ML20155A963

Insp Rept 70-1151/98-07 on 980921-25.No Violations Noted. Major Areas Inspected:Assessment of Operational Readiness Status of Licensee Emergency Preparedness Program Changes Since Sept 1998 Insp

ML20155A963
Person / Time
Site:	Westinghouse
Issue date:	10/13/1998
From:	NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION II)
To:
Shared Package
ML20155A947	List: ML20155A943 ML20155A963
References
70-1151-98-07, 70-1151-98-7, NUDOCS 9810300030
Download: ML20155A963 (13)

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4 U.S. NUCLEAR REGULATORY COMMISSION REGION 11 Docket No.: 70-1151 License No.: SNM 1107 Report No.: 70-1151/98 07 Licensee: Westinghouse Electric Corporation Facility Name: Commercial Nuclear Fuel Division 4 Date: September 21-25,1998 Inspector: A. Gooden, Radiation Specialist Approved by: E. J. McAlpine, Chief Fuel Facilities Branch Division of Nuclear Materials Safety Enclosure 9810300030 981013 PDR ADOCK 07001151 C PM g3

Executive Summarv Commercial Nuclear Fuel Division NRC Inspection Report 701151/98-07 This routine unannounced inspection was conducted to assess the operational readiness status of the licensee's emergency preparedness program, and assess program changes since the September 1998 inspection. Areas that were reviewed included training; emergency facilities and equipment maintenance; independent audit; and the adequacy of emergency procedures.

The report includes one week of inspection activity from a regional-based Radiation Specialist.

Based on interviews, program documentation, and operability checks of select equipment, within the areas examined, the licensee's emergency preparedness program appeared to be maintained in a state of readiness for responding to various postulated accidents. The l inspection disclosed the following aspects of the licensee's program:

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• The independent emergency preparedness audit lacked details to demonstrate that the program assessment included procedures, training, equipment, and drills / exercise observations (Paragraph 2.a.2).

• The checklist format for emergency procedures provided users with adequate details for ensuring that appropriate actions were taken in response to an incident (Paragraph 2.b.2).

• Emergency procedures were revised and enhanced based on actual events and/or drill l results (Paragraph 2.b.3).

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• Non-required table top drills provided an enhancement to emergency response training program (Paragraph 2.c.3).

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• Results from an off hours communications drill demonstrated that timely activation and staffing of the Emergency Control Center required management attention (Paragraph 2.c.3).

• The interface with offsite support groups was properly maintained (Paragraph 2.d.3).

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• Emergency facilities and equipment were maintained in an adequate state of readiness (Paragraph 2.f.3).

Attachment:

i Persons Contacted and Exit Interview l List of items Opened, Closed, and Discussed List of Acronyms i

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Reoort Details

1. Summarv of Plant Status  !

i This report covers a one week period. There were no unusual plant occurrences during i the inspection. Routine plant operations and roof repair work were observed.

2. Emeroency Preoaredness (88050) (F3)

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a. Review of Proaram Chances (F3.01)

(1) Insoection Scooe

Changes to the Site Emergency Plan (SEP), emergency procedures, organization, facilities, and equipment were reviewed to assess the impact on the effectiveness of the program; and to verify that changes l met commitments, license conditions, and SEP changes were provided to '

NRC in accordance with 10 CFR 70.32(i). The independent audit was reviewed to verify adequacy of scope and depth, technical capability of

the auditor, documentation of findings, and adequacy of corrective actions.

! .(2) Observations and Findinas Since the September 1997 inspection, with the exception of SEP and -

emergency procedure (EP) changes, no other changes were made.

Changes to the EPs were considered procedure enhancements and are discussed below in Paragraph 2.b. Regarding the licensee's SEP changes, the NRC determined that additional information was required before making a final decision regarding impact of changes on program effectiveness. Based on the additionalinformation and commitments discussed during a teleconference call, the SEP changes were approved by NRC via letter dated May 8,1998. During the onsite inspection, the inspector reviewed the licensee's actions in response to the NRC approval letter and determined that the licensee had completed corrective actions consistent with written response (letter dated April 7,1998) and verbal commitments (teleconference call of May 6,1998).

Documentation for the annual independent audit was reviewed and an interview was conducted with the auditor to determine the adequacy of the audit in meeting Section 7.8 of the SEP. Based on the documentation, the inspector determined that the audit was a very detailed review of the SEP to determine if the SEP was consistent with guidance in Regulatory Guide (RG) 3.67 (Standard Format and Content for Emergency Plans for Fuel Cycle and Materials Facilities) and requirements in 10 CFR 70.22. However, the audit documentation lacked details to show critical program elements such as emergency response training, facilities, equipment, or offsite support agency interface were reviewed. Thus, the inspector questioned the auditor regarding what additional aspects of the program were reviewed, The interviewee i indicated that although the primary focus of the audit was the SEP, the

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audit also included observation of the biennial exercise, a check of the emergency vehicle and supplies, training records, and surveillance records for omergency equipment and supplies were reviewed. The l interviewee acknowledged that the documentation to support such areas audited was lacking from the report.' Based on the interview and audit documentation, the inspector emphasized the importance of the l development and implementation of an audit plan and checklist to ensure l the audit was performed in a manner consistent with the SEP requirement. This aspect of the audit program was previously discussed in an NRC Inspection Report (70-1151/97 05). The auditor's current position involved emergency planning and the development of Plans and procedures for the Emergency Management Team at the Westinghouse Energy Systems Business Unit (ESBU) site. Audit findings requiring l corrective actions were assigned in the licensee's commitment tracking system (CTS) for followup.

l (3) Conclusions Based on the review of records and interviews, the inspector determined that the changes to the licensee's SEP met commitments, license conditions, and NRC requirements. Based on SEP transmittal l documentation, changes were distributed in a timely manner. The individual who conducted the independent audit was technically qualified, but lacked an audit plan, audit checklist, or detailed guidance. The audit I

report lacked detail to demonstrate that the audit was performed in a manner consistent with Section 7.8 of the SEP.

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b. Implementina Procedures (F3.02) l l

(1) Insoection Scoce The administrative system for review, approval, and distribution of SEP l Implementing procedures (referred to as EPs) was reviewed. Changes to l EPs were also reviewed to assess the impact on the effectiveness of the program and verify that revised EPs continue to implement the SEP.

(2) Observations and Findinas The inspector reviewed six procedures that were revised since the last inspection for applicability and adequacy in implementing the SEP. The I changes appeared to be procedural enhancements or updates and l continued to implement the SEP. Several changes resulted from the Septembeir 1997 biennial exercise. The checklist format for emergency l procedures provided users with adequate details for ensuring that appropriate actions were taken in response to an incident. The administrative system for review and approval of changes was reviewed and determined to be an adequate system for ensuring that revised procedures did not reduce the effectiveness cf the program. The inspector verified that the approval authorities as discussed in Section 7.1 of the SEP reviewed and approved the revised procedures, and changes were distributed to controlled copy holders in a timely manner. During a

3 facility tour, the inspector found one example of a procedure in a controlled copy (CC.10) of the EP manual that was outdated. The licensee took immediate action to update the manual. The inspector  :

considered this as an isolated rather than a programmatic example in that all remaining locations that were che~cked had current copies of the SEP, EPs, and the emergency telephone directory. This failure constitutes a violation of minor significance and is not subject to formal enforcement

, action.

The inspector noted that several agreement letters with offsite support groups were maintained by the licensee. The agreement letters and the emergency telephone directory containing phone numbers for onsite and offsite emergency response personnel were maintained current and updated at a frequency in accordance with the SEP requirements.

.(3) Conclusions Procedures were revised and enhanced based on actual events and/or drill results. Procedures were written in a checklist format and appeared to be user-friendly. Changes to EPs were distributed to controlled copy holders in a timely manner.

c. Trainina and Staffina of Emeraency Oraanization (F3.03)

(1) insoection Scoce J Emergency response training was reviewed to determine its adequacy and specificity and whether it was in accordance with Section 7.2 of the l Plan. The adequacy of the administrative and/or physical notification i system for staffing the emergency organization with trained personnel during off hours was reviewed.

(2) Observations and Findinas Training lesson plans included details from the revised procedures and lessons learned from the biennial exercise involving a simulated bomb.

The inspector noted that personnel from the Regulatory Engineering Operations (REO) staff, with responsibility for performing surveys during an emergency, were provided training associated with the selection of radiation survey instruments and respiratory protection. In addition to the records review, the inspector verified via interviews with key members of the emergency response organization (ERO) that personnel were familiar with their roles and responsibilities during an emergency, and had been trained during the calendar year (CY). Since the last inspection (September 1997) of this area, the licensee implemented a program of

, non-required quarterly table-top drills to maintain the proficiency of ERO l personnel. During an interview with the Site Emergency Director, the inspector was informed that the table-top scenarios and walkthroughs had provided good training and a better understanding of the various

! roles.

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4 Regarding ERO staffing and activation during backshifts and off-hours, the inspector concluded from recent drill results that the licensee's administrative system introduced inherent delays to timely notification and i ultimate activation of key ERO personnel. The current system employs

the " call tree" methodology which reiuires l key ERO members to notify l other response personnel regarding the need to respond prior to

, departing for the site. Drill documentation disclosed the following results from attempts to contact a total of 51 responders:

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• Some responders would have been delayed in arriving at the site j by needing to contact other ERO members on the " call tree".

• Eight of fifty one responders would have arrived onsite within an hour or less from the start of the simulated accident.

• Twenty-five of fifty-one responders site arrival time would have been in excess of an hour (maximum arrival time was in excess of

! two hours),

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• Eighteen of fifty-one responders were never contacted.

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in response to the results and the inspector's conclusions, plant management stated that the drill benchmarks were not fully understood i

relative to the timeliness of notification and estimated time of arrival to site. The licensee indicated that consideration may be given to the implementation of a pager system for all key personnel required to respond; but as a minimum, all personnel with responsibility as an alternate emergency director would be available via pager or other notification / communication equipment (e.g., cellular phones). The.

emergency preparedness contact discussed as an interim measure, a revision to the current call-tree to provide improvements in activation and staffing time. The inspector informed the licensee that the corrective actions to improve the ERO activation and staffing time were being  ;

tracked as an inspector followup item (IFl 98-07-01). 1 i

(3) Conclusions )

Based on records review and interviews with key ERO personnel, the training of responders was judged to be sufficient to implement their respective responsibilities in protecting the onsite and offsite populations.

Although program improvements were noted involving ERO staffing and activation of the Emergency Control Center (ECC), the ERO timely activation and staffing of the ECC during off hours require additional management attention. The perfomance of non required quarterly table-top drills was considered a significant improvement to the emergency response training program.

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d. Offsite Sucoort (F3.04)  !

(1) Insoection Scopa Licensee activity in the areas of training, agreements, and exercises, was reviewed to determine if the licensee was properly coordinating with offsite authorities.

(2) Observations and Findinas Training documentation showed that the licensee conducted offsite support training in CY 97, and according to the licensee, CY 98 training was scheduled for October 1998 and will include site familiarization tours for the Columbia Fire Department. The offsite support groups were also ,

invited to participate in the last biennial exercise (Saptember 1997). l All agreement letters were reviewed and renewed in accordance with the SEP, and the licensee provided offsite copy holders with updates and revisions to the SEP in a timely manner.

(3) Conclusions l l

! Based on documentation, the offsite interface was properly maintained as l evidenced by training opportunities and offsite authorities were invited on l an annual basis for site familiarization tour and meeting to discuss matters of a mutualinterest.

e. Drills and Exercises (F3.05)

(1) insoection Scoce Section 7.4 of the SEP required that one biennial on-site exercise wi!! be performed involving a full-scale test of the entiro emergency response organization. Assess the degree of challenge posed by scenarios and verify that primary and alternates to the ERO have participated in a drill and/or exercise.

(2) Observations and Findinas The last full scale exercise conducted in fulfillment of the requirement in the SEP was September 25,1997. The exercise scenario planning for the aforementioned exercise was considered as a program strength in light of the training benefit provided (see NRC Report No. 70-1151/97-05). Scenario documentation for several table-top drills conducted during CY 98 was reviewed and appeared to provide sufficient challenge and details to improve the proficiency of response personnel in the implementation of EPs. The inspector reviewed attendance rosters for drills and the CY 97 exercise and determined that primary and

alternates had participated in the CY 97 exercise, or one of several drills conducted in CY 98.

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6 (3) Conclusions The scenario development team for exercises and drills provided scenarios which were adequate for evaluating the varied emergency I

response functions.

f. Emeraency Eauioment and Facilities (F3.06)

(1) Insoection Scoce I

l Facilities and equipment were inspected to determine whether the

! licensee's ECC, emergency response equipment, instrumentation, and supplies were maintained in a state of operational readiness.

Documentation was reviewed to verify that the licensee was performing ,

, periodic inspections and maintenance in accordance with the SEP, and to l l review the reliability of equipment based on serviceability during i inspections.

l (2) Observations and Findinas The inspector verified the operability of equipment during a facility tour.

All equipment selected for verification was calibrated and operated in accordance with the design and intended use. Through a review of

. documentation, the inspector determined that all equipment was properly l maintained and appeared to be reliable. The usability of self-contained l

breathing apparatus units at three different locations (Guard Shack, chemical area main step off pad, and Conversion Control Room) was checked and no problems noted. During the weekly test of the criticality warning system (CWS), the inspector examined the operability and audibility from the respiratory protection facility to ensure previously

, identified audibility concern (IFl 97-05-10) was resolved via installation of l an additional horn. No problems were noted.

(3) Conclusions Based on facility tours, interviews, and surveillance documentation, the inspector concluded that the licensee's facilities and equipment were j maintained in a state of operational readiness.

g. Followuo on Previousiv Identified items l

(1) Insoection Scoce The licensee's system for tracking exercise findings was reviewed to l determine if issues were being tracked, responsibilitis were being assigned, and corrective actions were being taken in a timely manner.

The inspector also reviewed actions taken by the licensee to correct previous issues to determine if corrective actions were adequate and had been completed.

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(2) Observations and Findinos The licensee's system for tracking items resulting from an event,  :

exercise, or drill, known as the " commitment tracking system" (CTS),  !

provided management with a periodic status update regarding open items  !

and how timely items were being resolved.  !

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• (Closed) IFl 96-03-06: Verify the actions to ensure timely activation and staffing of the ECC.

Corrective actions were taken by the licensee to identify the minimum staff required to activate the ECC in addition ,

to changing the procedure for demonstrating timely activation and j notification of ERO personnel. Drill results disclosed additional corrective actions were required to improve the timeliness and resulted in a new open item (see Paragraph 2.c.2).

• (Open) IFl 97-05-01: Revise the Pre Fire Plan (PFP) by mid 1998.

Several sections of the PFP were reviewed and discovered in need of updates. The inspector was informed that software upgrades were necessary before the required updates could be i completed.

e (Open) IFl 97 05-03: Develop an audit checklist and audit plan l detailing the areas of the audit and the acceptance criteria.

An audit plan or checklist was not available during the CY 97 audit, but was being developed and planned for implementation during the CY 98 audit.

e (Closed) IFl 97 05-04: Provide training to exercise controller / evaluator personnel to improve performance.

Training was provided to personnel identified as controllers for the CY 99 exercise on January 8,1998. Referenced training addressed past exercise problems associated with controller responsibilities, and the controller action checklist.

e (Closed) EW 97-05-05: Failure to activate a bomb search team in accordance with procedures.

Emergency Procedure C-09 entitled " Bomb Threat," was revised to provide enhancements in communications, search team activation, and techniques for conducting the search. Drills were conducted subsequent to the procedural revisions to assess the adequacy of changes and personnel familiarity with changes.

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• (Closed) EW 97-05-06: Failure to initiate a search, and provide medical attention for the missing injured employee.

The ERO was trained on procedures involving response to injured / missing personnel and tabletop drills conducted during April and May 1998.

e (Closed) EW 97-05-07: Untimely response by security personnel to unlock the south gate.

! All security personnel were retrained on Emergency Procedure S-01 " Security Actions

• on November 18,1997 with emphasis on providing timely response to Gates one and five during emergencies (actual or drills). Additionally, during the annual l training (May 1998) for security personnel, emphasis was placed on timely response and the establishment of site controlled access during actual events and simulated emergencies.

• l (Closed) IFl 97-05-09: Verify actions taken in response to I i

communications during a bomb threat.

Emergency Procedure C-09 entitled " Bomb Threat," was revised I for consistency with current acceptable practices associated with l the use of cellular phones, two-way radios, beepers, and other frequency emitting devices in a potentially explosive environment.

Acceptable methods of communicating during a bomb throat and/or potentially explosive situation were included in the procedure.

i e (Closed) IFl 97-05-10: Verify corrective actions taken to ensure the audibility of CWS alarms inside the respirator protection facility.

Since the last inspection of this area, the licensee had installed an 4

additional horn in the vicinity of the respirator protection facility. ,

The inspector verified the location of the horn and examined the I adequacy of audibility during the weekly test conducted September 24,1998. No problems were noted.

(3) Conclusions

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With the exception of IFls 97-05-01 and 97-05-03, the corrective actions were adequate for closure of previous issues.

h. Information Notices (ins) l (1) Inspection Scoce The inspector reviewed the following ins to determine if the information had been received by the licensee and what if any actions taken:

9 IN 96-70: Year 2000 Effect On Computer System Software IN 97 23: Evaluation and Reporting of Fires and Unplanned Chemical Reaction Events at Fuel Cycle Facilities l IN 98 08: Information Likely to Be Requested if an Emergency is Declared (2) Observations and Findinos Based on interviews and a review of select documentation, the inspector determined that each of the above ins were received and actions were taken as appropriate in response to the ins. In response to year 2000 readiness (IN 96 70), the licensee had established a year 2000 (Y2K) working group to inventory and identify on a site wide basis those areas which may be potentially impacted. By letter dated September 16,1998, the licensee provided NRC a written response detailing plans for dealing with Y2K. Regarding the remaining ins (IN 97-23 and IN 98-08),

procedural changes were made to incorporate certain details from the IN.

(3) Conclusions j The licensee's actions were appropriate.

3. Exit interview i

The inspection scope and results were summarized on September 25,1998, with those l persons indicated in the Attachment. The inspector described the areas inspected and discussed the inspection results associated with a communications drill demonstrating

! ERO stalting/ activation, the independent audit documentation, and the likely informational content of the inspection report with regard to documents and/or processes reviewed during the inspection. The licensee did not identify as proprietary any of the information provided during the inspection. Dissenting comments were not received from the licensee.

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ATTACHMENT

1. PERSONS CONTACTED Licensee Personnel .

• J. Allen, Plant Manager K. Bartsch, Technician, Regulatory Engineering Operations

• J. Bush, Manager, Manufacturing J. Byrd, Supervisor, Site Security K. Fowler, Manager Information Systems

• S. Gantt, Senior Regulatory Engineer

• W. Goodwin, Manager, Regulatory Affairs

'J. Heath, Manager, Regulatory Engineering and Operations J. Hooper, Senior Regulatory Engineer

'A. Kaminsky, Manager, Human Resources

• E. Reitler, Fellow Engineer

• P. Stroud, Manager, Security and Services

• R. Williams, Advisory Engineer, Regulatory Affairs Other licensee employees contacted included engineers, technicians, production staff, I security, and office personnel. '

• Denotes those present at the exit meeting on September 25,1998. l Other Personnel R. Sovic, Manager, Westinghouse Energy Systems Business Unit Nuclear Reaulatory Commission E. McAlpine, Chief, Fuel Facilities Branch

2. INSPECTION PROCEDURES USED IP 88050 Emergency Preparedness

3. LIST OF ITEMS OPENED, CLOSED, AND DISCUSSED ltem Number Status Descriotion l

l 70 1151/96-03-06 Closed IFl - Verify the actions to ensure timely activation and staffing of the ECC.

l 70-1151/97-05-01 Open IFl- Revise the PFP by mid 1998.

70 1151/97 05 03 Open IFl - Develop an audit checklist and audit plan detailing the areas of the audit and the acceptance criteria.

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2 Item Number Status Descriotion 70-1151/97-05-04 Closed IFI-Provide training to exercise controller / evaluator personnel to improve perforrtiance.

70-1151/97-05-05 Closed EW-Failure to activate a bomb search team in accordance tvith procedures.

70-1151/97-05-06 Closed EW Failure to initiate search, and provide medical attention for the missing injured employee.

70-1151/97-05-07 Closed EW-Untimely response by security personnel to unlock the south gate.

1 70-1151/97-05-09 Closed IFI-Verify actions taken in response to communications during a bomb threat.

70-1151/97-05 10 Closed IFl-Verify corrective actions taken to ensure the audibility of CWS alarms inside the respiratory protection facility.

70-1151/98-07-01 Open IFl - Review corrective actions to improve timely activation and staffing of the ECC.

4. LIST OF ACRONYMS ,

CC Controlled Copy CFR Code of Federal Regulations CTS Commitment Tracking System CWS Criticality Warning System CY Calendar Year ECC Emergency Control Center ED Emergency Director EP Emergency Procedures ERO Emergency Response Organization EW Exercise Weakness IFl inspector Follow-up Item IR inspection Report REO Regulatory Engineering and Operations RG Regulatory Guide SEP Site Emergency Plan