ML20202C028
| ML20202C028 | |
| Person / Time | |
|---|---|
| Site: | Portsmouth Gaseous Diffusion Plant |
| Issue date: | 01/30/1998 |
| From: | Toelle S UNITED STATES ENRICHMENT CORP. (USEC) |
| To: | Pederson C NRC OFFICE OF NUCLEAR MATERIAL SAFETY & SAFEGUARDS (NMSS) |
| References | |
| GDP-98-0013, GDP-98-13, NUDOCS 9802120146 | |
| Download: ML20202C028 (26) | |
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.[sLSEC A Cloo' al Energy Company January 30,1998 Ms. Cynthia Pc erson, Director SERIAL: GDP-98-0013 Division of Ni.alcar Material Safety U.S. Nuclear Regulatory Commission 801 Warrenville Road Lisle, Illinois 60532-4351 Portsmouth Gaseous Diffusion Plant (PORTS)
Docket No. 70-7002 Portsmouth Nuclear Criticality Safety Program Pedsed Corrective Action Plan - Quarterly Status Report
Dear Ms. Pederson:
USEC letter GDP 97-0217 dated December 22,1997, provided the Nuclar Regu;atory Commission (NRC) with a revised Corrective Action Plan for the Portsmouth Nuclear Cr:ticality I
Safety (NCS) Propam, in this letter, USEC committed to provide NRC with a quarterly status report of this Corrective Action Plan and to provide the initial report by January 31, 1998.
Accordingly, Enclosure 1 is the initial quarterly status report of the Portsmouth NCS Program k
Corrective Action Plan (CAP).
This status repon includes the results num the first quarterly review of the CAP (refer tc t
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Task 18), a status of the completion of CAP tasks, and the applicable findings from the first Safety, i
Safeguards, and Quality (SS&Q) assessment of the CAP (refer to Task 17).
A
_ to this submmal provides Revision 2 to the Corrective Action Plan for tiie PORTS NCS Program. This revision includes applicable commitments from USEC's response to NRC comments on the CAP (reierence USEC letter GDP 98-004 dated January 13,1998). Changes to the CAP are reflected by margin bus in the right-hand side of the document. Highlights of this revision are listed below:
The term "NCSA" has been replaced with "NCSA/E" to reflect that the CAP refers to both the Nuclear Criticality Safety Assessment and the Nuclear Criticality Safety Evaluation.
Subtas:.s 4.4. 4.6, and 4.7 h've been deleted since these subtasks were redundant to the approved training pro, rem (remaining subtasks vsere tenumbered accordingly).
90021P0146 990130 '
PDR Ar)OCK 07007002 C
PDR i
903 Packledge Drin. Bethesda, MD 20F17-18'd l
Telephone 301-564-3200 Fax 301-564-3201 http://www.usec.com
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Omces in Livermore, CA Paducah, KY Portsmouth, OH Washington, DC
6 Ms. Cynthia Pederson January 30,1998 GDP 98-0013, Page 2 s
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Two (2) new sections have been added to the CAP (i.e., Section D.7. " Response to Anomabus NCS 0)nditions," and Section D.8, "NCS Oversight").
Task 9, " Continuous improvement Program," has been revised to reflect current actions that are being tal.en to disseminate " lessons learned" from CAP activities.
U A new subtask (i.e.14.5) has been added to Task 14, "Cerrective Action Program Enhancemer.ts."
On January 29,1998, USEC notif'ied NRC of an event at tv.a S concerning the lack of an NCSA for various operations / controls in the X-326 Process Buildiag. As r result of this event, it has become apparent that the attached NCS CAP was not ade quate to identify this type of event.
USEC is further evaluating this type of esent to determine the root cause and corrective actions.
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The next quarterly status report will be provided to NRC by April 30,1998. There are no new commitments contlined in this submittal. If you have questions regarding this submittal, please contact Ron Gaston at (740) 897-2710.
Sincerely, A
s. R.
I Steven A. Toelle Nuclear Regulatory Assurance and Policy Manager Enclosures (2) a cc:
NRC Document Control Desk NRC Resident inspector-PGDP NRC Resident Inspector - PORTS NRC P cial Projects Branch 3
DOE Regnuory Oversight Manager l
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Quarterly Status Report of the PORTS Nuclear Criticality Safety Program Corrective Action Plan I.
Purpose To convey the status of the tasks in the Nuclear Criticality Safety (NCS) Corrective Action Plan (CAP).
1 II.
Scope This report documents the results of a review of the NCS CAP. This reviev. evaluated the adequacy and effectiveness of the Plan and the products of the Plan with respect to scope, implementation, priositization, and scheduling. Also considered and incorporated are the findings from Safety, Safeguards, and Quality (SS&Q) assessments of the CAP (refer to Task 17 of the Plan).Section IV " Details," describes the subject, status (relative to external and intemal due dates), and the resuhs of USEC's review.
l Ill.
Executive Summary l
Each o.f the tasks of the CAP is pmceeding according to schedule except for Task 3, "NCSA/Es Upgrade Project," and Task 8, " Vertical Slice Review." Efforts are underway to recover the schedule. Appropriate resources and talent are being applied to the tasks.
Several tasks require additional work (expanded work scope) as a result of the detailed review meetings to assess the products. These items are being documented and will continue to be tracked via the lessons-learnM program.
IV.
Details The following information is grouped according to the tasks listed on Tab!e 2 of the NCS CAP, revision 2. The cut-otTdate for this report was January 28,1998.
- Task 1--
Facility Review of Nt clear Criticality Safety Assessments / Evaluations (NCS A/E)s Target Date: 12/24/97 Comp!cte: The existing NCSAs were walked-down in each building whe:e fissile materials operations are performed. Deliciencies were documented on approximately 240 problem reports, evaluated for reportability, and where required, immediate compensatory action was taken. Overall the findings were: 1) tro instances of a loss of one of one control; 2) nine instances of a loss of one of two em.rol; and 3) three instance, of a loss of two of two controls. Other,long term, corrective actions will El-1 9
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be appropriately schedulet' and performed in accordance with the NCS Corrective Action Plan.
Task 2 Rcriew of NCSA/Es Regarding Qualifications Target Date: 2/28/98 On schedule: Two individuals did not meet PORTS Safety Analysis Report (SAR) requirements.
In addition, qualification records for four NCS experienced i
contractors are not on fi:e. NCSA/Es prepared by each individual have been reviewed. Five problem reports have been generated, several of which have resulted in the shutdown of the related operations. Other improvements and suggestions are being provided as additional input to the NCSA upgrade task. Two lessons learned are being prepared: one to increase the guidance provided in our procedure for peer review; and the other to add requirements to our procurement process for ensuring we have qualification records for contracted NCS engineers.
Task 3 NCSA/Es Upgrade Project Target Date:
Priority 1, 3/27/98 Priority 2, 7/31/98 Priority 3, 4/30/99 Behind schedule: The NCSA/E upgrade project has experienced some delays in starting due to coordination problems. To compensate for these delays the number of review teams is being expanded. Resources are being identified to accomplish this expansion. A procedure is in place to cover the upgrade project and the modif'ed process. The next set of review groups started on January 29,1998. The groups will cover the withdrawal NCSA/Es, waste streams in the X-340 complex, calciner and NO, scrubber in X-705, and storage requirements in X-710.
Task 4 Enhance NCSA/F Training (Interim Process)
Target Date: 2/28/98 On schedule: Complete thr iugh subtask 4.3 (compile list of document changes, identify training audience, and develop training module). The purpose of the training is to inform the personnel of the changes in the NCS program and the on-going corrective actior, tasks.
Subtasks 4.4,4.6, and 4.7 were eliminated in revision 2 of the NCS Corrective Actica Plan because these tasks were redundant to the approved training program which already covers the determination of when personnel being trained should be tested and how that testing is conducted.
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Task 5 SS&Q Review ofImplementation Target Date:
Priority 1, 4/27/98 Priority 2, 8/31/98 Priorit) 3, 5/30/99 nn schedule: Fubtasks 5.1 (develop list of NCSA/Es changes), 5.2 (prepare assessment Plan) and 5.5 (review canceled Engineering Notices) are complete. The review of Engineering Notices identified that the Work Control organization received copies of FNs, but orily as information. They were not on the controlled copy distribution. This will be entered as a lesson learned.
The SS&Q assessments will follow the upgrade of the NCSAs. The assessments in subtasks 3.3 and 5.4 will continue concurrent with task 3 (NCSA/Es Upgrade Project).
. Task 6 Complete Comprehensive Root Cause Analysis Target Date: 2/28/98 On schedule: ~he root cause analysis of 1997 NCS problem reports has been completed. L ults are being analyzed and a report is being prepared. The next level of detail being pursued is the specific fixes for each on the problem reports.
This is being done in a prioritized manner beginning with those for which we have no standard, policy, or administrative control.
Task 7 Compare Applicable Industry Standards Target Date: 1/31/98 Against NCS Program Or. schedule.
Task 8 Vertical Slice Review Yarget Date: 3/31/98 Behind schedule: The methodology has been drafted, but the team has not yet been assembled.
Revision 2 of the NCS Corrective Action Plan included a clarification that the vertical slice review will be conducted in accordance with a methodology document rather than a procedure.
Task 9 Continuous Improvement Program Target Date: 1/31/98 Complete: A procedure for documenting, tracking, and ensuring implementation of NCS lessons learned has been prepared and approved and is being implemented.
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4 Task 10 Personnel Qualineation Verification Target Date: 3/31/98 Ahead of schedule: The review of applicable industry guidance concerning the qualification of NCS personnel is expected to be complete by January 31,1998.
Several areas ofimprovement have been identified. In addition to other corrective actions, this will be documented in our lessons learned program.
Task 11 Outside/ Independent Assessments Target Date: 4/30/98 On schedule: The reports that fall within the scope of this task have been identified.
The reports to be included are the NRC findings, SS&Q findings, and reports documented by contractor personnel.
Task 12 Policy / Procedure Revision and Training Tarvet Date: 12/31/98 On schedule: NCS procedure changes have been initiated. Additional procedure changes have been ioentified and are being pursued. This is an on-going task. The procedure changes being made are: response to an anoinalous condition, NCS requirements in operating procedures, and the Murder Board procedure.
Task 13 Revise Training Program tur Site Personnel Target Date: 4/30/98 (Suhtask 13.5)
On schedule: An evaluation of the effectiveness of prior NCS training has been completed. The modified training approach includes providing group briefings on specific NCSAs as they are approved, in addition, field drills are conducted followin7, the training to provide "real life" scenarios of NCSA controls.
Task 14 Corrective Action Program Enhancements 7'.tet Date: 6/30/98 On schedule: An evaluation of the corrective action process has been completed and a report is being prepared, f
Task 15 Configuration Management Program Target Date: 2/28/98 Enhancements On schedule: A new procedure XP2-EG-CF1031, Implementing Action Worksheets, has been dralled and is being reviewed for comment. This procedure will require the originator of a change affecting configuration m identify flowdown requirements and obtain commitments from the responsible organizations to fulfill those requirements.
Additional actions are needed to ensure that changes in the NCSA/Eu are properly reflected in the required controlled documents and programs, such as the preventive maintenance program. Also, the new procedure must be coordinated with the other El-4 o
,o procedures that control plant configuration changes.
4 Task 16 Revist Assessment Programs Target Date: 3/31/98 On schedule: Criteria for assessment program reviews has been developed.
Assessments are being reviewed against this criteria. The focus of the reviews is to ensure that we are asking whether we are doing the right thing in addition to asking whether we a e doing what it says in the procedure.
Task 17 Oversight of Plan Implementation Target Date: 4/30/99 (Hi-monthly)
On schedule: The NCS assessment plan has been prepared and approved by the Independent Assessment Group (IAG) and the surveillan ::s are o;i schedule.
l The results of the I AG assessments have been factored into this report: there were no negative findings.
Task 18 Evaluation and Feedback Taivet Date: Quarter 1y starting on 1/31/98 j
On schedule: The results of this evaluation are included in this report.
Task 19 Evaluate Continued use of Murder Hoard Target Date: Not befour 5/31/98 i
On scheduy: The murder board is being used as described in tue NCS corrective action plan. This is an ongoing activity.
Activity D.7 Response to Anomalous NCS Conditions Target Date: 2/11/98 On schedule: The requirements have been implemented via a standing orde and training. Applicable procedure changes we being made.
Revision 2 of the NCS Corrective-Action Plan included a clarification that the decision as to whether the NCS Engineer needs to be present to direct the recovery operation will be made by the PSS and the NCS Engineo..
Activity D.8 NCS Oversight on the Operating Floors Target Dme: 2/2/98 On schedule: Personnel have been identified and arrangements are being made to have NCS oversight on the operating floors to ensure continued heightened awareness of the importance of NCS controls.
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- PORTS Nuclear Criticality Safety Program Corrective Action Plan, Revision 2 A.
Background
As part of the Certification Application effort, PORTS NCSA/Es were upgraded to provide snore rigorous and accurate NCS documentation. This effort was completed in December of 1996. Subsequent to this cfTort,in early 1997, USEC began to question the effectiveness of the NCS program. This concern was based, in part, on the large number of Problem Reports being generated that identified problems with the implementation of the Nr'-
program. In October 1997, it was determined that the NCSA/E controls developed to keep l.
cooling water from entering the process gas system during the cell treatment process were not being properly maintained. Further evaluation of this event detennined that the respective NCSA/E was flawed. Subsequent to this event, it was identified that Engineering -
Notices-(ens) were being used to amend requirements in NCSA/Es, effectively-l circumventing the NCS reviuv and approval process.
L The identification of these problems and the recognition that they represent deficiencies in the implementation of the NCS program liave resulted in the need to establish e
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comprehensive Corrective Action Plan.- The gor.ls of this Plan are to put in place a high quality NCS program and to ensure that NCS implementing documents provide the i
necessary level of safety. These goals will be accomplished by:
- (1)
Ensuring the safety of ongoing Fissile Material Operations (FMOs);.
(2)
Ideritifying the scope and depth of the deficiencies (root causes);
(3)
. Initiatiry an interim program to review and correct NCSA/Es in a prioritized manner l based oa their potential risk; (4)
Evaluating and upgrading NCS programmati: controls and related management systems;
'5)
Reviewing completed NCSA/Es against the enhanced program for potential changes; I
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and (6)
Improving the NCS training for NCS and site personnel.
.The remainder of this Plan lists both completed acticns and actions which remain to be completed. Those actions remaining to be completed have, for completeness been broken into sub-tasks which are contained in the body of the plan by task numbei. Each remaining task is preceded by a short description. The date by which each overall task will be completed is contained in Table 2.
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B.
Immediate Compensatory Actions J
in November 1997, USEC recognized, based on the magnitude of the deficiencies being identified, that immediate compensatory measures would be required while an overal! NCS program upgrade was being fonnulated. These immediate actions included an evaluation of program safety, shutdown of certain FMOs, and the imp!ementation of an additional review of past problems. These actions are discussed in more d+ tail below.
1.
Evaluation of Program Safety An evaluation of NCS program safety was initiated in order to provide management with confidence that the findings identified to date do not represent an immediate safety inelem. The following specific actions were initiated in order to provlde this level of confidence.
(a)
Walkdown_of_NCSA/Es_ Associated _with_SAILAccident_ Scenario l
Walkdowns were performed on 13 NCSA/Es determined to be associated l
with the Safety Analysis Report (SAR) accident analysis. These walk-downs were completed and concluded that the associated NCSA/E controls were I
adequately implemented. Twenty-two prs were identified, one of which was l
a 24-hour NRC event report.
l (b)
Review _ofliutveillancelequirements - A review was performed to verify that NCS surveiliances and Technical Safety Requirement (TSR) surveillances for single contingency FMOs were being performed. No surveillances were overdue.
(c)
Building. Review _ofECSA/Es - The managers for each building in which l
FMOs are perforrad have begun to review the i olementation status of existing NCSA/Es in their buildings. These
. sews are to ensure that the I
descriptions in Part A of the NCSA/Es are accurate and complete and that the l
controls identified in Part B and Part C are being implemented. The plan for performing these reviews follows:
Task i Building Review of NCSA/Es l
Subtask No..
Description 1.1 Develop a list of NCSA/Es by facility. Assign l
reviews and schedule for completion.
1.2.
Develop review guidance for building personnel.
1.3 Perform training of building personnel, using the guidance developed in Subtask 1.2.
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s l.4 Perfonn reviews of NCSA/Es. Report completion to l
Nuclear Safety Manager.
1.5 Write Problem Reports for identified deficiencies.
1.6 Evaluate Problem Reports for reportability.
1.7 Develop corrective action to address deficiency identiGed in Problem Report.
1.8 Implement corrective actions.
(d)
Review _of3CSA/Es_ Completed _bylon-qualifiedlersonnel - It was i
determined that NCS engineers that were not properly qualified authored certain NCSA/Es. These NCSA/Es are being reevaluated by qualified NCS l
personnel. The plan for performing these reviews follows:
Task 2 Review of NCSA/Es Completed by Non-qualified Personnel l
SubtaskNo.
Description 2.1 Develop list ofindividuals who are not qualified.
2.2 Develop list of NCSA/Es that were anthored or peer l
reviewed by these individuals.
2.3 Write a review plan.
2.4 Assign review team (s),
j 2.3 Review NCSA/Es on the list against the guidance l
providt 1in the review plan. Document deficiencies in a Problem Report. The Problem Report system will be used to document and initiate the corrective actions for these deficiencies.
2.6 For NCSA/Es that have identified deficiencies, assign l
a qualified NCS engineer to correu problems.
- 2.7 Correct NCSA/Es, l
(e)
Reviemof EvenLReports - A focused review was performed of all event reports where either single or double contingency was lost. Each event was evaluated to ascertain what conditions remained which would have prevented a criticality. This review concluded that conservatisms built into the NCSA/E process were efTective in providing protection even under a loss of contingency situation.
2.
FMOs Shutdown FMOs such as cell treatment activities and those covered by NCSA/Es which were improperly altered by ens were either brought into compliance or stopped until compliance was achieved by either changing the requirements or changing the E2-3
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,e activity. In addition, FMos may be stopped as a result of the reviews performed under Task 2.
3.
Daily Review of Problem Reports A team of NCS personnel has been assembled to review Problem Reports, on a daily basis, to ensure that the proper immediate actions and reporting were taken. In addition, a flowchart for providing assistance to the PSS for NCS prs has been developed and is being used by NCS personnel in responding to requests from the PSS. The purpose of the flowchart is to ensure that the thought process for all NC5 engineers is consistent when responding to the PSS. Also, a two man rule for responding to NCS prs has been put into effect along with implementation of the Duty NCS engineer. These activities will be proceduralized.
C.
Root Cause Analysis Thme separate root cause evaluations of problem reports related to the NCS program have been, or are being, performed since the cell treatment NCSA/E problem was identified: 1) l l
an informal evabiation perfonned by the Nuclean Safety Manager; 2) a Taproot review on NCS Problen, depo.is from 1997 performed by the Corrective Action Program Manager; and
- 3) an ongoing Taproot evaluation on the 1997 NCS related Problem Reports intended to drive the individual root causes down to a Level 5 (specific) cause. These Problem Reports included deficiencies ider:tified in NRC Inspection Reports and Internal Assessment L
Findings. The details of each of the three evaluations follow, l
1.
Nuclear Safety Manager - This evaluation was performed to support the development of an initial corrective action program. Fou specific root causes were cited:
management systems failure; technical rigor in the development and implementation of NCSA/Es was inadequate; the Audit and Evaluation Process did not work to detect l
NCS problems; and the Standard, Policy, or Administrative Control (SPAC) governing the development of NCS A/Es was confusing or incomplete. These root I
causes were used tojustify the main thrust of the corrective action program which was described in USEC letter GDP-97-2030, dated November 10,1997.
2.
Corrective Action Program Manager - To provide a more detailed evaluation of the root causes, the Corrective Action Program Manager performed a formal Taproot root cause determination. Problem reporis written against the NCS program in 1997 were evaluated to detennine near root causes and then an aggregate set of those near root causes was evaluated. The near root causes were largely grouped into three main root cause focus arer.s: NCSA/E errors. 84, Procedure flowdown errors-95, and Failure to follow procedures-124. The aggregate set determination yielded three root causes:
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Errors in the NCSA/Es-Some NCSA/Es were determined to have technical a.
crrors which mad it diflicult to implement their requirements in the field, b.
Inadequate implementation-In some cases the requirements contained in the
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NCSA/Es were not adequately implemented in the field.
l Self assessment and internal corrective action processes were inadequate to c.
detect and correct the problems.
3.
Comprehensive Root Caus : Evaluation-In response to questions regarding assurance that all root causes have been identified and are being addressed in the corrective actian program, a third root cause evaluation was initiated. This Taproot evaluation was performed by a team consisting of the Nuclear Safety Manager (part time),
PORC chairman (part time), a Taproot process facilitator, and a number of individuals who were familiar with the details and history surrounding the Individual Problem reports theraselves. At a minimum, twe individuals plus the facilitator were g
presert for the evaluation of each Problem Report.
h The first step in this evaluation was to identify, in flow chart form, the process of development, review and approval, activation, and implementation of a typical NCSA/E. Each step in the process was assigned an identifying number. The l
Problem Reports were evaluated to a Level 4 "near root cause". Each Probler..
Report was also associated with a specific step number. The results are as follows:
Number of Pmblem Reports Step Nuniber Step Description Associated 1
Identification of Fissile Material Operation 5
2 Part A Preparea 28 3
Part B. Part C Prep ced 52 4
NCS Subcotamittee 1
5 PORC (approval of NCSA/E) 1 l
6 Procedure Development 18 7
Procedure Review Board 0
8 PORC (approval of procedures) 0 l
9 Verification Walkdown 28 10 Activation 1
11 Use (implementation) 113 12 Monthly Ops walkdown 1
13 Biennial NCS walkdown i
14 SelfAssessments 4
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,. t The above results were then evaluated against the Taproot list of root causes. For each Step, the basic root causes which clearly did not apply were eliminated and those which did, a
or could, apply were captured on a list of root causes to be treated. The result of this evaluation is a list of root causes sorted by process block number. This sort is shown in Table 1.
3' The root causes listed in attached Table I will be corrected as part of the NCS corrective action program.
Validation of the results of the root cause evaluation and other completion activities will be completed in accordance with Task 6 which is located in Section E of this plan.
D.
Interim NCSA/E Review Process l
While the longer term upgrades to the NCS administrative control p 2ss are identified, developed, and implemented, a number of enhancements will be added to the NCSA/E l
development, approval, and implementation process. They irclude:
S 1.
Enhanced Review Process (Murder Board)
To ensure that the NCSA/E development process is carried out properly, an l
additional review board has been added to enhance the PORC and subcommittees' review. This review board is referred to as the murder board and works in accordance with a fonnal chaner. The owner (operations) r.nd developer (NCS Engineer) are tasked with presenting drafted NCSA/Es in front of a board consisting l
of a minimum of ibur professionals representing Nuclear Safety, Operatioas, Mainterance, Work Control, or Safety, Safeguards and Quality whose task is ensuring inat aspects of the drall NCSA/E (e.g., assumptions, calculations, procedure l
steps) are correct. This satisfaction is created by obtaining the appropriate answers to questions from the board from the NCSA/E developer and/or owner. The murder l
board concept has been borrowed from the reactor industry where it has proven to be successful in improving the quality of final docu aents such as NCSA/Es. This l
addition to the existing process will improve the quality of the NCSA/Es and help the l
NCS and Proccdure Review Board subcommittees of the PORC improve the quality of their reviews. The Murder Board will be used until USEC is satisfied that the quality of NCSA/E development and review has reached an acceptable level.
I
- pry, Discontinuing the use of the Murder Board will not be considered until at least May 31,1998.
The Murder Board will review major revisions of NCSA/Es tnd new NCSA/Es. At I
the discretion of the Nuclear Safety Manager, minor changes to NCSA/Es will be l
excused from Murder Board review.
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2.
Involven:ent by Owners and Engineering As noted in the root cause results, the lack of ownership by the actual r sers (owners) of the NCSA/Es has been responsible for a large portion of the NCSA/E problems.
l This lack of ownership has contributed to the technical shortcomings of the NCSA/Es when proper support and reviews of dran NCSA/Es were not adequately l
performed, and contributed w a lack of understanding of the final NCSA/Es I
themselves, resulting in implementation deficiencies.
To correct this problem, representation by the implementing organization in the form of a management individual and a hands-on user (typically an hourly person), a System Engineer, and a NCS engiocer will be required on the team which develops the NCSA/E, supports its progress through the review and approval process, and l
performs the required plant walkdowns to verify the NCSA/E, This will help ensure I
the technical accuracy of the NCSA/E, ensure that any required actions can actually l
be physically accomplished, and that the procedures implementing NCSA/E actions l
are conect. It will also help ensure that the actual implementation in the field will be correct. (Note: Murder Board members cannot be used as members of the walkdown and review teams, llowever, members of the murder board will accompany the review teams on field walkdowns of selected NCSA/Es.)
l In addition, a review will be performed to verify all PORC approved NCSA/E's are l
being implemented or are in the process of being implemented in the field.
3.
Revise NCS Procedures In orde-to ensure the interim NCS administmive contrt i
. ire mplemented correctly and cc sistently, the procedures which provide the administrative controls will be revised to reflect the interim changes. Refer to Section E, Task 12 (NCS Policies and Procedures) for a discussion of the plan to implement these procedure revisions.
4.
Review /Walkdown NCSA/Es using the Prioritized List l
In parallel with activities to improve the NCS program, existing NCSA/Es will be i
subjected to the NCSA/E Upgrade Project on a prioritized basis. The list of l applicable NCSA/Es. by priority, was included in Enclosure 2 to USEC letter GDP l
97-0217 dated December 22,1997. This will ensure that high risk NCSA/Es are I
reviewed for technical adequacy and proper procedural flowdown and implementation as soon as practical.
As the long term programmatic improvements are implemented, NCSA/Es which l
have been subjected to the interim process will be evaluated to determine if they need to be reverified to ensure they reflect all program improvements. Once the NCS E2-7
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am improvements have been incorporated into procedures and site personnel trali..ag is complete, this new program will be used to finish the reviews and walkdowns on the remainder of the NCSA/Es. The plan for performing these reviews l
follows:
Task 3 NCSA/E Upgrade Project l
SubtaANo.
Subtask Description 3.1 Classify the NCSA/Es into three groups according to priority.
l 3.2 Verify that all PORC approved NCSA/Es are activated or l
progress toward activation is being accomplished.
s 3.3 Form review groups consisting of representatives from NCS, Systems Engineering, Operations Management, and a hands-on operator or maintenance technician, 3.4 Develop a procedure for the performance of reviews and walkdowns. Maintain procedure current through life of upgrade project.
3.5 Table top scrub NCSA/Es and their supporting documents l
l 3.6 Field walkdown all NCSA/Es.
l l
3.7 Ensure consistency with PGDP NCSA/Es for similar l
activities.
3.8 Accelerate processing ofidentitied changes to NCSA/Es and I
procedures.
3.9 Review and approve NCSA/E implementing procedure l
changes.
3.10 Walkdown PORC approved NCSA/Es to document their l
readiness for activation.
5.
Enhance NCSA/E Training l
In response to recent NCS events, the General Manager conducted all-hands briefings to communicate management's expectations regarding implementation of NCS controls. To further ensure that the interim NCSA/E Review process is implemented l
correctly, training will be provided to personnel who will use, or be affected by, the interim process. The plan for developing and imp;ementing this training follows:
Task 4 Enhance NCSA/E Training l
SubtaskRo.
SubtaskDescription l
4.1 Compile list of administrative controls document changes.
l 4.2 Identify target training audience by organization or job l
function l
4.3 Develop training module for each target group.
I 4.4 Administer training.
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In addition to the interim process training, training will be given as determined to be necessary to comn. micate such things as lessons leamed from the NCSA/E l
s walkdowns currer:tly being performed or other information determined to be important for all affected personnel to know. The exact nature of this training may vary from required reading, memos and e-mail messages to fermal classroom
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training, depending upon the nature and complexity of the subject matter.
6.
Safety, Safeguards and Quality (SS&Q) Review ofImplementatio:i As part of the ongoing self-assessment activities at PORTS, SS&Q will be tasked with monitoring the implementation of new NCSA/Es in the field. This monitoring l
will utilize ANSI /ASQC Zl.4, Sampling Procedures and Tables for Inspection by Attributes, for sampling guidance and is expected to take the form of a series of assessments that will begin as the NCSA/Es coming from the interim change process l
are implemented, currently scheduled for mid to late February. The plan fer implementing this review process follows:
Task 5 SS&Q Review ofImplementation Subtask.No.
Subtask. Description i
5.1 Develop list of NCSA/E changes from Task 3.
l 5.2 Write an Assessment Plan. The plan will include, in part, a sample review of NCSA/E requirements and verification of l 3
those requirements in the implementing procedures.
5.3 Schedule assessments as an extension of Subtask 3.10's schedule.
5.4 Perform assessments in accordance with applicable procedures 5.5 Complete a review of all canceled Engineering Notices to ensure that the Document Control Organization has functioned properly to make each controlled copyholder and each affected organization aware of the cance ed Engineering Notices and therefore the cancellation of that specific operation as defined by the Engineering Notice.
7.
Respanse to Anomalous NCS Conditions l
l To ensure consistency between the GDPs, PORTS is providing the following l
guidance to plant personnel as to the actions to take in tasponse to anomalous l
conditions regarding NCS controls:
I l
Activities in the immediate area will be stopped.
l The area will be secured.
l E2-9 aws
The supervisor of the person discove-ing the condition will be notified.
l The Plant Shin Superintendent (PSS) will be notified and will subsequently I
notify the NCS manager or the Duty NCS Engineer.
j
- An NCS Engineer will direct the recovery operation. (The NCS Engineer 1
along with the PSS will decide if the NCS Engineer should be present during l
the recovery operations.)
I l
These actions have been communicated via a standing order and training of all FMO l
personnel has been completed. These actions will also be incorporated into the l
appropriate procedure (s) by 2/11/98. These actions fulfill the requirements of 1 paragraph 7.6.4 of ANSI 8.20 - 1991 and of paragraph 5.2.2.2 of the Safety Analysis l
Report.
l 1
I S.
NCS Oversight l
1 NCS oversight will be prosided on the operating floors (one shift per day) by 2/2/98 l
to ensure continued heightened awareness of the ire ortance of NCS controls. This j
is a temporary measure which will remain in effect until USEC is assured that proper l
awareness has been achieved regarding NCS controls.
l E.
Programmatic Upgrades Task 6 Complete a Comprehensive Root Cause Analysis The problem reports (and other deficiency reports) that have been written during the past year have identified many deficiencies. These deficiencies when taken individually, or as groups of similar deficiencies, can be used to identify weaknesses in the program and/or its implementation. This task is intended to ensure that lessons have been learned from our known problems, and incorporated into corrective actions. Since part of the root cause aaalysis has been done, this task starts with the nc t action to complete this task. (For the completed actions see Section C Root Cause Analysis, of this plan.)
SubtasitNo.
Subtask Description 61 For each step of the NCSA/E process review a representative saniple I
of the prs associated with that step and identify the specific Level 5 root cause(s).
6.2 Verify that the root causes identified above are included in the summary level r:at causes which were identified by the root cause team. For those that are not, revise the root cause documentation, increase the sample size, and submit a lessons learned / enhancement in accordance with the procedure described in Task 9.
6.3 If the detailed review root causes are included in the summary level root causes, document the review.
E2-10 b
6.4 For each Level 5 root cause associaud with each step of the NCSA/E l
process,(See Table 1 attached) or assocised Management Systems, develop programmatic changes to correct root cause as part of this Corrective Action Plan for input to Task 12.
Task 7 Compare applicable Industry standards against NCS program To ensure that the NCS program complies with all applicable Industry standards, a detailed revie,v will be performed. This review will be point by point, and the product of the review will be a set of NCS administrative control changes to be implemcnted. The plan for this review follows:
I SubtaskRo.
Subtask. Description 7.1 Review applicable Indnstry standards.
7.2 Develop a list of applicable requirements.
7.3 Conipare requirement list to our NCS programmatic controls and develop a discrepancy list.
7.4 Evaluate discrepancies for need for immediate action, a Problem Report, or reportability.
7.5 Take any necessary immediate actions.
7.6 Evaluate discreparcies for need for interim action.
7.7 Develop and implement any laterim actions required.
7.8 Develop long term progr~ matic enhancements, for input to task 12.
Task 8 Vertical Slice Review To ensure that we have identified all potential arcas of enhancemt nt, an in-depth vertical slice review of the NCS program will be performed. The vertical slice review will be perfonned by a team coasisting of the NCS Managers from PORTS and PGDP and an outside expert in NCS. Using selected NCSA/Es, the review will identify any enhancements l
that could be implemented to improve the program. The vertical slice method is intended to look at all aspects of the NCS program from the initial identification of a potential Fissile Material Operation to the use of the NCSA/E in the field, including on-going assessments.
l The subtasks of this activity are shown below.
Suhtask30.
Subtask _ Description 8.1
/ ssemble the team for the vertical slice review.
8.2 bevelop a methodology for doing the review. The methodology shall l
cover:
selection of NCSA/Es to ensure that all aspects of the l
program are included in the review, E2-11 3
,. o selection of NCSA/Zs to ensure that all organizations aEccted by the NCS program are included in the review.
the methods to be used for the review, the documentatian to be provided as a rescit of the review, the methods to be used to initiate changes to the N 'S program (e.g., Procedure Development Forms.)
8.3 Conduct the vertical slice review of the program using each selected l
NCSA/E. (As each NCSA/E is completed, enhancements to the NCS l
{
program will be developed.)
8.4 Submit program enhancements to the Nuclear Safety Manager for inclusion in the continuous improvement mechanism for the NCS Corrective Action Plan. (See Task # 9).
Task 9 Continuous improvement Program i
Throughout the NCS Corrective Action Plan implementation, there will be a lessons leamed 1
program to ensure that lessons teamed arc documented, disseminand to the appropriate l
personnel, and incorporated into procedures, as applicable. Thdessons leamed program will l
ensure that the NCS program and implementation contimic to improve over time. Another i
major part of the lessons leamed program is ensuring that previously approved products are l
sufficient to ensure safety in light of the new lesson learned. Each lesson learned will be l
i reviewed to identify the effect on related NCSA/Es whether or not the respective NCSA/E l-has already been reviewed under the Corrective Action Plan. Lessons leamed that affect the l
l safety of approved Fissile Material Operations (FMOs) will be documented in a PR. The PR l
will then be used as the method to document the specific actions taken to ensure safety.
l SubtasLNo.
SubtasLDescription 9.1 Develop or revise a procedure applicable to all personnel involved in the NCS Corrective Action Plan implementation, that provides the guidance for documenting lessons learned and enhancement ideas.
The procedure shall cover:
use of a standard format.
a documented disposition for each lesson learned to identify how and when to incorporate the enhancement into the process.
A documented identification of the potential affect of the
-.ahancement on previous work performed under the NCS Corrective Action Plan.
Prir;ary users of the lessons learned / enhancement mechanism.
E2-12
9 6
llow the lessons learned will be shared with all affected organizations. Training will be utilized as necessary to ensure proper undeistanding of the lessons learned.
9.2 Implement the new procedure.
9.3 Track the disposition of each lesson teamed / enhancement idea to k
ensure that those agreed to by the Nuclear Safety Manarc are incorporated ioto the NCS program.
9.4 For those NCSA/Es that are affected by changes in the program due l
to lessons learned throughout the program, ensure that there is a positive control mechanism to track the need for a re-review to incorporate the lessons learned.
Task 10 Personnel QualiNation Verincation To ensure all PORTS NCS personnel qualification requirements meet applicable industry standards, a detailed review ofqualification requirements will be accomplished to verify their adequacy. Engineers not meeting upgraded standards will be retrained as necessary. The plan to tccomplish these reviews follows:
Subtask No.
SubtaskBescription 7
10.1 Review available qualification requirements in applicable industry guidance.
10.2 Compare guidance to existing administrative control procedures.
10.3 Resolve any identified discrepancies (revise procedures).
10.4 Compare qualification requirements to NCS engineers' records 10.5 Generate list of people to have upgrade qualifications.
10.6 Utilizing the new procedures, qualify individuals identified in step 10.5.
Task 11 Outside/ Independent Assessments As part of the etTort to identify potential areas ofimprovement, assessment reports performed by independent groups, e.g., George Bidinger, Quality Assurance and the Plant Performance Review Committee, etc., will be re-reviewed and re-evaluated to identify problem areas in the NCS program and to ensure proper closure of the issues. Additionally, NRC inspection reports will be evaluated for similar problem areas. Problems identified through this review will be considered for programmatic improvements. The plan for performing these reviews follow s:
E2-13
4 Subtask.No.
Subtask Description
< l 1.1 Identify reports that fall within the scope of this ta.ek.
I 1.2 Review each report and document potential problem areas.
I 1.3 Compare the list of prob:em areas with the list of known deficiencies identified through other means (e.g., comprehensive root cause, ANSI
]
reviews, etc.)
11.4 For those problem areas that were not documented under other tasks, identify potential programmatic improvements using the process established for feedback oflessons learned and enhancements, (See Task #9).
Task 12 Policy / Procedure Revision and Training The NCS program from beginning to end (each st.:p of the process) has had problem reports associated with it over the past year. The root cause evaluation has identified the problem reports from 1997 and the steps of the NCS program to which they are associated, in order to provide long term enhancemce to the NCS program and thereby ensure that the NCSA/Es and their implementation. is excellent, we plan to upgrade NCS policies and procedures.
As programmatic upgrades are identified, it is expected that a number of procedures and other administrative control documents will need to be changed. These changes will also have to be communicated to affected personnel through training. Changes will need to be coordinated to maximize efticient use of procedure and training resources. The plan to accomplish needed changes to policies / procedures follows:
SubtasLNo.
Subtask Description 12.1 Implement procedure changes for interim program as described in Section D.
12.2 Develop list of needed procedure changes, new procedures, from the applicable tasks.
12.3 Accomplish procedure changes (including requin t reviews).
12.4 Develop training modules.
12.5 Identify target audience for training.
12.6 Administer needed training.
12.7 Implement procedure changes.
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- e:
t=
Task 13 Revise Training Program for Si e Personnel One of the identified root causes for NCSA/E implementation problems was that the training -I on NCSA/Es was not effective. To address this, the overall training for NCSA/Es will be I
evaluated to identify impros ements which are needed. The plan to accomplish this review and upgrade follows:
Subtask _No.
Subtask. Description -
13.1-Evaluate results of prior training.
13.2 Develop a list of programmatic problems.
[
13.3 Perfonn a root cause evaluation on each identified prob em.
13.4
= identify actions to nddress root causes.
13.5-Incorporated improvements into the training administrative control process.
13.6 Upgrade training modules to reflect improvements.
13.7-Determine retraining required to reflect upgrades.
13.8 Administer required retraining using the revised program.
Task 14 -
Corrective Action Program Enhancemen;3
' As a result of the review of the current NCS program implementation deficiencies, it is apparent that many ot the existing problems hase been in existence for some time, (e.g.,
- there are 500+ problem reports related to NCS from 1997 ) Ifour corrective action program ~ -
was effective many, if not most. of the NCS problems should have been solved after their first appearance. While this ineffectiveness of the corrective action program for PORTS is applicable to areas other than NCS, the subtasks described below are intended to focus on the NCS related portions of the corrective action program.-
Subtask _No.-.
SubtasLDescription 14.1 Evaluate the PR procedure and form to determine what improvements are required to better document the following:
immediate actions taken.
actions taken to prevent recurrence, extent of condition evaluation, root cause determination, corrective actions taken, basis for safety and compliance with TSRs and NCSA/Es.
l 14.2 Ensure that the team assigned to determine the response to an NCS related PR includes a representative from the NCS organization.
14.3 All NCS prs should include an evaluation for the extent of condition of the problem on other activities and equipment.
E2-15
14.4 Evaluate the administrative system of the corrective action program, especially the status tracking and action response mechanism, to streamline the process so the reporting of completed actions arJ tracking of open items is less time intensive.
14.5 Enhance the corrective action program by implementing the l
improvement ideas.
l Task 15 Configuration Management Program Enhancements As changes are made to the NCS program, it is imperative that supporting design documents are changed appropriately to maintain : eir accuracy and consistency with one another. The plan Ihr effecting the needed changes to design documents follmvs:
Subtask.No.
Subtask Description 15.1 Develop program changes to ensure that engineering documents are maintained consistent with NCSA/Es.
l 15.2 Implement the new program requireme:.. :
Task 16 Revise Assessment Programs As part of the overall upgrade of our NCS program, evaluation of supporting programs will be done and any changes or improvements identified as necessary will be accomplished.
Among the most important of these programs is the assessment program. All of the various assessment processes will be reviewed for potential improvements. The plan to accomplish these reviews follows:
Subtask No.
Subtask Description 16.1 Develop criteria for assessment program reviews.
16.2 Review each assessment program against criteria.
16.3 List any identified problems.
16.4 Perform a root cause evaluation on each identified problem.
16.5 Develop list of root causes.
16.6 Develop corrective action plan for each program.
16.7 Train affected personnel 16.8 Implement upgraded assessment programs.
E2-16
Task 17 Oversight of Plan implementation.
i To provide assurance that the Corrective Action Plan is being implemented in accordance -
with management's expectations, SS&Q will perform bi monthly assessments, to verify
- proper implementation. The first assew.nent will be completed before the first quarterly review.
SubtaskEo.
Subtask _ Description 17.1-Develop assessment plan and schedule to be used to evaluate the efTectiveness of Corrective Action Plan implementation.
17.2 Perform assessments as defined in the assessment plan.
I F.
Schedule See Table 2.
G.
Evaluation and Feedback i
i
- As this Plan is implemented, adjustments to action scope, prioritization, and schedules may
}
' be required. At least each quarter, a fonnal review will be performed to assess the adequacy l
.and effectiveness of the program, included in this review will be an assessment of the L
existing schedule and the findings from the applicable SS&Q assessment addressed by. Task -
17.-
Task 18
. Evaluation and Feedback SubtasLRo.
Description 18.1 Gather pertinent status information.
18.2 Compare status with the respective Task requirement and schedule.
18.3:
Initiate any required corrective actions.
I 8.4 Factor in lessons learned through Task 9.
18.5 Report to management.
E2-17 l
a
Table 1. Root Cause by Process Block Number 1
2 3
4 5
6 7
8 9
10 11 12 13 14 I
No SPAC*
X X
X X
X l
SPAC not Strict Enough X
X Confusing or incomplete X
X X
X SPAC Technical error X
X X
X Procedure use not required but X.
X X
X X
X should be Procedure difficult to use X
Task not analyzed X
Accountability X
X X
Procedure facts wrong X
Training Lesson Plan X
X X
No way to implement SPAC i
' SPAC-Standards, Policies, or Administrative Controls NOTE: For NCSA/E process step names, refer to Section C.3.
[
E2-18
g
'l y
Table 2. Implementstion Schedule End Dates Task # -
Description Target Date 1
' Facility review of NCSA/Es 12/24/97 l
jg Review of NCSA/Es regarding qualifications -
2/28/98 l
L3 NCSA/Es Upgrade Project Pri 1 3/27/98 Pri 2 7/31/98 Pri 3 4/30/99 4
Enhance NCSA/E Training (Interim Process) 2/28/98 l
5 SS&Q Review ofimplementation Pri 1 4/27/98 Pri2 8/31/98 Pri3 5/31/99 6
Complete Comprehensive Root Cause Analysis 2/28/98 7
Compare applicable industry standards against NCS Program 1/31/98 8
Vertical Slice P.eview 3/31/98 9
Continuous improvement Program
.1/31/98 10 Personnel Qualification Verification 3/31/98 11 Outside/ Independent Assessments 4/30/98 12 P61 icy /Procedura Revision and Training 12/31/98 13 Revise Training Program t~ r Site Personnel 4/30/98 o
(Subtask 13.5) 14 Corrective Action Program Enhancements 6/30/98 i
15 Configuration Management Program Enhancements 2/28/98
-16 Revise Assessment Programs 3/31/98 17 Oversight of Plan Implementation 4/30/99
--- (bi-monthly) 18-Evaluation and feedback Quarterly starting on 1/31/98
-19 Evaluate continued use of Murder Board Not before 5/31/98 D.7 incorporate Response to Anomalous NCS Conditions into 2/11/98 Procedure (s).
D.8 Provide NCS Oversight on Operating Floors 2/2/98 E2-19
_ _ _ _ _