ML20155B538
| ML20155B538 | |
| Person / Time | |
|---|---|
| Site: | Portsmouth Gaseous Diffusion Plant |
| Issue date: | 10/23/1998 |
| From: | NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| Shared Package | |
| ML20155B516 | List: |
| References | |
| 70-7002-98-14, NUDOCS 9810300170 | |
| Download: ML20155B538 (22) | |
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! U.S. NUCLEAR REGULATORY COMMISSION REGIONlil Docket No: 70-7002 i Certificate No: GDP-2 i l
Report No: 70-7002/98014(DNMS) l i
Facility Operator: United States Enrichment CerMration !
Facility: Portsmouth Gaseous Diffusion Plant l Location: 3930 U.S. Route 23 South i P.O. Box 628 Piketon, OH 45661 l
l Dates: August 31 through September 4,1998 i
- l. Inspectors: K. G. O'Brien, Senior Resident inspector l
C A. Blanchard, Resident inspector J. R. Davis, Senior Criticality Safety inspector
! S. Larson, NRC Contractor i
l Approved By: Roy J. Caniano, Acting Director Division of Nuclear Materials Safety l
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9810300170 991023 '
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EXECUTIVE
SUMMARY
United States Enrichment Corporation Portsmouth Gaseous Diffusion Plant NRC Inspection Report 70-7002/98014(DNMS)
The inspection focused on the plant staff's implementation of Compliance Plan Issues and the adequacy of an internal self-assessment of the closure status of Compliance Plan Issues, implementation of Selected Compliance Plan Issues l
The inspectors determined that the plant staff had successfully implemented the corrective actions required to resolve Compliance Plan Issues 17, and 21. In addition, the plant staff took action to improve the training initially provided as a part of the successful closure of Compliance Plan issue 10. The inspectors also concluded that the plant staff had not properly completed 1 corrective actions associated with Compliance Plan issues 8,9, and 23. The failures to properly implement the corrective actions for three Compliance Plan issues are examples of a violation of Condition 8 of the Certificate of Compliance.
Self-Assessment of Comoliance Plan Closure Performance The inspectors determined that the plant staff had effectively demonstrated, in most cases, an
, ability to review and accurately determine the closure status of Compliance Plan issues during l
a recent self-assessment. The self-assessment program was noted to include the development of clear and objective acceptance criteria for most Compliance Plan commitments and )
documentation that most items had been completed. However, some examples of inadequate i assessment of the closure status of items continued to be observed. In addition, some corrective actions, proposed to resolve the identified deficiencies, were not se ficient to resolve the deficiencies or to ensure future compliance with the regulatory requirements. The ;
inspectors also identified several instances in which actions, specified for four Compliance Plan '
Issues, were not completed within the required timeframes. The failures to properly implement the corrective actions for four Compliance Plan issues are examples of a violation of Condition 8 of the Certificate of Compliance.
Status Reportina of Compliance Plan Activities The inspectors identified a violation in that the certificatee failed to provide complete and accurate information regarding the completion of corrective actions specified in Compliance Plan on at least three occasions.
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Report Details I. Comollance Plan Implementation and Self-Assessment Review l
l C1 Implementation of Selected Compliance Plan Issues
- a. Inspection Scope (40500) l The inspectors assessed the certificatee's actions to implement several Compliance Plan issues. The Compliance Plan issues assessed included:
l 1. Issue 17: " Fire Protection Procedures and Hot Work Program"
- 2. Issue 21: " Management Controls" The inspectors also completed a previous assessment of the certicatee's actions to implement and document the completion of several Compliance Plan issues associated with the nuclear criticality safety program. The nuclear criticality safety program-related l Compliance Plan issues assessed included:
- 3. Issue 8: " Nuclear Criticality Safety Approval Documents" l 4. Issue 9: Nuclear Criticality Safety Approval implementation"
- 5. Issue 10: " Nuclear Criticality Safety Training for Managers" l 6. Issue 23: " Plant Changes and Configuration Management"
- b. Observations and Findinas issue 17:
Compliance Plan issue 17 documented that procedures for the Fire Protection Program, for hot work operations, and for fire suppression and detection system testing and inspection did not contain sufficient technical guidance and process controls to meet the requirements of the Safety Analysis Report (SAR) Section 5.4, " Fire Protection." The Plan of Action and Schedule (PAS) for issue 17 documented that all activities to recolve issue 17 noncompliances would be complete by December 1997. In March and July 1998, the certificatee sent letters to the NRC which identified that all actions associated with issue 17 had been completed.
The inspectors reviewed Procedure XP2-SS-FS1031, " Fire Protection Program," to ensure that the procedure provided guidance required to maintain an effective fire protection program. The inspectors noted that Procedure XP2-SS-FS1031 clearly articulated required training requirements for Fire Service (FS) commanders, firefighters and employees as required by SAR Section 5.4.5, " Staffing and Training." The procedure also provided an overview of the fire protection program including fire inspections, hazardous material response, inspection and testing of fire protection L systems and equipment, and emergency medical services.
The inspectors reviewed Procedure XP2-SS-FS1033, " Fire Protection Requirements for Welding, Burning, and Hotwork Practices," to ensure that the procedure delineated an effective program to perform welding, burning, and hotwork operations safely. The inspectors noted that the procedure specified the roles and responsibilities of fire 3
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service, firewatch, Industrial Hygiene and Safety, and Health Physics personnel, Manager in Charge, Service Manager, and welders. In addition, the procedure defined controls to ensure that maintenance personnel conducted hot work according to industry fire prevention practices. The inspectors identified that the procedure provided clear guidance to ensure that the fixed fire protection systems were operable before maintenance personnel performed hotwork operations in sprinkler-protected buildings in accordance with Technical Safety Requirements (TSRs) 2.2.3.4.A and E and 2.7.3.3.A and E.
The inspectors discussed with the FS Group Manager the building fire protection inspections and survey process. The FS Group Manager explained that Procedure XP4-SS-FS1910, " Fire Protection Engineering Building Surveys and Inspections," issued December 16,1996, was developed to direct the performance of fire protection inspections. The inspectors noted that the procedure required, in part, that the FS Group document and take appropriate action to resolve concerns found during fire protection inspections and surveys. The inspectors reviewed inspections and surveys performed in Buildings X-326, X-330, and X-333 from March 3 through August 31,1997. The inspectors noted that FS personnel performed the inspections and surveys within the required schedules and documented fire protection concerns in detail, in addition, the FS Group Manager provided the inspectors with nonconformance reports developed to document each of the fire protection inspection or ,
survey findings per the certificatee's reporting procedures. The inspectors noted that I the certificatee adequately corrected identified concems addressed in inspections and l survey findings for Building X-330. '
The inspectors also concluded that the certificatee developed and implemented two procedures for the testing and inspection of fire suppression and detection systems.
In addition to Procedure XP4-SS-FS1910 discussed above, on April 30,1998, the certificatee issued Procedure XP2-SS-FS1032,"High Pressure Fire Water System Program," which identified management's roles and responsibilities for the inspection, i
testing, maintenance, and repair of the High Pressure Fire Water System (HPFWS) as ;
required by SAR Section 5.4.1 and 5.4.2.
Based upon the above described sampling reviews, the inspectors concluded that the revised fire protection procedures contained sufficient technical guidance and process controls to provide an adequate fire protection program. In addition, the inspectors l determined that the certificatee performed fire protection inspections and surveys as i specified in the associated procedures. As a result, the inspectors concluded that the l certificatee had completed the actions required by Issue 17.
Issue 21:
Issue 21 documented an incomplete development and implementation of management controls. Specifically, the certificatee stated in issue 21 that management controls, as described in SAR Sections 5.0 and 6.0, the Quality Assurance Program (QAP), and other regulatory documents, had not been incorporated into existing plant organizational roles, responsibilities, relationships, and authorities and had not been incorporated into existing plant procedures. The issue 21 PAS documented that all activities requiring action would be completed by December 1997. In March and July 1998, the certificatee sent letters to the NRC which identified that all actions associated with issue 21 had been completed.
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The inspectors reviewed the certificatee's method to ensure that regulatory requirements were incorporated into plant policies and procedures. During discussions with the Nuclear Regulatory Assurance (NRA) manager, the inspectors were informed of l the method used by the plant to identify, catalog, and cross-reference regulatory '
commitments to the plant policies and procedures that implemented the requirements.
The NRA manager indicated that plant staff had performed a review of the Application for United States Nuclear Regulatory Commission Certification in order to identified regulatory requirements and for entry into a procedure information management system (PIMS) database. Once entered into the database, the regulatory requirements were then sorted by cognizant activities and disseminated to the responsible organizations.
The responsible organizations were directed to identified implementing procedures for cognizant regulatory requirements and to provide the feedback to the NRA staff.
Finally, the NRA staff performed a quality check to ensure that the responsible organizations adequately addressed the regulatory requirements in the appropriate procedures and entered the corresponding procedure numbers into the database.
The inspectors selected random TSR and SAR regulatory requirements to determine if l the requirements were adequately incorporated into plant procedures . The inspectors determined that the procedures identified in the database for incorporation of selected TSR and SAR regulatory requirements appeared to be accurate as of March 16,1998.
However, the inspectors also concluded that the certificatee had not updated the I database as information changed and the certificatee could not rely upon the database !
to assure that the commitment to incorporate regulatory requirements into plant policies and procedures continued to be met at the time of the inspection. Additionally, the inspectors identified that some procedures did not thoroughly address the regulatory requirements. !n discussions with the inspectors, the Independent Assessment Group Manager indicated that an internal audit, Audit Report Number OP-EN-98-A001,
" Environment Protection," issued on August 11,1998, also identified a weakness in the process for maintaining the database. At the time of the inspection, the plant staff were in the process of developing a corrective action plan to resolve the identified weakness.
The Independent Assessment Group Manager indicated that the corrective action plan would be completed by September 18,1998.
The inspectors reviewed the plant staff's incorporation of the responsibilities and authorities described in SAR Section 6.1 into job descriptions. Section 6.1 specified the minimum qualifications, functions and responsibilities for 25 key certificatee staff positions. The inspectors determined that the certificatee had developed job descriptions for the 25 key certificatee staff positions and adequately addressed the required qualifications, functions, and responsibilities. The inspectors also identified that Procedure UE2-HR-PA1035, "Lockheed Martin Utility Services (LMUS) Organization Structure and Charts," provided a process to approve proposed appointees for the 25 key certificatee staff positions. Step 6.1 of the procedure required the certificatee to document confirmation of an individuals qualifications against the qualification outlined in the job descriptions and SAR. In discussions with the inspectors, the Human Resource Manager stated that in May 1997,~ the Site Compensation Representative confirmed all staff in the 25 key certificatee positions met the qualifications, functions and responsibilities described in SAR Section 6.1, but had not documented this effort on the qualification review form. On September 3, the Human Resource Manager issued an internal letter stating, in part, that the certificatee will perform another review of the 25 key certificatee staff positions and document the confirmation of qualifications in accordance with Procedure UE2-HR-PA1035.
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I t On September 4, the Human Resource Department completed a review of the 25 key certificatee staff positions. The review confirmed that each incumbent had the education and experience required for the position held.
The inspectors concluded that the certificatee appeared to have adequately incorporated SAR regulatory requirements into policies and procedures in accordance with the Compliance Plan PAS for Issue 21. However, the inspectors and the certificatee's intemal Audit Report Number OP-EN-98-A001, " Environmental Protect;on,"
identified that the database used to document the proper completion of the process had not been maintained. As a result, the continued accuracy of the information could not be ensured.
l issue 8:
l Compliance Plan issue 8 recorded two broad programmatic noncompliances in that some nuclear criticality safety activities were not adequately supported by completed or clearly documented evaluations which consistently employed the double contingency principle or other accepted bases for operations and evaluations. A third noncompliance was also recorded in that some administrative aspects of the nuclear criticality safety program, including aspects related to compliance with ANSI standards, had not been proceduralized or documented. The Plan of Action and Schedule (PAS) for issue 8 documented that the noncompliances would be corrected no later than November 30, 1996.
-In NRC Inspection Report (IR) 70-7002/98204, the NRC documented a previous partial review of the activities undertaken to correct the noncompliances associated with Issue 8. Results of the partial review indicated that the documentation, maintained by
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the certificatee to demcnstrate that all of the issue 8 noncompliances were properly resolved, appeared to be inadequate. In addition, the NRC identified some recent incidents, documented in either plant nonconformance reports or Bulletin 91-01 reports, which appeared to indicate that some current nuclear criticality operations were still not properly described or documented in nuclear criticality safety evaluations.
As a result of the findings described in IR 98204, the NRC opened an Unresolved item (URI) (70-7002/98204-01) to track the resolution of the inspection findings.
During the current inspection, the inspectors discussed the issues raised in IR 98204 i with plant and criticality safety management. The inspectors were informed by plant l management that a further review, since the inspection documented in IR 98204, of the adequacy of the previous closure of Issue 8 noncompliances had not been conducted.
Plant management indicated their belief that sufficient findings existed as developed and documented in NRC irs 70-7002/97013 and 98204, and in nonconformance reports during implementation of the nuclear criticality safety corrective action plan to conclude that the issue 8 PAS was not properly implemented. Management further indicated that one of the root causes for the plant staff not recognizing the inadequate implementation previously was the weak or non-existent closure criteria developed to direct resolution of the Compliance Plan documented noncompliances.
During the current inspection period, the inspectors noted several plant staff identified findings which further confirmed the previous inadequate implementation of the PAS for issue 8. Some of the recent findings by the plant staff included indications that 140 of 180 nuclear criticality safety evaluations and approvals did not receive a plant change 6
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review,15 of 140 reviewed evaluations and approvals did not receive Plant Operations Review Committee (PORC) approval, and 5 of 140 evaluations and approvals did not receive a field review or walkdown.
Condition 8 of the Certificate of Compliance requires, in part, that the certificatee shall conduct its operations in accordance with the statements and representations contained in the Compliance Plan. Issue 8 of the Compliance Plan requires, in part, that by November 30,1996, that all existing and new nuclear criticality safety operations shall be documented in and implemented by approved nuclear criticality safety evaluations and approvals, The failure by November 30,1996, to ensure that all nuclear criticality safety operations were documented in and implemented by approved nuclear criticality safety evaluations and approvals, as evidence by the findings described above and in NRC IR 98204, is an example of a Violation (VIO 70-7002/98014-01a).
Issue 9:
The Description of Noncompliance for issue 9 documented that inconsistencies existed I l between the specifications in nuclear criticality safety approvals (NCSAs) and the
! supporting implementing procedure and work-site postings. The Issue 9 PAS required l plant staff to review all NCSAs, identify and track the designated nuclear criticality safety
! conditions, specifications, and controls and to verify fullimplementation. The PAS also l l required that all activities necessary to resolve the stated noncompliances shall be !
completed no later than March 3,1997, the date the NRC assumed regulatory authority.
In NRC IR 70-7002/98204, the NRC documented a previous partial review of the activities undertaken to correct the noncompliances associated with issue 9. Results of the partial review indicated that insufficient information was available in the issue 9 closure file to determine if all the noncompliances had been identified and resolved. For example, during a review of the Building X-705 nuclear criticality safety operations, the plant staff identified that a sufficient number of deficiencies existed in the implementation of the nuclear criticality controls to warrant a shutdown of the building
! operations The issue 9 closure file included a related note which indicated closure file information would be updated following a review of the shutdown operations that would be conducted prior to resumption of the operation. However, the inspectors determined that the closure files were not updated for 5 operations that were resumed between April 1
, and August 1997. In addition, the inspectors noted that subsequent plant I
! nonconformance reports, associated with some of the resumed operations, indicated l l problems consistent with an absence of prior review of equipment configuration and '
l proper application of the relied upon controls (X-705 Microfiltration System spill). An URI 70-7002/98204-01, was opened to track resolution of the findings.
During the current inspection, the inspectors noted that the plant staff had not performed a followup review of the issues documented in IR 98204 The plant staff indicated to the inspectors that reviews were proposed based upon an understanding that other ongoing plant staff reviews may provide adequate information to conclusively determine the completeness of previous closure actions. However, the plant staff also conceded that sufficient information appeared to already exist, as documented in irs 97013 and 98204
- and based upon findings developed during implementation of the nuclear criticality
, safety corrective action plan, to demonstration that issue 9 was not completed in accordance with the PAS.
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. i Finally, just prior to the inspection, the plant staff identified, documented in a l
nonconformance report, and made a Bulletin 91-01 report of another example of a I procedure in use that allowed operations at an enrichment level greater than evaluated and approved in the nuclear criticality safety documents. Previous successful and t complete implementation of Issue 9 should have precluded the continued use of this I procedure with incorrect nuclear criticality safety specifications and controls.
Condition 8 of the Certificate of Compliance requires, in part, that the certificatee shall conduct its operations in accordance with the statements and :epresentations contained in the Compliance Plan. Issue 9 of the Compliance Plan requires, in part, the plant staff to review all NCSAs in order to identify and track the designated nuclear criticality safety conditions, specifications, and controls and to verify full implementation into plant procedures and postings by IUlarch 3,1997. The failure of the plant staff to ensure that all plant procedures and postings fully implemented all of the conditions, specifications, and controls included in applicable NCSAs by November 30,1996, as evidence by the ;
findinga described above and in NRC IR 98204, is an example of a Violation (VIO 70-l 7002/98014-01b). '
Issue 10:
Issue 10 of the Compliance Plan documented a noncompliance with the SAR in that managers responsible for oversight of nuclear criticality safety operations had received only general nuclear criticality safety training. The PAS for the issue indicated that a list J of affected managers would be developed and that a specific course of nuclear criticality safety training focused on a manager's responsibilities would be provided by March 31, 1996.
In IR 70-7002/98204, the NRC concluded that issue 10 was adequately completed; however, some weaknesses were identified involving the course objectives and content.
Specifically, the inspectors noted that the training ccurse did iot include a discussion of j the nuclear criticality safety basis (i.e., nuclear criticality safety evaluations and approvals, incorporation of controls into operating procedures, etc.). The inspectors also noted that the absence of discussion on the safety basis during the course may have contributed to the problems noted with adequate completion of issues 8 and 9.
During the current inspection, the inspections were informed by plant staff that specific actions were being taken to address the apparent weakness identified in the previous training program. Specifically, the plant staff indicated that revisions to the course materials were in the process of being made to highlight the nuclear criticality safety basis to manager. The plant staff indicated that the revisions were expected to be completed by September 15,1998. In addition, the inspectors noted that all management was required to take the course once every two years. Therefore, any weaknesses fostered as a result of the previous training should be corrected for all management staff within a two year period.
Issue 23:
The Compliance Plan documented in Issue 23 broad programmatic noncompliances and weaknesses associated with the development and implementation of a configuration management program. The PAS for Issue 23 included corrective actions to resolve both the noncompliances and weaknesses on a graded approach based upon the safety 8
significance of the affected plant components. The most significant items, Quality (Q) and Augmented Quality Nuclear Criticality Safety (AQ-NCS) quality class components and systems were scheduled for completion no later than March 3,1997.
A previous partialinspection of the completion of Issue 23 corrective actions for AQ-NCS items, as documented in IR 70-7002/98204, identified that some structures, ,
systems, and components (SSCs) relied upon for nuclear criticality safety had not been '
specifically identified and controlled as AQ-NCS SSCs. In addition, the IR noted that a cause for the findings appeared to be a weak knowledge and understanding of the governing procedure for the identification and control of AQ-NCS SSCs. Specific examples of SSCs that were relied upon for nuclear criticality safety but were not identified and controlled by the configuration management system included components associated with the microfiltration system (blank flanges, and air line valves), open unfavorable geometry containers (container lids not present or secured) and the product withdrawal assay machines.
During the current inspection, the inspectors determined that the plant staff had performed a self-assessment of the activities completed to address some Issue 23 noncompliances. The self-assessment results indicated that the noncompliances were properly resolved. However, the inspectors noted that the self-assessment focused only on those items identified as "AQ" quality class. Therefore, all questions raised in IR 98204 were not necessarily addressed.
Finally, the inspectors noted that a second, separate, NRC inspection of the nuclear j criticality safety area, NRC IR 70-7002/98206, also identified inadequacies in the plant staff's identification and control of SSCs associated with nuclear criticality safety. The )
inspectors noted that a violation, VIO 98206-02, was identified for the findings discussed in IR 98206 and that the certificatee had responded to the violation with corrective actions that appeared to also address the findings in IR 98204. Specifically, the corrective actions proposed to revise the governing procedure to include more detailed uiteria by which to identify AQ-NCS SSCs, to re-review all the outstanding criticality safety documents to identify previously overlooked SSCs, and to provide appropriate training to affected staff to ensure consistent future implementation of the procedure.
The inspectors reviewed applicable sections of the revised procedure and noted that the scope of which items should be classified as SSCs was increased to include alarms and installed engineered safety features, both passive and active, that are relied upon for double contingency. ,
i Condition 8 of the Certificate of Compliance requires, in part, that the certificatee shall conduct its operations in accordance with the statements and representations contained in the Compliance Plan. Issue 23 of the Compliance Plan requires, in part, the plant staff to rev,,. y all nuclear criticality safety documents in order to identify, track, and control those structures, systems, and components relied upon for nuclear criticality safety by March 3,1997. The failure of the plant staff to ensure that all structures, systems, and components relied upon for nuclear criticality safety were identified, tracked, and controls, by March 3,1997, as evidence by the findings described above and in NRC IR 98204, is an example of a Violation (VIO 70-7002/98014-01c).
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Based upon the information provided above and for Issues 8,9, and 10, and documented in the associated violation, the inspectors consider the questions associated with Unresolved item 98204-01 resolved and the item is closed.
- c. Conclusions The inspectors determined that the plant staff had successfully implemented the corrective actions required to resolve the noncompliances associated with Compliance Plan issues 17, and 21. In addition, the plant staff took action to improve the training initially provided as a part of the successful closure of Compliance Plan issue 10. The inspectors also concluded that the plant staff had not properly completed corrective
, actions associated with Compliance Plan Issues 8,9, and 23. The failures to properly implement the corrective actions for three Compliance Plan Issues are examples of a violation of Condition 8 of the Certificate of Compliance.
C2 Certificatee's Self-Assessment of Compliance Plan Closure Performance
- a. Insraection Scope (40500_1 The inspectors reviewed a recently completed plant staff self-assessment of previous Compliance Plan closures. The review was structured to be an independent verification of the previous closure efforts and to determine if the self-assessment methods were well defined and documented. Compliance Plan issues reviewed as a part of the plant's self-assessment and by the inspectors included:
- 1. Issue 3: " Autoclaves" ,
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- 2. Issue 6: "X-705 Microfiltration influent pH Shutdown System Replacement"
- 3. Issue 7: "HEPA Filter Systems Testing"
- 4. Issue 18: " Emergency Packets" l
- 5. Issue 27: " Assessments"
- 6. Issue 42: "UF, Leak Detector Sensitivity Testing"
- b. Observations and Findinas issue 3:
Compliance Plan Issue 3 identified ten noncompliances associated with 13 autoclaves for which specific actions were required in order to ensure that the autoclaves could be operated, maintained, and tested in accordance with NRC requirements. l The issue 3 PAS required specific noncompliances to be corrected by individual dates l and required the development of a detailed timeline for the comp!etion of issues generically associated with all of the autoclaves. The PAS also specified that the all noncompliances associated with the first of the thirteen autoclaves shall be completed by May 1,1998, and associated with the last of the 13 autoclaves shall be completed by February 1, 2001.
The inspectors reviewed the self-assessrnent closure criteria and documentation developed to support closure of the issue. The inspectors noted that most of the closure criteria developed specifica!'y, for the first autoclave appeared reasonable, well defined, objective, and in agreement with the requirements specified in the Compliance 10
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1 Plan. In addition, the documentation gathered by the plant staff as a part of the !
self-assessment process to demonstrate that the required Issue 3 activities were !
performed was noted by the inspectors to be comprehensive and well organized.
The inspectors identified that the closure criteria and performance information used to l
support the completion of PAS Item 9 was not adequate. Specifically, the closure -
criteria required only that the plant staff receive and submit to the NRC a referenced 1 American Society of Mechanical Engineers code interpretation by May 1,1998. The self-assessment documentation indicated that the specified closure activities had been completed and indicated that the item was complete. However, the inspectors noted ;
that PAS Item 9 also required NRC approval. The PAS did not include provisions for the I l
plant staff to consider the required actions for the first autoclave complete without NRC approval of the plant staff's use of the code interpretation. Based upon the incorrect I definition and application of closure criteria for item 9, the plant staff incorrectly determined that item 9 was completed and authorized the restart of the first autoclave. 1 The regulatory implications of the failure to receive prior NRC approval of the plant staff's use of the code interpretation are being tracked as an Unresolved item as l previously documented in NRC IR 70-7001/98012 (URI 70-7001/98012-01).
The inspectors also determined that the plant staff's formal methods for tracking the completion of the PAS items for the remaining 12 autoclaves were inconsistent with a Compliance Plan issue 3 PAS requirement to develop and follow a detailed schedule for the activity. Specifically, the inspectors identified that a detailed schedule had been developed but was not incorporated into the formal tracking system used to define and document Compliance Plan Issue PASS. Instead, the formal tracking system only included the final completion date.
Issue 6: l l
The PAS for Compliance Plan issue 6 required the pH monitoring probes in the X-705 Microfiltration System to be moved from the influent to the effluent line of the l microfiltration process. The pH of the effluent is an indication of the amount of dissolved uranium in the effluent. The system is designed to shut down if the probes detect a pH of less than 7.0 to avoid transferring uranium to a tank with an unfavorable geometry.
The noncompliances statement indicated that the probes, while located in the influent line, experienced fouling and spurious activations due to back-leakage of acidic solution from the overhead storage. The PAS also stated that relocation of the probes closer to the unfavorable geometry tank would provide a higher degree of confidence in the safety of the operation.
The inspectors performed a field walkdown of the system and verified the modification of the pH probes location in the system piping. Calibration and test data since the modification were also reviewed to determine the adequacy of the corrective action in preventing the unnecessary activations. The inspectors determined that the system had not activated since the modification; however, the test data also indicated problems with calibration drift. As a result, the plant staff had increased the calibration frequency from quarterly, as required by TSR 2.6.3.5, to monthly. The inspectors also obtained four evaluations performed by the system engineer to determine the cause of the out-of-tolerance findings. The data shows a positive trend (less calibration drift) and the inspectors concluded the problem was being adequately addressed.
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The internal self-assessment reviewed the modification closeout form, evidence of post-modification testing of the system to verify correction of the problem, and verified that the safety system was identified as a "Q" system in the Boundary Definition Manual.
The inspectors reviewed the closure criteria and concluded that the criteria and closure evidence were adequate. The inspectors determined that issue 6 had been properly comp'eted and noted that the internal self-assessment included appropriate criteria and documentation to support a similar conclusion.
Issue 7:
Compliance Plan issue 7 documented three actions required to address noncompliances associated with the operation and testing of HEPA filtration systems.
The three actions included the modification of existing HEPA systems to facilitate in-place leak testing, the identification and testing of portable HEPA systems, and the identification of fixed HEPA systems that did not require modification or testing. The latter actions was to be performed based on criteria established by the HEPA Filter System Team and an ALARA committee. The issue 7 PAS required all of the actions to be completed by June 30,1997.
The inspectors reviewed the closure criteria developed for each of the three requirements as a part of the internal self-assessment. The inspectors concluded that the criteria were reasonable, appropriate, and included adequate specificity. The inspectors noted that the evidence files, which included information used to conclude that all of the required effort for a specific requirement had been completed, for the first two required actions included adequate information to demonstrate that the actions were properly performed. The inspectors performed an infield verification of a sampling of systems associated with the first two required actions and did not identify any problems. The intemal self-assessment also concluded that the first two actions were properly implemented.
The inspectors also reviewed documentation associated with the third required action.
During the review, the inspectors noted that all of the information necessary to demonstrate that the actions required to exempt certain HEPA systems from modification or testing had been completed was not included in the evidence files.
Specifically, the evidence files did not include information which would demonstrate that each of four criteria, as specified by the HEPA Filter System team and the ALARA Committee, had been met prior to a HEPA system being exempted from modification and testing. The inspectors noted that the internal self-assessment had concluded that the required actions had been completed.
The inspectors discussed the findings with plant personnelinvolved in completion of the original closure activities. During the discussions, the inspectors were informed that the conclusions for HEPA systems not requiring modification or testing was justified against the most restrictive of the four criteria for the specific system. In addition, the plant l personnel believed that each of the other criteria was reviewed; however, information l that may support the conclusion was not immediately accessible in an appropriate l format. As a result, the plant staff planned to recreate the data and add it to the evidence file. The inspectors performed a sampling review of a number of HEPA systems that did not require modification or testing and did not identify and anomalous conditions.
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l The inspectors determined that the issue 7 evidence file lacked adequate technical documentation to support the closure of the issue. Specifically, the evidence file did not include sufficient evidence to demonstrate that HEPA syste.ms, excluded from modification or testing requirements, met each of the four criteria developed by the HEPA Filter System Team and the ALARA Committee. In addition, the inspectors concluded that the internal self-assessment was not sufficiently rigorous, in this case, to identify the information shortfall.
Condition 8 of the Certificate of Compliance requires, in part, that the certificatee shall conduct its operations in accordance with the statements and representations contained in the Compliance Plan. Issue 7 of the Compliance Plan requires, in part, that by June 30,1997, documentation shall be on file to justify any downgrade of any HEPA filter systems. The failure to develop and maintain documentation on file, by June 30, l 1997, to justify the downgrade of HEPA filter systems against per the four criteria developed by the HEPA Filter System Team and the ALARA Committee is an example of a Violation (VIO 70-7002/98014-01d).
Issue 18:
Compliance Plan issue 18 identified a broad noncompliance in that building emergency l packets (EPs) did not contain current information. The SAR specified that the EPs were to contsin information about the building, the facility layout, specific hazards and other information applicable to the individual facility and were to be used in lieu of pre-fire plans. The PAS for issue 18 committed the plant staff to update the EPs to include:
(1) general building / area layout drawings and sketches, (2) critical action, equipment, or material listing, (3) facility / area utility services, (4) facility emergency systems and equipment, (5) list of hazardous, toxic, and/or radioactive materials, including compressed gases, and (6) lists of facility tenant organizations. The EPs were to be updated by October 1,1996.
The inspectors noted that the internal self-assessment determined that the EPs were still deficient with respect to commitments 1 through 5 as of July 1998, and that the issue had been incorrectly reported as completed. In addition, the internal self-assessment identified that the plant procedure used to direct preparation and maintenance of EPs did not require that the EPs include the 6 items specified in issue 18.
The inspectors reviewed the evidence file and the original nonconformance report issued to track the completion of the PAS for issue 18. The inspectors verified that the EPs had been updated at least once prior to the October 1,1996, completion date based upon an Action Response Status Form (ARSF) associated with the nonconformance report. However, the inspectors also noted that the ARSF specified only that the EPs needed to be updated to reflect the current building configurations and did not include a listing of the six requirements included in the Compliance Plan Issue 18 PAS. Management approvals, indicating that the nonconformance had been appropriately resolved, were also included on the ARSF. The inspectors determined that the evidence attached to the ARSF provided verification of the " stated" action had been completed but did not ensure that the base nonconformance had been resolved.
Through discussions with the plant staff, the inspectors determined that noncompliance reports and ARSFs often included abbreviated information, an apparent weakness in the plant process used to direct and track the closure of noncompliances.
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Based upon the findings of the internal self-assessment, the plant staff initiated a second nonconformance report concerning the EPs. The inspectors reviewed the corrective action plan developed in response to the nonconformance report and noted that the plan required the addition of updated drawings and sketches, to include the l location of compressed gases and utility shutdowns, to the EPs with a June 30,1999, due date. The inspectors noted that the due date was chosen based upon a need to update many of the facility drawings and without consideration of the original l October 1,1996, due date or the need for NRC approval of changes to the Compliance l Plan-specified performance dates. The inspectors also noted that the corrective action i plan did not direct a revision to the controlling plant procedure for the EPs to require the revised drawings or to include the other items listed in the PAS for Issue 18.
During followup discussions of the findings with plant staff, the inspectors were informed that the failure to include a procedure update requirement in the corrective action plan was an oversight. As a result, the plant staff immediately amended the corrective action plan to include a requirement to update the procedure. However, the inspectors noted that the revised corrective action plan did not require the procedure to include all of the items listed in the issue 18 PAS. Specifically, the procedure update requirement omitted the inclusion of utility shutdowns in future updates. The inspectors were informed that the Fire Chief had argued that the utility shutdowns were not necessary in the EPs and that the corrective action plan author felt that the Fire Chief's opposition to the requirement was sufficient grounds by which to waive the requirement. The inspectors noted that the proposed course of action was inconsistent with the Compliance Plan and the current plant processes for modifying regulatory requirements.
Both the original and modified corrective action plans were reviewed and approved by the Corrective Action Review Board without the above referenced deficiencies being identified.
The inspectors concluded that the internal self-assessment process correctly determined that the actions required to complete issue 18 had not been performed. The inspectors also determined that a weakness in the corrective actions process, which contributed to the original failure to complete the Compliance Plan actions, continued to exist as demonstrated by the original corrective action plan developed based upon the self-assessment process findings. Specifically, the corrective action plan was developed and approved without the necessary rigor to ensure that the regulatory and performance requirements were adequately stated.
Condition 8 of the Certificate of Compliance requires, in part, that the certificatee shall conduct its operations in accordance with the statements and representations contained in the Compliance Plan. Issue 18 of the Compliance Plan requires, in part, that by October 1,1996, building EPs shall be updated to reflect current facility configurations and conditions including: (1) general building / area layout drawings or sketches, (2) critical action, equipment, or material listing, (3) facility / area utility services, (4) facility emergency systems and equipment, and (5) lists of hazardous, toxic, and/or radioactive materials, including compressed gases. The failure to update by October 1,1996, all of the EPs to include the information specified in items number 1 through 5 is an example of a Violation (VIO 70-7002/98014-01e).
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Issue 27:
Compliance Plan issue 27 identified a single broad programmatic noncompliance associated with the management process for conducting internal assessments. The issue 27 noncompliance statement specificality stated that plant procedures required development and upgrading to define criteria and guidance for the conduct of organizational level assessments, in all organizations, in a uniform manner. The PAS for issue 27 required all actions to be completed by September 30,1996. l l
The inspectors reviewed the closure criteria developed as a part of the self-assessment i process for Issue 27. The criteria appeared reasonable and appropriate. Reviews of the previous closure materials, conducted as a part of the self-assessment process, determined that a procedure had been implemented which included criteria and l guidance for conducting organizational self-assessments had been issued. However, ;
the plant review, conducted as a part of the self-assessment process, also initially I determined that the previous closure information was insufficient to demonstrate that all organizations had implemented an organizational self-assessment program. Based upon the deficient finding, a plant nonconformance report was written and a further record review was conducted. During the further record review, the plant staff identified records from past organizational self-assessments which were used to conclude that issue 27 had been successfully completed.
The inspectors performed an independent review of the materials referenced in the self-assessment results as a basis for closure of Issue 27. During the review, the inspectors noted that the referenced procedure had been changed several times since the original September 1996 PAS required completion date. The inspectors also determined that changes made to the original procedure and maintained in the current procedure did not address the specific noncompliance stated for Issue 27. Instead, the changes merely restated a need for plant management to require each major plant group to conduct organizational self-assessments. Missing from the procedures was resolution of the fundamental noncompliance stated as the basis for issue 27, that is,
" procedures . . . need to specify criteria and guidance for conducting assessments in a uniform manner."
The inspectors discussed the findings with the management and staff of the plant quality assurance organization. The staff confirmed the inspectors observation that very few changes had been made to the procedures since inclusion of the language that required organizational level self-assessments. One other change made to the procedure was to provide some additional logistical-type instructions for individuals actually conducting the assessments. However, the inspector noted that this information did not serve to either further specifying criteria to be used or guidance to follow for the conduct of an organizational self-assessment program.
During discussions with the plant manager and others, the inspectors were informed that plant management had initiated a separate review of the organizational self-assessment process. The review was initiated to determine the root cause for ineffective and incomplete organizational self-assessments and to propose corrective measures. Based upon the review results, plant management determined that the organizational self-assessment program lacked sufficient criteria and guidance to allow individual groups to develop adequate self-assessment programs. As a result of the insufficient criteria and guidance, the individual groups had created abbreviated, generic l
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1 j check sheets to serve as the driving force for the self-assessments. The inspectors noted that the intemal review findings appeared to be identical to the problem statement included in the Compliance Plan and the generic check sheets were the same documentation previously used as evidence to demonstrate that the actions specified in the PAS had been completed.
In response to the internal review, plant management directed the development and implementation of significant changes to the organizational self-assessment process.
The inspectors reviewed the changes which were embodied in Procedure XP2-QA-QA1038, " Organizational Self-Assessment," Revision 0, dated September 1,1998, and Document POEF-LMUS-144, ' Organizational Self-Assessment Guide," Revision 0, dated September 1998. The inspectors noted that the procedure and guide defined the minimum areas to be addressed by organizational self-assessments and provided very specific criteria and guidance for the development and performance of self-assessments. The plant staff were just beginning to implement the materials at the end of the inspection.
The inspectors determined that the plant staff had not appropriately implemented the PAS for issue 27 by the original due date specified in the PAS and had incorrectly determined, during the recent Compliance Plan self-assessment, that the Issue had been previously completed. However, the inspectors also concluded that a separate review of the organizational self-assessment program and subsequent corrective actions appeared to address the deficiencies for which the Compliance Plan issue had been written. As a result, the inspectors determined that the actions required by the PAS had been implemented as of September 1,1998.
Condition 8 of the Certificate of Compliance requires, in part, that the certificatee shall conduct its operations in accordance with the statements and representations contained in the Compliance Plan. Issue 27 of the Compliance Plan requires, in part, that by September 30,1996, an organizational level assessment program will be implemented consisting of the preparation and implernentation of a procedure for the performance of organizationallevel assessments in a uniform manner. The failure to specify criteria and guidance for conducting organizational level assessments in a uniform manner until September 1,1998, is an example of a Violation (VIO 70 7002/98014-01f).
Issue 42:
Compliance Plan Issue 42 identified a single noncompliances associated with the process gas leak detection (PGLD) systems. Specifically, the Compliance Plan documentation stated that detector testing methods had not been developed that established a precise correlation between the detectability of " test smoke" arid the detectability of uranium hexafluoride (UF.) and its reaction products. The Issue 42 PAS required the certificatee to develop and complete a program to related the response of PGLDs to the test methods and to actual UF leakt la addition, the certificatee was required to use the revised testing methods for the performance of required testing (TSR surveillances). The PAS required all actions to be completed by July 31,1997.
As a result of the certificatee's self-assessment of the closure of Compliance items, the plant staff determined that the PAS for issue 42 had not been fully implemented.
Specifically, the plant staff concluded that a correlation between the detectability of " test
! smoke" and UF. had been developed; however, the correlation had not been translated 16
into a revised testing methodology foi use as a part of the routine testing of the detectors. In the self-assessment summary report, the plant staff acknowledged that the newly developed method had not been implemented in the field and that the deficiency had been previously documented in a February 9,1998, plant nonconformance report. In addibon, the final self-assessment report stated that only a l few infield detectors had been tested using the new methodology and that a corrective action plan to resolve the deficiency had been recently developed.
The inspectors reviewed the referenced nonconformance report and the corrective action plan developed to resolve the noncompliance. The inspectors noted that the nonconformance report, the corrective action plan, and the materials originally provided
, as evidence that issue 42 had been completed on schedule did not address the continued need for operability of the PGLD detectors. Specifically, the original closure evidence stated that another project required completion prior to infield implementation of the new testing methodology. The second project was scheduled for completion six months after the PAS specified date for completion of issue 42. In addition, the original closure information misstated the PAS closure requirement by omitting the sentence, " Subsequent testing of the detectors would use the revised methodology."
The corrective action plan, developed in response to the February 1998 nonconformance report, outlined a timeline for infield testing of the detectors or replacement of the infield detectors with laboratory-tested detectors that extended completion of the PAS to February 2000. Both the nonconformance report and the i corrective action plan acknowledged an apparent need to perform testing of all detectors after the PAS completion date of June 30,1997, using the revised methodology, however, neither document identified the detectors as inoperable. In fact, both i documents appeared to justify the lack of an operability decision based upon differences I between the Paducah and Portsmouth Compliance Plans for the same issue. The Paducah Compliance Plan explicitly defined a period of time over which the revised testing methodology would be implemented while the Portsmouth Compliance Plan only stated that subsequent testing would employ the revised method.
The inspectors briefed plant management on the findings developed for issue 42 and discussed the apparent operability implications. Initially, plant management did not concur that the PAS required all subsequent testing, including applicable routine TSR ,
operability testing, to be performed using the new methodology. However, the l Inspectors noted that the certificatee had committed in the pre-certification TSR questions and answers, which formed the basis for the Compliance Plan issue, to use ,
the newly developed methodology for the TSR tests. Based upon an independent review of the inspectors findings, the plant management declared the affected detectors inoperable, initiated the TSR-required compensatory actions, and began development of the necessary procedures required to complete the required testing.
The inspectors determined that the plant staff had not completed the actions required for Issue 42 by the dates specified in the Compliance Plan. The inspectors also concluded that the plant staff's internal self-assessment of Compliance Plan issues had appropriately identified the incorrect closure. However, neither the internal self-assessment nor plant management's previous review of a February 1998 nonconformance report identified that the plant staff's failure to implement the revised testing methodology had resulted in continued operations with inoperable PGLDs. As of the end of the inspection, the plant staff had not completed the issue 42 PAS.
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l l Condition 8 of the Certificate of Compliance requires, in part, that the certificatee shall i conduct its operations in accordance with the statements and representations contained l In the Compliance Plan. Issue 42 of the Compliance Plan requires, in part, that
! beginning July 31,1997, subsequent testing of process gas leak detectors shall be conducted using the revised method developed in accordance with issue 42. The failure I to conduct testing of process gas leak detectors, using the methodology developed in accordance with issue 42, after July 31,1997, is an example of a Violation (VIO 70-7002/98014-01g). l l c. Conclusions The inspectors determined that the plant staff had effectively demonstrated, in most cases, an ability to review and accurately determine the closure status of Compliance Plan Issues during a recent self-assessment. The self-assessment program was noted to include the development of clear and objective acceptance criteria for most Compliance Plan commitments and documentation that most items had been completed. However, some examples of inadequate assessment of the closure status of Pms continued to be observed. In addition, some corrective actions, proposed to resolve the identified deficiencies, were not sufficient to resolve the deficiencies or to ensure future compliance with the regulatory requirements. The inspectors also identified several instances in which actions, specified for four Compliance Plan issues, were not completed within the required timeframes. The failures to properly implement the corrective actions for four Compliance Plan issues are examples of a violation of Condition 8 of the Certificate of Compliance.
C3 Status Reporting of Compliance Plan Activities
- a. Inspection Scope The inspectors reviewed the completeness and accuracy of information provided to the NRC and associated with the Compliance Plan issues.
- b. Qbservations and Findinas During review of the Compliance Plan Issues discussed in Sections C1 and C2, and in NRC IR 98204, the inspectors noted that both the inspection results and the plant staff's own self-assessment efforts indicated that actions required by several of the Compliance Plan Issues either were not completed or were not completed within the timeframes specified in the Compliance Plan. Specifically, the inspectors noted that the certificatee's self assessment efforts, completed July 24,1998, identified that i noncompliances associated with issues 18 (EPs) and 42 (UF, leak detection) had not l been resolved. In addition, the inspectors identified, as a result of the current inspection and that documented in NRC IR 70-7002/98204, that noncompliances associated with issues 7 (HEPA System Testing),8 (NCSAs),9 (nuclear criticality safety implementation), 23 (configuration management), 27 (organizational self-assessments) and 42 (UF leak detection) had not been completed.
or each of the noncompliances that were not resolved, the inspectors determined that i
me plant staff had entered the findings into the plant nonconformance database, had l initiated corrective measures to address the identified deficiencies, and had developed l target dates by which to resolve the noncompliances. For some of the noncompliances, 18
it l
those associated with the nuclear criticality safety program, the inspectors noted that the plant staff had also communicated the corrective actions and completion dates to the NRC as a part of a related Notice of Violation response. The inspectors reviewed the target dates for the individual noncompliances and determined that in all cases the
! dates were beyond the commitments previously specified in the Compliance Plan.
Some of the revised target dates extended into the year 2000. The inspectors also noted that none of the revised target dates had been approved by the NRC with the exception of the those target dates provided as a part of the nuclear criticality safety program-related Notice of Violation.
L ,
l Finally, the inspectors reviewed correspondence provided to the NRC since i December 1997 and related to the completion status of the corrective actions required for each Compliance Plan issue. The inspectors noted that the December 1997, March 1998, and July 1998, Compliance Plan status reports i indicated that all of the actions associated with issues 8,9,18,23,27, and 42 had i l been completed. However, information maintained by the plant staff in the l nonconformance tracking database and provided to the NRC in other correspondence clearly indicated that many of the actions required to resolve the noncompliances had not been completed. l Title 10 of the Code of Federal Regulations, Part 76.9 requires, in part, that information provided to the Commission must be complete and accurate in all material ,
respects. The certificatee's failure on at least three occasions, in the December 1997, l March 1998, and July 1998 Compliance Plan Quarterly Status Reports, to provide the Commission with complete and accurate information regarding the completion status of corrective actions required by the Compliance Plan for issues 8,9,18,23,27, and 42 is a Violation (VIO 70-7002/98014-02)
- c. Conclusions The inspectors identified a violation in that the certificatee failed to provide complete and accurate information regarding the completion of corrective actions specified in the Compliance Plan on at least three occasions.
V. Manaaement Meetinas .
1 X1 Exit Meeting Summary )
The inspectors presented the inspection results to members of the facility management on September 4,1998. The facility staff acknowledged the findings presented and indicated i concurrence with the facts, as stated. The inspectors asked the plant staff whether any materials examined during the inspection should be considered proprietary. No proprietary information was identified.
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1
I PARTIAL LIST OF PERSONS CONTACTED l
)
Lockheed Martin Utility Services
'J. Brown, General Manager
- S. Fout, Operations Manager
- J. Morgan. Enrichment Plant Manager
- D. Waters, Acting Nuclear Regulatory Affairs Manager United States Enrichment Corporation
- L. Fink, Safety, Safeguards & Quality Manager
- J. Miller, USEC Vice President, Production United States Nuclear Reoulatory Commission
- C. A. Blanchard, Resident inspector, Portsmouth Gaseous Diffusion Plant
- J. R. Davis, Senior Criticality Safety inspector, FCOB, NMSS
- K. G. O'Brien, Senior Resident inspector, Paducah Gaseous Diffusion Plant
- P. L. Hiland, Acting Deputy Division Director, DNMS, Region lli
- W. M. Troskoski, Acting Section Chief, FCOB, NMSS I
- Denotes those present at or participating telephonically in the exit meeting held on September 4,1998. l INSPECTION PROCEDURES USED !
IP 40500: Self-Assessment l
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- . - . - - _ _ . . ~ - . - - - .
ITEMS OPENED, CLOSED, AND DISCUSSED Opened 070-7002/98014-01 VIO Failure to complete corrective actions required to resolve I noncompliances identified in the Compliance Plan 070-7002/98014-02 VIO Failure to provide complete and accurate information relative to the status of actions required to resolve noncompliances identified in the Compliance Plan Closed 070-7002/98204-01 URI Potential failure to adequately complete corrective actions prescribed in the Compliance Plan for issues 8,9, and 23 Discussed 070-7002/98206-02 VIO Failure to identify nuclear criticality s :ty items in the ;
configuration management program l
Compliance Plan issues issue 6 CLSD X-705 Microfiltration influent pH Shutdown System Replacement i
Issue 17 CLSD Fire Protection Procedures and Hot Work Permit Program issue 21 CLSD Management Controls issue 27 CLSD Assessments 21
..** a LIST OF ACRONYMS USED AQ Augmented Quality ARSF Action Response Status Form CFR Code of Federal Regulations EP Emergent,y Packets FS Pre Services HEPA High Efficiency Particulate Air HPFWS High Pressure Fire Water System IR Inspection Repcii LMUS Lockheed Martin Utility Services NCS Nuclear Criticality Safety NCSA Nuclear Criticality Safety Approval NOV Notice of Violation NRA Nuclear Regulatory Assurance NRC Nuclear Regulatory Commission PAS Plan of Action and Schedule PDR Public Document Room PGLD Process Gas Leak Detection PIMS Procedure information Management System PORC Plant Operations Review Committee Q Quality QAP Quality Assurance Plan SAR Safety Analysis Report SSC Structure, System, and Component TSR Technical Safety Requirement UF6 Uranium Hexafluoride URI Unresolved item VIO Violation 22
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