which delineates the required and reconunended areas of audit oversight has been developed based on regulatory requirements and Emergency Plan and Implementing Procedure requirements. The audits strive to be compliance and performance based. Areas ofimprovement or enhancement are frequently identified and documented in audits as Performance Issues. These documented Performance Issues offer suggested areas ofimprovement for management consideration. Repeated or significant Performance Issues have been escalated to QDR's for correction. Corrective Actions associated with deficiencies are verified or observed to have been completed prior to the close out of the deficiency.
All deficiencies closed since the performance of the last audit in a functional area are reviewed for the effectiveness of the corrective actions in the current audit.
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The procedure which administratively controls the QDR process,1000-ADM-721iO2, states in part in section 4.3.3 that the NSA - Manager "..shall have a conference (either in person or via phone) to obtain concurrence of the action party regarding the nature of the deficiency and the need for corrective action".
This is not to be interpreted as NSA negotiating a deficiency with a corrective action party. This process of discussion prior to issuance of the deficiency is to allow the perspective corrective action party to supply information which the auditor or assessor may not have had available when the deficiency was drafted. If the corrective action party cannot supply information which contradicts the deficiency, but still refuses to accept the deficiency, a proceduralized process of escalation is pursued. This escalation process provides j
access to increasing levels of management from first line management to the Office of the President.
As evidenced by the issuance of QDR's 932010,942005, and 962013, which were wntten agamst identified trends de'ennined to be significant conditions adverse to quality, trending is and will continue to be utilized by the NSA audit staff.
As discussed throughout this iesponse to the Notice of Violation, deficiencies were identified and documented as required. QDR 942005 documented the ineffective corrective actions of QDR 932010.
NSA performed an effectiveness review six months after the implementation of the corrective actions associated with QDR 932010, and found the actions were not effective in preventing significant recurrence of this deficiency. As a result of this effectiveness review, QDR 942005 was issued to document the ineffective corrective action. These QDR's are the highest tier 10CFR50, Appendix B, Criterion 16 corrective action mechanisms utilized at TMI. The corrective actions of QDR 942005 have been efTective, in that a recurrence of the progranunatic breakdown in maintaining ERO qualifications has not beer.
observed. This is evident by a failure rate of significantly less than one percent which has been identified since the close-out of QDR 942005.
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