ML20199L507
| ML20199L507 | |
| Person / Time | |
|---|---|
| Site: | Westinghouse |
| Issue date: | 02/05/1998 |
| From: | Allen J WESTINGHOUSE ELECTRIC COMPANY, DIV OF CBS CORP. |
| To: | Lieberman J NRC OFFICE OF ENFORCEMENT (OE) |
| References | |
| CON-NRC-98-004, CON-NRC-98-4 70-1151-97-205, NUDOCS 9802090217 | |
| Download: ML20199L507 (17) | |
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Westinghouse Comm6tclal Nucleat to n Electric Corporallon fuel Division
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S NRC-98-004 Febmary 5,1998 U.S. Nuclear Regulatory Commission ATrN: Mr. James Lieberman, Director Office of Enforcement One White Flint North 11555 Rockville Pike Rockville, MD 20852 2738 Oentlemen:
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SUBJECT:
REPLY TO A NOTICE OF VIOLATION I
REFERENCE:
REPORT NO: 70 1151/97 205 Pursuant to the provisions delineated in Section 2.201 of the NRC's
- Rules of Practice," Part 2, Title 10, Code of Federal Regulations, Westinghouse herein provides formal response to your letter of January 6,1998, regarding your inspection of the Columbia Fuel Fabrication Facility (CFFF),
conducted during the period of August 25 29,1997, to review the circumstances surrounding the June 23 and August 25,1997 loss of criticai4y control events.
Appendix A provides our response to the cited violations of NRC requirement; identified in the Notice of Violation attached to the January 6 letter.
Westinghouse presented the information documented in the attached response to the NRC Staff at the October 29,1997 Enforcement Conference held in connection with the events and inspection. /.t that time, we provided a detailed response to the incidents giving rise to the apparent violations presented In your October 2,1997 letter with Inspection Report 70-1151/97-205.
Our response included Westinghouse's understanding of the incident and our contir4uing comminnent to maintaining overall safety at the Columbia Fuel Fabrication Facility. As discussed at the Enforcement Conference, and as more fully described in Appendix A, Westinghouse believes that the comprehensive and lasting corrective actions it has taken in response to the events at issue violations contained in the Notice of Violation, including the concerns expressed in the NRC's January 6,1998 letter transmitting the Notice of Violation, so as to prevent recurrence of such violations and to resolve such concerns.
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70-1151 97o205 Febmary 5,1998
- Page 2 of 4 -
- Moreover, it is of fundamental importance to reemphasize that, in connection with the cited events,
'l at no - time was ~ safety compromised for CFFF employees, the public, or the environment, i
Notwithstanding this basic premise, the specific events and resulting violations and their significance
._ to the need to conduct plant operations and implement the CFFF nuclear criticality safety process in accordance with all safety and regulatory compliance requirements in the future have been treated
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very seriously at CFFF. Appropriate _ management oversight has been taken, and will continue, to
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prevent recurrence.
in response to the two incidents, Westinghouse has undertaken investigations and performed structured root cause analyses of the events; and, has implemented substantive,_long term remedial actions to both address the specific incidents and violations, and to prevent prog.vnmatic recurrence, in addition, Westinghouse has formed a Regulatory Process Review Team, facilitated by the CFFF Plant Manager, to review regulatory processes at CFFF, with initial focus on the nuclear criticality safety regulatory process. The results of completion of this Team's work, as incorporated as a part of our existing Safety Margin Improvement Program initiatives, will improve our comprehensive program to further enhance plam operations involving the processing of special nuclear material (SNM) such that they are conducted in accordance with the safety requirements specified in the renewed license, in addition, the Team's activity will result _in an enhanced self assessment program to confirm that specific license requirements are being implemented in accordance with management's expectations.
As part of our immediate corrective actions, Westinghcuse performed a comprehensive, facility-wide field verification of plant equipment, to demonstrate that the as exists geomett,, and volume criticality safety; controls used in the facility match the assumptions in design documents. - There were three components in this major effort: (1) field verifications to comparc process drawLngs and drawing measurements to as-built or installed equipment, and to confirm all existing equipment is reflected on
'drawingst (2) file verification of systems' documentation to confirm analyses exist for equipment; and '
(3) process hazards analyses of plant ventilation systems, focusing on nuclear criticality safety.. This effort has established that the as-exists plant conditions regarding engineered controls match the Plant safety basis.
Beyond these specific corrective actions, there continues to exist at CFFF multi-level, proven
- operational conduct and management control processes to identify and resolve non-compliances in a prompt,- effective and safety-conscious manner. Recognized tools supporting these processes are " Red Books" - for documenting process upsets, Process Hazards Analysis Root Cause /.aalysis, Commitmer" Mcking and the Safety Margin Improvement Program. Westinghouse's significant committed resources and our prompt, comprehensive and effetive corrective actions to restore NRC Staff's confidence and trust in CFFF, reaffirm our management commitment, attention and care L toward licensed responsibilities.
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"/O 1151-97 205 1
' February 5,1993 Page_3 of 4 e
s With respect to NRC commentt_ in its transmittal letter concerning Double Contingency Protection (DCP), Westinghouse agrees that there is no substitute for rigorous and stmetured identification,
. establishment, and maintenance of appropriate safety controls prior to and during the' processing of l
i-SNM. 'We continue to note, however, that as a factual matter for the two incidents in question, double contingency protection existed at all times at CFFF.
i Westinghouse further agrees that a judgment call by criticality engineers is not an acceptable j
substitute for completing a documented safety assessment with appropriate verification and review, as mquired by the license. - However, for each of the two incidents in question, CFFF nuclear criticality
. safety (NCS) engineers confirmed and verified that the component could be operated safely in that doubic contingency protection, in reality, existed. This'was the basis for system restart. It is our t
intent to continue working with the NRC Staff to provide better defimtion of system restart criteria for CFFF.
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-In addition, as committed in our December 12,1997 letter (RA WLO-97 057), by June 30,1998, the CFFF Plant Manager. regulatory staff and Regulatoly Complia ee Committee (RCC) will review the i.
organizational structure and leadership at CFFF to evaluate it's effectiveness relative to ongoing regulatory compliance initiatives, current workload and assigned functional responsibilities. The.
L infotmal stmeture and effectiveness of, and continued need for, " process review" teams also will be'
-i scrutinized and re evaluated. If the continued use of such teams is found to be appropriate, they will-be chartered and assigned responsibilities by the CFFF Plant Manager. Management oversight and control, and monitoring of progress for completion of these initiatives, as well as other ongoing initiatives and regulatory commitments, will be provided by the CFFF Plant Manager and the RCC, using the existing Safety Margin Improvement Program (SMIP) and Commitment Tracking System
- (CTS) processes. These actions respond to NRC's concerns about the level of management oversight
' and the camprehensiveness of our response toward licensed responsibilities.
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.cstinghouse assures the NRC Staff that the two incidents, and subsequent enforcenent action knc, sotice of Violation, have received attention at the highest levels of our management, i
Westinghoase :learly understands the importance of maintaining safety at CFFF, and complying with
'NRC_ Regulations, conditions of the License, and all commitments to the NRC.
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- 1151-97-205 February 5,1998 Pago 4 of 4 3
E I hereby affirm that the statements made in this response me 'me and correct to the best of my knowledge and belief. Should you have any questions or require additional information, please telephone Mr. Wilbur Goodwin of my staff at (803) 77612610, Extension 3282.
Sincerely.
-WESTINGHOUSE ELECTRIC COMPANY cl 6 Qh __
JagB. Allen, Plant Manager Columbia Fuel Fabrication Facility Attachments: Appendix A cc:
U. S. Nuclear Regulatory Commission U. S. Nuclear Regulatory Commission Regional Administrator, Region II Director, Of0ce of Nuclear Material Atlanta Federal Center Safety and Safeguards 61 Forsyth Street, SW, Suite 23T85 Washington, DC 20555 Atlanta, GA 30303 7
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J.E 1151 97-205 I
- February 5,1998
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- Page 1 of 13 APPENDIX A LWESTINGHOUSE RESPONSE TO THE ITEMS OF NONCOMPLIANCE
-1 IDENTIFIED IN THE NRC NOTICE OF VIOLATION j
DA.
The following information is provided in response to the Inspectors' observation of
' Westinghouse's failure to: "... conduct adequate incident investigation and followup =
actions... ":
A.1 ACKNOWLEDGMENT OF THE VIOLATION -
a With the reservatiop: expressed at the October 29,1997 Enforcement Conference that-
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acions to re-establish system safety were taken prior to system restart, Westinghouse acknowledges Subsections 1.a'and 1.b of the violation. With respect to Subsection 1.c of the violation, Westinghouse acknowledges that a formal root cause analysis was not initiated prior to system restart, but maintains its position that it is acceptable' to
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complete root cause investigations and implementation of corrective; actions, beyond
.those required to establish system safety, after system restart. _. Notwithstanding these reservations, Westinghouse has _ taken both immediate_ and. lasting comprehensive, effective corrective actions to address all aspects of the. violation as presented in the
A.2 - REASON FOR THE VIOLATION r
' With respect to the Pellet Line 1 Granulator Hopper, the Westinghouse Columbia Fuel -
l Fabrication Facility -(CFFF) Incident Review Committee :did not react beyond - the operational aspects of the incident; and, in-depth root-cause analyses and corrective actions, not related to re-establishing -system safety, to address programmatic issues were not initiated in a timely manner. In addition, CFFF management oversight and review activities, including the CFFF se_lf-assessment process, did not identify and elevate the issue giving rise to the violation to produce a response and corrective actions on a programmatic basis.
However, CFFF Management continues to believe it is acceptable to complete root cause investigations and complete implementation of corrective actions, beyond those required to re-establish system safety, after restart. This is based upon, CFFF 3
- Nuclear Criticclity Safety Engineers having confirmed and verified that the Pellet Area Ventilation System Moisture Dropout Tank could be operanJ safely in that double contingency protection actually existed.
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- Feb: vary 5,1998 L Page 2 of 13 A.3 IMMEDIATE ACTION TAKEN AND THE RESULTS ACHIEVED
- 1. Procedure RA-111. " Safety Signiicant Incident investigations," was revised to add:
P Criteria on timeliness of Root Cause Analysis (RCA) activities and for -
e prioritizing recommendations and implementing corrective actions; -
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- Guidance to RCA tea.ns to consider management control and regulatory :
processes in their deliberations; Requirement that 'RCA-teams be~ chartered with _ specific management' L
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-instructions so1that all of the potential root __causes are ; addressed,.
including the need to comply with License conditions; and,
. Guidance on event recovery and restart authority.
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2.
The revised procedure was approved and fully implemented, and user personnel were trained in its application; thus, full compliance with License requirements was attained.
A.4 ACTIONS TO PREVENT RECURRENCE il.
- A C"FF teem comprised of engineers who _will perform incident investigations,-.
and 9FFF managers who will make decisions concerning incident notifications.
p has been established. The team will work to gain common understanding with R
the NRC Staff on safety significant incident notification and restart criteria. As -
L necessary,. revisions - to ~ procedures will be made to clarify common understandings.
2.
Design basis incident event trees will beideveloped to guide decision makers in the process for evaluating the need for making incident notifications. A broader application of the root-cause analysis (RCA) process will be-implemented so that both investigation of "on-the-floor" aspects (to focus on immediate actions.
- taken and results achieved), and " administrative" aspects (to focus on actions taken to prevent recurrence) are appropriately-addressed in h timely and effective manner.
A structured post-incident recovery process _ will be i developed and implemented to restore (or confirm) the design safety basis, and verify closure.. A " data-pack" will be developed and implemented to enable prompt retrieval of " cradle-to-grave" documentation for each incident requiring notification evaluation. (Scheduled completion date: September 30,1998.)
1 15 DATE WHEN FULL COMPLIANCE WILL BE ACHIEVED.
A Full compliance has been achieved based on immediate actions taken. Tne scheduled completion date for long-term actions to prevent recurrence is as noted in.s.4 above.
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B.
The following information is provided in response to the Inspectors' observation of
, Westinghouse's failure to:... conduct an adequate criticaPy safety evaluation and technical. review for each significant portion of a process to identify the specific contro's_ necessary to assure _ safe operation, and incorporate those controls into the process design criteria...":
-B.11 ACKNOWLEDGMENT OF THE VIOLATION iWestinghouse acknowledges the violation.
B.2 REASON FOR THE VIOLATION Thera'were ambiguities and shortcomings in certain CFFF procedures governing conduct of Criticality Safety Evaluations (CSE's); and, CFFF Nuclear Criticality Safety-Engineers were inadequately trained in the preparation and review of CSE's. ' Further,.
verification that the as-exists geometry and volume criticality safety controls used in the facility match the assumptions in; CFFF design documents had not been-comprehensively; assured.
In :: addition,-- CFFF management' oversigt and review activitics, including the.CFFF self-assessment process, did not identify and elevate the issue giving rise to the violation to produce a 4:sponse and corrective actions on a programmatic basis, s
l B.3' IMMEDIATE ACTION TAKEN AND RESUL'1S ACHIEVED 1.
The Pellet Line Granulator Hopper CSE and Pellet Ventilation System Moisture Drop-Out Tank CSE were updated to meet License commitments.
2,'
Procedure.RA-104,," Regulatory Review of - Configuration Change Authorizations," was revised and implemented to include:
Field verifications of identified controls, equipment, etc.;
1 Adequate reviews of changes; Applicable drawings to be signed off are identified during the review process; Safety significant controls that require preventive maintenance are specified
' during the review process; and, Applicable safety significant controls are identified and placed in Procedure e
RA-108, " Safety Significant Interlocks."
3.
Training to the revised procedure was performed and documented for those individuals involved with reviewing changes; and, to emphasize the importance of following procedures.
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E-1151-97-205 Febmary 5,1998-
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Comprehensive training of CFFF Nuclear Criticality Safety Engineers in the preparation and revision of CSE's was provided.
5.
A comprehensive, facility-wide field-verification of plant equipment,- to demonstrate that the as-exists geometry and _ volume criticality safety controls used in the facility match the assumptions in__CFFF design documents was -
completed. There were three componems of this major effort:
e Field. verifications to - compare. process - drawings and drawing) measurements to as-built or installed equipment and to-confirm all existing equipment is reflecied on drawings; File verification of systems' documentation to confirm analyses exist for.
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equipment; and
. Process -hazards analyses of plant-ventilation systems, focusing on e
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nuclear criticality safety.
B.4 ACTIONS TO PREVENT RECURRENCE Criticality Safety Analyses (CSA's), and Criticality Safety Evduations (CSE's) will be collected into an' indexed, controlled file. All geometry and volume controlled facility components described in the file will be identified, and field-verified. L All CSA's 'and.
CSE's in the file will be-upgraded and/or completed in accordancefwith license d
requirements, and summaries (in the format of the current CFFF License Annex)=will-be submitted to NRC on a-mutually agreed upon schedule. - All passive and active' engineered controls identified in the summaries will be ficid-verified to be installed and functional. - All' completed CSA's and CSE's will be independently peer-reviewed in accordance with license requirements and related procedures. Configuration control
. data packages for ongoing changes to facility structures, systems and components will be filed with their respective CSA's and/or CSE's, to provide a substantially complete, "living" framework for previously committed to system Integrated Safety Assessments -
- (ISA's) that will ultimately become the final design safety basis.
-(Scheduled completion date: March 31,1999.)
The system ISA's will be performed in accorsoce with license requirements and CFFF-approved guidelines.
The schedule for completing system ISA's - will be coordinated with the schedule for establishing the interim design safety basis (CSA's/CSE's), to maximize efficient utilization of resources.
System ISA's will identify preventive and mitigative controls relied upon for environmental protection, radiation safety, nuclear criticality safety and safeguards, chemical safety, and fire c
- safety. Identified controls will be classified according to their safety significance, placed under the appropriate level of quality assurance to assure their reliability, and placed under an appropriate maintenance program to assure their availability. System ISA's will be summarized in a License Annex that will be usei so ths.t all cognizant stakeholders have a common understanding of each system's preventive and mitigative controls, and_ their safety _ significance. Configuration control data packages for on-1 going changes to facility structures, systems and components will be filed with their J
70-1151-97-205 February 5,1998 l
Page 5 of 13-l re'spective system ISA's, and the License Annex will be updated on a real-time basis to provide a substantially complete,. "living" design safety basis for the CFFF.
(Scheduled completion date: November 5, 2002.)
l The CFFF management of change process will be restructured so that all' regulatory--
significant changes to structures, systems, components and adminis'.rative processes are covered with respect to receiving cppropriate safety / regulatory review. The elements of this restructured and integrated process will consist of subprograms such as configuration control, software control, maintenance activities, procedures, etc. Any
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new or changed structure, system, component or administrative process that is not covered by the basic process (such as development projects, new business evaluations,.
etc.) will be covered by a separately documented regulatory adminiarative process.
The restructuring initiatiw will begin with a thorough process analysis of how all proposed changes to the plant design safety basis are documented, reviewed and-approved.
Then, appropriate supplementary elements will be developed and implemented to provide total management of change coverage. To round out the program, the total coverage process will be proceduralized, and all affected personnel will receive and ~ acknowledge training in the restructured process. (Completion date:
December 15, 1998.)
t B.5 DATE WHEN FULL COMPLIANCE WILL BE ACHIEVED Full compliance has been achieved based on immediate actions taken. The scheduled completion dates for long-tum actions to prevent recurrence are as noted in B.4 above.
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7 70-1151 97-205 February 5,1998 Page 6 of 13 C.-
The following information is provided in response to the inspectors' observation of Westinghouse's failure to: "... functionally verify that c)ntrols necessary for the safe operation of a process were installed to match the requirements identified in the design-
- criteria...": -
C.1" - ACKNOWLEDGMENT OF THE VIOLATION Westinghouse acknowledges the violation.
- C.2 REASON FOR TI'.3 VIOLATION
- There were _ ambiguities and shortcomings in certain CFFF procedures governing
p-functional verification of safe:y-significant controls; and, CFFF Nuclear Criticality l-Safety Engineers were inadequately trained in such functional verifications.. Further,
- verification that the as-exists geometry and volume critical!ty safety controls u' sed in the -
facility match the assumptions in CFFF design documents had not been systematically assured. In addition, CFFF management oversight and review activities, including the C'FFF self assessment process, did not identify and elevate the issue giving' rise to the violation to produce a response and corrective actions on a programmatic basis.
L C.3 IMMEDIATE ACTION TAKEN AND RESULTS ACHIEVED-1 1.
The volumes of Pellet Line Granulator Hoppers and Pellet Ventilation System Moisture Drop-Out Tanks were field-verified.
q 2.
Procedure, RA-104, '" Regulatory Review -of Configuration - Change.
Authorizations," was revised, approved, and fully implemented; and
. appropriate personnel were trained as more fully described in the response to
-B.3.
3.
Comprehensive training of CFFF Nuclear Criticality Safety Engineers in CSE preparation and revision, including the need to functionally verify safety-significant controls, was provided.
4.
A comprehensive, facility-wide field-verification of plant equipment, to demonstrate that the as-exists geometry and volume criticality safety controls used in the facility match the assumptions in CFFF design documents was completed as more fully described in the response to B.3.
C.4 ACTIONS TO PREVENT RECURRENCE See the response to B.4.
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- C.5 DATE WHEN FULL COMPLIANCE WILL BE ACHIEVED
- F all compliance has been achieved based on immediate actions taken. The scheduled completion dates for long term actions to prevent recurrence are as noted-in the.
response to B.4.
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- D.
The following information is provided in response to the Inspectors' observation of -
-Westinghouse's ; failure to:
assure that all assumptions relating to process / equipment / material theory, function, and operation, including credible upset '
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. con t ons are ust fied, documemed, and independently reviewed...":-.
D.11 ACKNOWLEDGMENT OF THE VIOLATION i
' Westinghouse acknowledges the. violation as stated in the Final Notice of Violation.
Westinghouse continues to maintain its position, however, that-it-is acceptabl_e to complete investigations and implementation of corrective actions, beyond 1 those
- required to establish system safety, after system restart.
' D.2 REASON FOR THE VIOLATION There were ambiguities and deficiencies in certain CFFF proceduresi governing
- Justification, documentation, and-review of CSE asssmptions; and, CFFF Nuclear -
Criticality Safety Engineers were inadequately _ trained in the conduct, documentation, and review of CSE assumptions. Further, verifications that geometry and volume 3
- criticality safety controls used in the facility match the assumptions in CFFF design-documents had not been comprehensively assured. In addition, CFFF management-
-oversight and review activities, including-the CFFF self-assessment process, did not identify and elevate the issue giving rise to the violation to produce a response and-corrective actions on a programmatic basis.
D.3 cIMMEDIATE ACTION TAKEN AND RESULTS ACHIEVED 1.-
Procedure RA-104,
". Regulatory Review of Configuration Change Authorizations," was revised,- approved, and fully implenented; and appropriate personnel were trained as more fully described in response to
.B.3.
22.
Comprehensive training of CFFF Nuclear Criticality Engineers in CSE preparation and revision,-including the need to assure that all assumptions relating to process / equipment / material theory, function and operation, including
. credible upset conditions are justified, documented and independently reviewed, was provided.
3.
A comprehensive, facility-wide field-verification of plant equipment, to
- demonstrate that the as-exists geometry and volume criticality safety controls us:d u, the facility match the assumptions in CFFF design documents, was
' completed as more fully described in the response to B.3.
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70-1151-97-205 February 5,1998 Page 9 of 13 '
D.4 - ACTIONS TO PREVENT RECURRENCE
. See the response'to B.4.
. D.5 D TE WHEN FULL COMPLIANCE WILL BE' ACHIEVED' Full compliance has been achieved based on immediate actions taken. The scheduled completion dates for long-term actions to prevent recurrence are as noted in the-2 response to B.4, -
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Page 10 of 13
. E.
The following information is provided.in response to the Inspe: tors' observation of-
~ Westinghouse's failure tor "... establish adequate written procedures to specify the management program for licensed activity records involving nuclear criticality safety evaluations and analysis..."'
- E.1 1 ACKNOWLEDGMENT OF THE VIOLATION
= Westinghouse acknowledges:the violation in that the CFFF Records Maintenance Procedure CA-004, although covering nuclear c:sticality safety records, did not in:lude sufficiently detailed guidance _with respect to such records and their-retrieval.'
-In iaddition, Westinghouse acknowledges that _the original nuclear safety analysis for the Pellet Area Granulator Hoppers could not be located -at the time of the NRC's-
' inspection.-
Notwithstanding these reservations, Westinghouse f has taken both.
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' immediate and lasting comprehensive, effective corrective action to address all aspects of the violation as presented in the Notice of Violation.
' E.2 : REASON FOR THE VIOLATION The CFFF procedure governing maintenance, control and storage of, and access to, CFFF records _did not specifically list nuclear criticality safety documents, or inchide -
sufficiently detailed guidance with respect to_ maintenance of such records and their.-
retrieval.
I E.3L IMMEDIATE ACTION TAKEN AND THE RESULTS ACHIEVED 1.
Procedure CA-004, " Columbia' Plant Records - Management Policy," 'was revised to enhance guidance and requirements for the mabtenance and control of nuclear criticality safety documents, and, requirements for the storage of and '
access to nuclear criticality safety documents.
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The revised procedure was approved and fully implemented, and appropriate personnel were trained; thus, full compliance with License requirements was attained.
E.4 -
ACTIONS TO PREVENT RECURRENCE Regulatory records and documents such as CSA's, CSE's, criticality safety calculations
.("CALCNOTES") and computer code val!dations will be maintained and controlled in accordance with written procedures (see, e.g. E.3 above). In addition, such documents and records will be indexed in a manner consistent with the goal of " prompt retrieval" (e.g., for timely incident evaluation, timely response to NRC Staff requests, etc.)... The process _will-begin with identifying documents and records for maintenance end retention. Then, as required, implementing procedures will be developed for document control and recordkeeping.
Documented training in, and acknowledgment of, regulatory document control and recordkeeping policies and procedures will complete 1
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' these actions to prevent recurrence. This pmgram will be patterned after the existing, effective process used by CFFF Product Assarance to' control documents and maintain records. (Scb:duled Completion Date: July 31,1998.)
E.5
- DATE WHEN FULL COMPLMNCE WILL BE ACHIEVED.
t Full compliance has been achieved based on inunediate actions taken. The scheduled completion dates for long-term actions to prevent recurrence is au noted in E.4 above..
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70-1151-9/4 05 February 5,1998 Page 12 of 13 F.
The following information is provided in response to the Inspectors' observation of Westinghouse's failure in the items noted to: ".., develop or implement nuclear criticality safety procedures and policies that identify the requirements for
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implementation of applicable NRC regulations and license conditions...":
F.1 ACKNOWLEDGMENT OF THE VIOLATION Westinghouse acknowledges the individual examples of the violation as set forth in the NRC's Statement of Violation. Westinghouse has taken both immediate and lasting comprehend e, effective corrective actions to address all aspects of the violation as presented in the Notice of Violation.
F.2 REASON FOR THE VIOLATION There was no systematic methodology or process in place at CFFF to provide that a'l required license requirements or NRC regulations were incorporated in administrative and operating procedures; or, to provide compliance quality assurance oversight.
F.3 IMMEDIATE ACTION TAKEN AND THE RESULTS ACIIIEVED 1.
An extensive review of Chapter 6.0 of (" Nuclear Criticality Safety") of SNM-1107 was performed and applicable program elements were incorporated into new or revised procedures. All procedural deficiencies cited in the Notice of Violation were addressed through procedure revisions. All new and revised procedures were approved and fully implemented, and appropriate personnel were trained.
'2.
Further, Criticality Safety Evaluation Guidelines, which are included as a subset of "CFFF Baseline Integrated Safety Assessment Guidelines," were prepared, formalized and approved.
F.4 ACTION! TO PREVENT RECURRFNCE In the future, applicable SNM-1107 license conditions will be evaluated; and appropriate plans management will assure incorporation of all necessary license conditions into policies and procedures prior to their required use. Where written policies and procedures are required by the license, they will be developed or revised, as necessary, and approved for use, and be available to the personnel responsible for their implementation. Any assertion that a plant activity meets an explicit license condition will be supported by a policy or procedure. The process will be com; leted in accordance with the following steps:
1.
Gain a common understanding of license commitments, as stated in the SNM-1107 License Application, required plans, etc., (per following paragraph).
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[2. Link the requirements to, and/or reflect in,' regulatory guidance procedures, policy 1
manuals, handbooks, etc.
- 3. -Link such guidance to, and/or reflect in, appropriate _ operating procedures, quality control instructions, etc.
- 4. Document training in, and acknowledgment of, policies and procedures to complete the process.
" Process" Chapterr, 1.0,'2.0,3.0,4,0,11.0 and 12.0 of the CFFF SNM-1107 License Application will be formally " translated" to document how the commitments will be j
implemented.
" Program" Chapters 5.0, 7.0, 8.0, 9.0, and 10.0 of the License -
Application will be cross-referenced to applicable implementing procedures. Chapter 6.0, (" Nuclear Criticahty Safety"), of the License Application will be re-written as-necessary to_ clearly reflect ' exactly how the program is being implemented to meet--
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NRC-Staff expectations; then, will be cross-referenced to applicable: implementing-
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procedures. Schedules for independent internal and external compliance quality audits will be developed and implemented.
A methodology for Regulatory Compliance-Committee (RCC) review of compliance quality audit f'mdings and recommendations, including documented tracJing to closure, will be developed and implemented.
This program will be based upon the process used by CFFF Product Assurance which '
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-has been effective in reflecting their requirements into administrative and operating procedures. (Scheduled Completion Date: December 31,- 1998.)
-- F.5-DATE WHEN FULL COMPLIANCE WILL BE ACHIEVED.
- Full compliance has been achieved based on immediate actions taken. The scheduled completion date for long-term actions to prevent recurrence is as noted in F.4 above.
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