ML20207A308

Forwards Response to Impep Questionnaire,Per 990205 Request. Copy of Regional Procedure 0517A, Mgt of Allegations, & Mgt Info Status Rept Covering Period Through 990131 to Suppl Responses to Impep Questionnaire Encl

ML20207A308
Person / Time
Issue date:	03/01/1999
From:	Dyer J NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
To:	Paperiello C NRC OFFICE OF NUCLEAR MATERIAL SAFETY & SAFEGUARDS (NMSS)
Shared Package
ML20207A262	List: ML20207A258 ML20207A296 ML20207A308 ML20207A317
References
NUDOCS 9905260260
Download: ML20207A308 (119)

Text

I L i UNITED STATES

1. 1. km KEtug'o,, NUCLEAR REGULATORY COMMISSION 8h 7 REGION 111

{ j e

801 WARRENVILLE ROAD LISLE, ILLINOIS 60532-4351

%*****/ March 1, 1999 MEMORANDUM TO: Carl J. Paperiello, Director, NMSS FROM: James E. Dyer, Regional Administrator hfff g4/

SUBJECT:

INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM REVIEW - COMPLETED QUESTIONNAIRE As requested in your February 5,1999 memorandum, Region til has prepared the attached response to the Integrated Materials Performance Evaluation Program (IMPEP) questionnaire. In addition, we have attached a copy of Regional Procedure 0517A,

" Management of Allegations," and the Management Information Status Report covering the period through January 31,1999, to supplement the responses to the IMPEP questionnaire.

Attachments: As stated (3)

/

cc w/atts: D. Cool, NMSS S. Moore, NMSS CONTACT: Monte Phillips, DNMS 630/829-9806 9905260260 990519 PDR ORG NOMA PDR J

INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM OUESTIONNAIRE RESULTS REGION ll1 REPORTING PERIOD: MARCH 1997 TO PRESENT A. COMMON PERFORMANCE INDICATORS j

l. Status of Materials insoection Proaram

1. Please prepare a table identifying the licenses with inspections that are overdue by more than 25% of the scheduled frequency set out in NRC Inspection Manual Chapter 2800. The list should include initial inspections that are overdue.  ;

l Insp. Frequency j Licensee Name (Years) Due Date Months O/D  !

l Region 111 currently has no overdue inspections that exceed the 25 percent scheduling frequency set out in NRC Inspection Manual Chapter (MC) 2800 after having been extended / reduced based on performance. In addition, j there sre no overdue initial inspections.

2. Do you currently have an action plan for completing overdue inspections? If so, please describe the plan or provide a written copy with your response to this questionnaire.

Not applicable.

3. Please identify individual licensees or groups of licensees the State / Region is inspecting more or less frequently than called for in NRC Inspection Manual Chapter 2800 and stata the reason for the change.

l Routine inspections are currently performed in accordance with MC 2800, j including the option for extending for good performance or reducing for poor performance the inspection frequency. This approach is part of the manual chapter, as specified in Section 05.01. Followup inspections for escalated enforcement cases are routinely scheduled within 6 months of the exit date for the inspection that identifies the escalated enforcement item. This is assured through assignment into the action item tracking system (AITS) for the conduct of the followup inspection. In addition, Region lli continues to implement its broadscope inspection initiative. 4 Through this initiative, major broadscope licensees are visited more frequently than specified in MC 2800 to allow for performance-based inspections of limited scope of activities in progress, with the intent being that over an entire MC 2800 inspection cycle, the full scope of inspection activities would be completed. Otherwise, Region lli does not have any other specific licensees or groups of licensees which are routinelv inspected less frequently than dictated in the manual chapter.

4. Please complete the following table for licensees granted reciprocity during the reporting period.

Number of Licensees Number of Granted Reciprocity Licensees Priority Permits Each Year Inspected Each Year Service licensees CY97-1 CY97-1 performing CY98 - 0 CY98-O teletherapy and irradiator source installations or changes CY97 - 3 CY97-1*

1 CY98 - 3 CY98 - 1

• CY97-0 CY97-0 2 CY98 - 0 CY98 - 0 CY97 - 5 CY97-2 3 CY98 - 4 CY98 - 1

• There are no priority 4 4 licensees CY97 - 6 CY97-1 All Other CY98 - 8 CY98 - 0*

t Reciprocity assist requests CY97 - 9 from other Regions N/A CY98 - 0

• - Note that this does not meet MC 1200 inspection frequencies. This was identified by the Region during one of its self-assessments. Corrective actions are in progress.

S. Other than reciprocity licensees, how many field inspections of radiographers were performed?

Region ill performed 13 field inspections of radiographers in 1997 and 14 field inspections of radiographers in 1998.

6. For NRC Regions, did you establish numerical goals for the number of inspections to be performed during this review period? If so, please describe your goals, the number of inspections actually performed, and the reasons for any differences between the goals and the actual number of inspections performed.

Region lli established numerical inspection targets to coincide with the number used in the budget formulation process. These were not used as numerical goals as NMSS had specified that no numerical goals were 2

required. For FY 97 and FY 98 the target number was 680. In actuality, we completed 675 inspections in FY 97, and 682 inspections in FY 98.

We have subsequently included as a quantity metric in the Region lli operating plan the total number of inspections due during the fiscal year (the budgeted number is 630). Through the second quarter of FY 99, the number due was 118 in the first quarter, and 118 due in the second quarter.

We completed 127 inspections during the first quarter of FY 99, and 65 inspections through the first month of the second quarter of FY 99.

it. Technical Quality of Insoections

7. What, if any, changes were made to your written inspection procedures during the reporting period?

In addition to the inspection procedures delineated in the NRC Inspection Manual Chapters and Management Directives that were revised (such as MC 87), the Region also maintains regional procedures that closely parallel many agency procedures, such as handling of allegations, communications with outside agencies, etc. These procedures are routinely reviewed on a two-year frequency and modified as necessary.

Regional procedures that have been modified since the last IMPEP are as follows:

RP 0238, " Inspector Objectivity," revised 1/16/97 RPO400F, " Notice of Enforcement Discretion," revised 6/1/98 RPO400K, "Non-cited Violations," issued on 12/30/98 RP 0517A," Management of Allegations," revised 3/5/98 RP 0518, " Handling Fitness-for-Duty Matters," revised 3/11/98 ,

RP 0610A, " Inspection Reports," revised 9/29/97 l RP 0615, " Augmented inspection Team Reports," revised 1/7/98 l RP 0721, " Processing 10 CFR Part 21 Reports," revised 4/2/98 RP 0725, " Recommending Third party Assistance to Licensees," revised 11/3/97 RP 0961," Release of Draft NRC Reports and Other Documents," revised 11/3/97 RP 1204, " Assignment of Inspection Responsibilities," revised 6/6/97 RP 1209, " Team inspections," revised 5/13/97 3

in addition to this process, the regional DNMS Inspection staff conducts a quarterly assessment of Inspection-related activities. Out of these assessments, " lessons learned" documents are generated, if necessary, and forwarded to the inspection staff for implementation. Divisional procedures or " lessons learned" developed and implemented during this assessment period were as follows: " Lessons Learned from Recent Escalated Enforcement Cases," " Materials inspection Assessment -

Extension and Reduction of Inspection Frequencies," " Lessons Learned from the Suspension of the Black Rock, Inc., License," " Major issue:

Lessons Learned from LaFarge Inspection Effort," " Transmittal of Results of Materials inspection (Medical Events) and Lessons Learned," " Major issue: Lessons Learned from University of Michigan Allegation Response," " Lessons Learned - Contested Enforcement Cases,"

" Assessment of Reciprocity Program," and " Review of Misadministration / Medical Event Followup Inspections."

8. Prepare a table showing the number and types of supervisory accompaniments made during the review period. Include:

Inspector (s) Supervisor kicense Cateaorles pale l Nelson Jorgensen Contaminated Site 3/7/97 Hays Phillips Teletherapy, Radiopharmacy, Med w/QMP 3/19-21/97 Slawinski Madera Med with QMP 3/20-21/97 House Jorgensen License Termination 4/28-5/1/97 Kulzer/ Lee Jorgensen Contaminated Site 5/13-14/97 Kock / Cameron Phillips General Licensee, Man. & Dist. Broad. 5/23/97 Kock / Young Phillips Port. Gauge, Radiography, Med w/QMP 7/23-25/97 Landsman Jorgensen Decommissioning Power Reactor 8/26/97 Kulzer/ Lee Jorgensen Contaminated Site 9/10-11/97 Gattone . Madera Fixed Gauge 9/17/97 Kulzer/ Lee Jorgensen Contaminated Site 10/10-11/97 Landsman Jorgensen ISFSI 11/12/97 Snell Jorgensen Decommissioning Power Reactor 11/12/97 Nelson Jorgensen Contaminated Site 12/18/97 Weber Madera Contaminated Site & Storage 12/5/97 Cameron / Kock Wright Man. & Dist. Broadscope 1/12-16/98 Leemon Jorgensen Decommissioning Power Reactor 1/20-23/98 Jones Wright Medical Broadscope 2/17-19/98 I Mitchell Wright Academic / Medical Broadscope 3/2-3/98 Cameron Wright . Academic Broadscope 3/4/98 i Wiedeman Madera . Medical Broadscope 3/26-27/98 Young Wright Academic / Medical Broadscope 4/1/98 McCann Jorgensen Contaminated Site. 4/8-10/98 Leemon Jorgensen Decommissioning Power Reactor 4/19-21/98 I House' - Jorgensen ' Decommissioning Power Reactor 4/22/98 l Parker Madera Port. Gauge, Med w/o QMP, Storage only 4/20-24/98 Mulay Wright in-Vitro lab, Med. & Academic Broad 4/30/98 Nelson / Landsman Jorgensen- Decommissioning Power Reactor 5/13/98 Null Madera Lost Source Potential Disposal Site 5/18/98 1 4 l

Inspector (s) Supervisor License Cateaories Date Null Madera Academic Broadscope 5/22/98 Young Wright Port. Gauge 6/22-23/98 Kock Wright Port. Gauge, Med w/o QMP 7/15-16/98 Nelson Jorgensen Contaminated Site 7/16/98 Landsman Jorgensen ISFSl 7/21-22/98 Go Madera Portable Gauge 7/27-28/98 LaFranzo Madera Radiography 7/29/98 Piskura Madera Med w/QMP & HDR 7/30/98 Leemon Jorgensen Decommissioning Power Reactor 8/12-14/98 Gattone Madera Port. Gauge, Med. w/QMP 8/24-25/98 McCann Jorgensen Contaminated site 8/31-9/1/98 Landsmen Jorgensen ISFSI 9/4/98 Cameron Wright Radiography 9/8/98 House Jorgensen Decommissioning Power Reactor 9/17-18/98 Wiedeman Madera Academic / Medical Broadscope 9/28/98 Mulay Wright Fixed Gauge, Med w/QMP 9/28-29/98 Kulzer/ Lee Jorgensen Contaminated site 9/29/98 Leemon Jorgensen Decommissioning Power Reactor 9/30/98 Leemon Jorgensen Decommissioning Power Reactor 11/13-14/98 McCann/ House Jorgensen Contaminated site . 12/15/98 Leemon Jorgensen Decommissioning Power Reactor 1/12-13/99 House Jorgensen Decommissioning Power Reactor 1/21/99 NOTE: With the exception of Mr. Hays and Ms. Piskura, all inspectors were j accompanied by a branch chief on at least one occasion during both FY 97 and FY 98. l Mr. Hays' inspection performance was observed and assessed on several inspections by two GG-14 senior inspectors during FY 98. Ms. Piskura was transferred to licensing in the middle of FY 97, so no accompaniment was conducted.

9. Describe internal procedures for conducting supervisory accompaniments of inspectors in the field. If supervisory accompaniments were documented, please ,

provide copies of the documentation for each accompaniment.

Supervisory accompaniment of Inspectors is performed in accordance with Regional Procedure 0316, dated November 13,1996. This procedure gives the division director the authority to establish processes for branch chief site visits and documentation. DNMS management's expectation has been that each branch chief is to accompany each inspector at least twice per year, with one of these accompaniments being one-on-one (inspector /

branch chief only). The expectation to document accompaniments was only recently implemented, specifically, DNMS management has requested that branch chief's complete an Inspector / Reviewer Assessment Form upon completion of each accompaniment beginning in July 1998.

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10. Describe or provide an update on your instrumentation and methods of l calibration. Are all instruments properly calibrated at the present time? )

l Fixed laboratory primary instruments (gamma spectroscopy, liquid scintillation and proportional counter) are calibrated annually and after any >

major modifications or repairs which could affect their calibrated status.

Approved laboratory procedures have been prepared to address calibration of each system and these procedures are available for auditor review.

Traceable calibration standards are used. In late 1998, the laboratory was removed from service temporarily for installation of a new gamma spectroscopic system and to accomplish procedure upgrades and other QA/QC program formalization. Each system was calibrated to support laboratory reactivation in December 1998, and all systems are properly calibrated at the present time.

The mobile laboratory is presently out of service for repairs to the detector. l it will be calibrated prior to return to service with newly procured I electronics and software. A draft calibration procedure will be exercised, under the oversight of a vendor representative, to accomplish the calibration and to identify any needed procedure enhancements before j issuance as a final, approved procedure.  !

Portable instruments are calibrated by a certified contractor, with laboratory calibrations conducted in accordance with our laboratory I procedures. Details are maintained in an ACCESS database maintained by  !

the laboratory staff. There has been no change in portable instrumentation since the last IMPEP.

Ill. Technical Staffina and Trainina  ;

11. Please provide a staffing plan, or complete a listing using the suggested format below, of the professional (technical) person-years of effort applied to the agreement or radioactive material program by individual. Include the name, position, and, for Agreement States, the fraction of time spent in the following areas: administration, materials licensing & compliance, emergency response, LLW, U-mills, other. If these regulatory responsibilities are divided between offices, the table should be consolidated to include all personnel contributing to the radioactive materials program. Include all vacancies and identify all senior personnel assigned to monitor work of junior personnel, if consultants were used to carry out the program's radioactive materials responsibilities, include their efforts. The table heading should be:

Name Position Area of Effort FTE%

G.Bonano Lab Operations Spec. Laboratory 100 J. Cameron Sr. Radiation Spec, inspection 100 C. Casey Health Physicist Licensing 100 C. Frazier Sr. Health Physicist Licensing 100 R. Gattone Radiation Specialist inspection 100 C. Gill Sr. Health Physicist Licensing 100 6

Name Position Area of Effort FTE%

T.Go Radiation Specialist inspection 100 R. Hays Radiation Specialist inspection 100 J. House Sr. Radiation Spec. Lab /Decom. Insp. 90/10 L. Hueter Health Physicist Licensing 100 l J. Jones Sr. Radiation Spec. Inspection 100 E. Kulzer Radiation Specialist Decom. Insp. 100 M. LaFranzo Radiation Specialist inspection 100 R. Landsman Project Engineer ISFSI/ Dry Cask Insp. 100 P. Lee Radiation Specialist Lab /Decom. Insp. 20/80 R. Leemon Rx Decom. Insp. Rx Decom. Insp. 100 1 M. McCann Sr. Radiation Spec. Project Mgmt. 100 S. Mulay Radiation Specialist inspection 100 J. Mullauer Health Physicist Licensing 100 D. Nelson Radiation Specialist Decom. Insp. 100 K. Null Sr. Radiation Spec. Inspection 100 G. Parker Radiation Specialist inspection 100 P. Pelke Health Physicist Licensing 50 D. Piskura Radiation Specialist inspection 100 W. Reichhold Health Physicist Licensing 50 W. Snell Health Physics Mgr. Lab /Proj. Mgmt. 50/50 l G. Watson Health Physicist Licensing 100 M. Weber Health Physicist Licensing /AMS Insp. 50/50 l D. Wiedeman Sr. Radiation Spec. Inspection 100 T. Young Radiation Specialist inspection 100 Region 111 has no vacancies, and consultants were not used to carry out any program responsibilities.

12. Please provide a listing of all new professional personnel hired since the last review, indicate the degree (s) they received, if applicable, and additional training and years of experience in health physics, or other disciplines, if appropriate.

No new professional personnel have been hired since the last review.

13. Please list all professional staff who have not yet met the qualification requirements of license reviewer / materials inspection staff (for NRC, inspection Manual Chapters 1246; for Agreement States, please describe your qualifications requirements for materials license reviewers and inspectors). For each, list the courses or equivalent training / experience they need to attend and a tentative schedule for completion of these requirements.

Qualification requirements for material inspectors are specified in MC 1246, Section 11. All Region 111 inspectors have completed the training requirements specified in MC 1246, Section 11, except for the following:

Kevin Null is scheduled to take the next scheduled " Inspecting for Performance" (H-304) cours.e. D. Wiedeman and/or J. Jones will attend the next scheduled " Health Physics Technology" (H-201) course. Of note, the requirement to attend the H-201 course resulted from the last issuance of 7

MC 1246. Prior to that time, inspectors could be grandfathered out of the course based on a recommendation from the branch and approval by the Regional Administrator. The two individuals remaining to take the H-201 course had been previously grandfathered. However, Region lil DNMS has elected not to exempt any inspectors from the H-201 course based on MC 1246. Region lil is and continues to be supportive of the H-201 course.

Qualification requirements for materials license reviewers are specified in MC 1246, Section 1. All Region 111 license reviewers have completed all of the training requirements specified in MC 1246, Section i except for the following: Cassandra Frazier, Gidget Watson, and Bill Reichhold have not yet completed the H-201 course. Prior to October 1996 all reviewers had been waived from this course; however, DNMS has decided that all reviewers will complete the course, if possible, by the end of calendar year 2000.

In addition to meeting the qualification recNirements of MC 1246, Region 111 also requires that each reviewer have sir, nature authority for a given category of license prior to independently signing a licensing action in that category. All reviewers have signature authority for medical, gauges, and ARDL (academic, research and development) licenses. In addition, most reviewers have signature authority for broad scopes, radiography, and teletherapy licenses. Reviewers obtain signature authority by completing a major amendment or renewal action for a given category under the subsequent review of an individual who has signature authority for that category. If the license action is completed without any errors, the reviewer is granted signature authority for that category.

14. Please identify the technical staff who left the RCP/ Regional DNMS program during this period.

Andrea Kock, Wayne Slawinski, and Mark Mitchell transferred to the Division of Reactor Safety. Toye Simmons transferred to the E:sforcement and investigations Coordination Staff. Pat Vacherion accepted a job in NMSS.

15. List the vacant positions in each program, the length of time each position has been vacant, and a brief summary of efforts to fill the vacancy.

As noted in our response to question 11, there are no vacan1 materials technical or administrative positions.

IV. Technical Quality of Licensina Actions

16. Please identify any major, unusual, or complex licenses which were issued, received a major amendment, were terminated, decommissioned, submitted a bankruptcy notification or renewed in this period. Also identify any new or amended licenses that now require emergency plans.

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Unusual or complex licensing actions reviewed and issued during the reporting period include, but are not limited to, the following:

Advanced Medical Systems. Inc. 34-19098-01: Licerise renewal denied due to inadequate decommissioning financial assurance.

Washinaton University. 24-00167-11: Renewal requiring a major consolidation of various licenses and revamping of the HDR program under the new guidance.

Zeneca AG Products. 04-26799-01: New license issued authorizing field studies using Carbon-14 to study the migration of radioisotopes.

Industrial and Research Measurements Systemc. Inc. 34-18214-01: New l license issued for Type A Broad Scope Manufacturing and Distribution program.

Indiana University and Medical Center.12-02752-08: Washinaton University and Medical Center. 24-00167-11: University Hospitals of Cleveland. 34-05469-01 and Ohio State University. 34-00293-02: Amendment issued granting the licensee authorization to use cobalt-60 sources in a Gamma Knife unit.

Cleveland Clinic Foundation. 34-00466-05: New license issued granting the licensee authorization to use cobalt-60 sources in a Gamma Knife Unit.

Curators of The University of Missouri. 24-00513-3t Amendment requesting several changes, including adding a new Rad Waste Building (approved); disposal of incinerator ash (approved); receipt of analytical samples (approved); approval to allow exempt sources received from licensees to remain exempt (approved); change in the release criteria for ,

patient animals (approved); and approval to utilize Tc-99m in diagnostic procedures performed on patient animals which are considered food animals (not approved- pending a request for additional information).

(Partial TAR)

17. Discuss any variances in licensing policies and procedures or exemptions from the regulations granted during the review period.

For the period April 1997 to March 1999, Region 111 submitted over 44 requests for technical assistance to NMSS. We do not deviate from licensing policies and procedures without first coordinating with NMSS.

A number of TARS that we submitted involved licensee requests for exemptions to the regulations; however, in almost all cases, the outcome was to not grant the exemption and to have the licensee agree to void the action rather than go through a formal denial. Examples of variances in licensing polices and procedures or exemptions from the regulations that were granted, subsequent to NMSS approval include, but are not limited to:

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l Maximum Technolooles. 22-01376-02: Licensee requested an interpretation of 10 CFR 34.41, two-person rule.

I St. John's Realonal Medical Center: License amended to reflect a joint venture to license a second, different corporation under the hospital's license.

Christ Hospital. 34-03831-02: Riverside Methodist Hospital. 34-01055-01:

and St. Vincent Hospital.13-00133-02: Amendment issued to authorize the licensees the use of Ir-192 seeds encased in nylon ribbon for intralumenal and intravascular brachytherapy.

University of Cincinnatl. 34-32001-01 Amendment issued authorizing the licensee to use a Capintec, Inc., " Beta C" beta counter dose calibrator.

18. What, if any, changes were made in your written licenaing procedures (new procedures, updates, policy memoranda, etc.) during the reporting peried?

All licensing reviews were conducted in accordar.ce with NRC Policy &

Guidance Directives and the recently-issued final volumes of NUREG-1556 as they pertained to specific classes of licenseos. These changes were in accordance with the requirements issued by NM9S. In addition, the Region also adopted a computer assisted licensing process, utilizing the computer to more efficiently generate and issue all licenses. This process was implemented the beginning of April 1998, greatly improving the efficiency of issuing licenses. Licensing staff conducted self-assessments of the quality assurance program for license issuance, licensing correspondence, and financial assurance records. Out of these assessments, " lessons learned" documents were generated. Divisional or Branch procedures developed and implemented during this assessment period were as follows: " Branch Procedure for Quality Assurance Program Team Review." in addition, the recommendations from the two other self- .

assessments were implemented, although a specific divisional or branch I procedure was not issued.  !

19. For NRC Regions, identify by licensee name, license number and type, any j renewal applications that have been pending for one year or more.

There are two renewal applications that have been pending for one year or more as of February 28,1999.

Date Actions to be Received Licensee License No. License Type Completed 9/26/97 Dowelanco 13-26398-01 Type A R&D Awaiting licensee's LLC broadscope response to deficiencies 10

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l Data Actions to be Received Licensee License No. License Type Completed l l

9/20/94- Battelle SNM-007 Everything - source Awaiting submittal of I Columbus material, critical an acceptable Labs mass special nuclear financial assurance material, type A R&D instrument from broadscope licensee NOTE: Battelle review complete except for obtaining a satisfactory financial assurance instrument (FAI). Several FAls have been submitted, reviewed by NMSS, and subsequently returned to licensee as deficient.

Dowelanco review has been delayed due to several extended vacations ,

by RSO resulting in extended response times for deficiencies and I delayed initiation of review.

V. Responses to Incidents and Alleaations

20. Please provide a list of the reportable incidents (i.e., medical misadministration, overexposures, lost and abandoned sources, incidents requiring 24 hour2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> or less notification, etc. See Handbook on Nuclear Material Event Reporting in Agreement States for additional guidance.) that occurred in the Region / State during the review period. For Agreement States, information included in previous submittals to NRC need not be repeated (i.e., those submitted under OMB clearance number 3150-0178, Nuclear Material Events Database). The list ,

should be in the following format: 1 The following is a list of event notifications received by Region lil's nWy ,

officer that DID NOT involve nuclear criticality safety violations, classified i mat

• rial loss, loss of control of classified material, safeguards violations, l cffslie notification events, or Bulletin 91-01 events for the Gaseous  ;

E iffusion Plants. Also not included are events at decommissioned  !

reactors that still have fuel on site. In the future, we would recommend this question be deleted from the IMPEP questionnaire, or modified to only request a listing of incident reports that were not reported to the NRC's Operations Center and assigned an Event Number.

Date of Licensee Name License No. Incident Type of incident Army-ACALA-Ft, Drum 12-00722-06 02/28/97 H-3 contamination event Paducah GDP GDP-1 03/04/97 Redundant equipment inop Paducah GDP GDP-1 03/05/97 Safety System Actuation Marion Steel Company 34-21123-01 03/10/97 Sealed source found in middle of site road reading > 200 mr/hr Gunderson Clinic 48-01277-02 03/06/97 l-131 underdose misadministration 11

Date of Licensee Name License No. Incident Type of incident Paducah GDP GDP-1 03/14/97 Stress corrosion cracking of cylinder packing nuts Paducah GDP GDP-1 03/18/97 2 of 3 criticality detection systems inoperable Paducah GDP GDP-1 03/18/97 Fire sprinklers obstructed Army-ACALA-Ft. Lewis 12-00722-13 03/13/97 Lost Americium-241 source Paducah GDP GDP-1 03/19/97 Fire sprinkler system inoperable Army-ACALA-Ft. Devons 12-00722-06 03/21/97 Worker and ares contaminailon e Paducah GDP GDP-1 03/22/97 Fire sprinkler system had obstructions and heads installed incorrectly Portsmouth GDP GDP-2 03/24/97 Small UF6 release from X-330 bldg Victoreen, Inc. 34-25957-01 04/15/96 Part 21 concerning radiation survey instruments - resistors could crack Paducah GDP GDP-1 03/26/97 High pressure fire water system in bldg. C-331 declared inoperable PaduChh GDP GDP-1 03/27/97 UF6 release detection & isolation system declared inoperable Paducah GDP GDP-1 04/03/97 Branch line of HP fire system disconnected in bldg. C-333 Portsmouth GDP GDP-2 04/03/97 Automatic isolation of autoclave Portsmouth GDP GDP-2 04/07/97 Top enrichment exceeded license limit Portsmouth GDP GDP 2 04/09/97 Surveillance requirements for HP fire system not met Portsmouth GDP GDP 2 04/09/97 High level alarm in autoclave Paducah GDP GDP-1 04/09/97 Fire sprinkler systems declared inop Paducah GDP GDP-1 04/09/97 Valid actuation of water inventory control system Paducah GDP GDP-1 04/14/97 Branch line of HP fire system discennected in Bldg. C-337 Army-ACALA-Ft. Riley 12-00722-13 04/14/97 Leaking Am-241 source with potential personnel contamination Army-ACALA-Aberdeen, 12-00722-06 04/14/97 Instructor contaminated while i MD improperly removing sources 12

Date of Licensee Name License No. Incident Type of incident Army-ACALA-Ft. Polk 12-00722-06 04/08/97 Broken H-3 source Paducah GDP GDP-1 04/15/97 Branch lines of fire water system not l connected in Bldgs. C-333 & C-337 l Paducah GDP GDP-1 04/16/97 Fire water system not connected in Bldgs. C-331 & C-337 Ohio State University 34-00293-02 03/28/97 Missing P-32 shipment  :

Paducah GDP GDP-1 04/21/97 Condensate alarm due to faulty probe  !

Steelastic Company, LLC General Lic. 04/22/97 Missing gauge containing Am-241 Army-ACALA-Europe 12-00722-13 04/22/97 Lost 2,184 AM-241 sources and

& -14 319 Ni-63 sources Paducah GDP GDP-1 04/23/97 Actuation of Q safety system due to valid signal Paducah GDP GDP-1 04/23/97 Sprinkle system deficiencies Army-ACALA-Ft. Devons, 12-00722-06 04/24/97 Broken & missing H-3 sources at Ft. Riley, & Aberdeen, MD various bases Paducah GDP GDP-1 04/25/97 Sprinkler system deficiencies Paducah GDP GDP 1 04/24/97 Autoclave declared inoperable Paducah GDP GDP-1 04/26/97 Sprinkler system deficiencies in Bldgs. C-315 and C-337 Paducah GDP GDP-1 04/30/97 Sprinkler system deficiencies in Bldg. C-315 i

Theda Clark Hospital 48-09494-01 12/20/96 Medical underdose misadministration Paducah GDP GDP-1 05/01/97 Installed actuators on autoclaves underrated (40 psi vs 80. psi)

Paducah GDP GDP-1 05/01/97 Sprinkler system deficiencies in Bldg. C-331  ;

Paducah GDP GDP-1 05/05/97 UF6 release in building C-337 Paducah GDP GDP-1 05/04/97 Sprinkler system deficiencies in i Bldg. C-315 l Army-ACALA-Ft. Stewart 12-00722-06 05/05/97 H-3 source found in a landfill j Syncor/ Washington Univ. 24-00167-11 05/06/97 Contaminated package received from Wash. University 13 1

Date of Licensee Name License No. Incident Type of incident Community Hospital of 13-06009-01 05/12/97 Medical underdose misadministration Indianapolis,IN Portsmouth GDP GDP-2 05/13/97 Autoclave declared inoperable Mallinckrodt 24-04206-01 05/14/97 Hand overexposure event Anheuser Busch. Inc. General Lic. 05/16/97 Lost two Am-241 sources Portsmouth GDP GDP-2 05/18/97 Autoclave declared inoperable Army-ACALA.-Ft. Hood 12-00722-14 05/20/97 Lost Ni-63 source Portsmouth GDP GDP-2 05/19/97 Inadvertent deactivation of smoke detectors Bureau of Mines 22-19667-01 05/22/97 Five Kr-85 smoke detectors missing Toledo Hospital 34-01710-05 05/22/97 l-125 seed inadvertently sent to landfill Paducah GDP GDP-1 05/22/97 Alarm inaudible in C-310 building Portsmouth GDP GDP-2 05/23/97 Autoclave isolated due to high pressure U. S. Steel General Lic. 05/24/97 Damaged Am-241 thickness gauge Private residence NONE 05/27/97 Source found in basement of home Columbia Hospital 48-02417-01 05/29/97 Medical underdose misadministration Paducah GDP GDP-1 05/30/97 Cascade cell trip function inadvertently turned off Portsmouth GDP GDP-2 06/01/97 Steam shutdown of autoclave during heating of cylinder Marquette General Hospital 21-05432-04 06/02/97 Medical underdose & wrong treatment site misadministration Portsmouth GDP GDP-2 04/07/97 Part 21 on lifting lugs for UF6 cylinders Portsmouth GDP GDP-2 06/10/97 Steam shutdown of autoclave during heating of cylinder Paducah GDP GDP-1 06/15/97 Inop. UF6 release detection system Portsmouth GDP GDP-2 06/24/97 Part 21 concerning computer software error for crane analyses program Paducah GDP GDP-1 07/01/97 Loss of C-310 criticality accident l alarm system i 14

Date of Licensee Name License No. Incident Type of incident Conam inspection Services 12-1659-01 02/27/96 Radiography overexposure

• Paducah GDP GDP-1 07/13/97 Alarm inaudible in C-310 building Army-ACALA-Ft. Irwin 12-00722-13 07/15/97 Lost Am-241 source Paducah GDP GDP-1 07/14/97 Autoclave steem isolation Missouri DOT 24-20415-01 07/17/97 Troxler gauge involved in traffic accident - gauge not damaged Portsmouth GDP GDP-2 07/21/97 Steam shutdown of autoclave during heating of cylinder Bowser-Morner, Inc. 34-17390-01 07/25/97 Stolen Troxler gauge Michigan DOT 21-03039-01 08/01/97 Two gauges damaged Paducah GDP GDP-1 07/10/97 Automatic actuation of crane hoist brake Middletown Regional Hosp. 34-08279-02 08/13/97 l-131 contamination event Mercy Hospital 21-15638-01 08/13/97 Unintended site misadministration Lutheran Hospital 34-01869-01 10/18/94 Medical misadministration 1-131 overdose

• CTL Engineering, Inc. 34-18533-01 08/20/97 Stolen CPN gauge Univ. of Cincinnati Hosp. 34-06903-05 08/22/97 Three 1-125 seeds possibly missing Paducah GDP GDP-1 08/31/97 Steam leak on autoclave during heating of cylinder Anco Testing 24-24459-01 09/05/97 Density gauge run over by car MQS Testing, Inc. 12-00622-07 09/08/97 Undamaged sealed source removed from a damaged guide tube Portsmouth GDP GDP-2 09/02/97 Steam shutdown of autoclave during l heating of cylinder Portsmouth GDP GDP-2 09/13/97 Smoke detectors actuated due to instrument line kink Syncor Pharm., St. Paul, 04-26507- 09/15/97 Empty package from St. Cloud MN 01MD hospital found to be contaminated University of Michigan 21-00215-04 09/15/97 Medical 1-131 underdose misadministration 4

15

Date of Licensee Name License No. Incident Type of incident l Army-ACALA-Picatiny 12-00722-06 10/03/97 Radioactive material shipped from NY Arsenal Army National Guard inappropriately Paducah GDP GDP-1 10/07/97 UF6 leak on purge air instrument line Paducah GDP GDP-1 10/06/97 Autoclave isolation during cylinder heating Portsmouth GDP GDP-2 10/09/97 Autoclave isolation during cylinder heating Harper Hospital- 21-04127-02 10/10/97 Contaminated empty package received Mallinckrodt Pharmacy 24-04206- from Harper Hospital 10MD Hammond Fire Department n/a 10/18/97 Troxler gauge found along roadway Portsmouth GDP-2 10/18/97 Autoclave isolation during cylinder feeding to cascade 1

Paducah GDP GDP-1 10/21/97 Power supply trip affecting alarm capability during UF6 withdrawal Paducah GDP GDP-1 10/21/97 Autoclave isolation on high steam pressure Portsmouth GDP GDP-2 10/20/97 Two cells had temperatures lower than allowed Portsmouth GDP-2 10/23/97 Inoperable cylinder high pressure steam cutoff valve Grant Riverside Methodist 34-03424-03 10/29/97 Medical misadministration with Co-60 Hospital teletherapy machine Enders Construction 48-18547-02 10/30/97 Earth mover ran over CPN gauge Portsmouth GDP GDP-2 11/06/97 Recirc water drains found plugged with sludge Western Atlas Logging 42-02964-01 11/08/97 Possible external exposure of Services -Crawford, MI 4 personnel to neutrons Blanchard Valley Medical 34-18674-02 11/03/97 Medical underdose misadministration Associates with l-131 Case West. Reserve Univ. 34-00738-04 10/31/97 P-32 contamination event McLaren Reg. Med. Ctr. 21-04171-04 11/10/97 Medical 1-131 underdose misadministration 16

l Date of Licensee Name License No. Incident Type of incident MQS Inspections, Inc. - 12-00622-07 11/16/97 Radiography source stuck in Lima, OH collimator due to drive cable failure i

Shannon & Wilson 24-18839-01 11/17/97 Damaged moisture density gauge S. C. Johnson & Son, Inc. 48-06453-01 12/02/97 Kay-ray level detector damaged j leaving source exposed Cancer Treatment Center 34-25978-01 12/05/97 Co-60 teletherapy medical overdose misadministration Calumet Testing Services 13-16347-01 11/21/97 Radiography source assembly separated from control cable Bittner Engineering 21-26010-01 12/11/97 Part of Cs-137 source rod found loose in unrestricted area Medcentral Health System 34-02007-02 12/16/97 Medical Co-60 teletherapy under dose '

I misadministration Portsmouth GDP GDP-2 12/19/97 Actuation of high condensate level shutoff system during cylinder heatup Health System Mn - 22-01519-02 12/30/97 Potential medical under dose Methodist Hospital misadministration Washington Univ. 24-00167-11 12/15/97 l-131 contaminated hospital waste transferred to landfill Paducah GDP GDP-1 01/12/98 Autoclave isolation during heatup of UF6 cylinder Wisconsin Centrifugal Co. 48-11641-01 01/13/98 Spring-loaded Co-60 teletherapy shutter failure & possible overexposure l l

Washington Univ. 24-00167-11 01/15/98 Medical misadministration due to 1 Sr-90 pellets being stuck in catheter in patient  ;

Paducah GDP GDP-1 01/21/98 High voltage UF6 detection system equipment failure Army-ACALA-Schofield 12-00722-06 01/22/98 H-3 contamination event Barracks, HI Miami Valley Hospital 34-00341-06 01/23/98 Receipt of contaminated package Paducah GDP GDP-1 01/23/98 Inoperable criticality accident alarm system Allied Signal, Inc. SUB-526 01/27/98 Alert declared due to UF6 release 17 l l

i l

l 1

Date of

( Licensee Name License No. Incident Type of Incident Paducah GDP GDP-1 02/01/98 Autoclave isolation during UF6 cylinder heatup Portsmouth GDP GDP-2 02/11/98 Small UF6 release from cascade cell Army-ACALA-Baumholder, 12-00722-13 02/12/98 Lost (& found) Am-241 source Germany Portsmouth GDP GDP-2 02/24/98 Autoclave isolation during UF6 cylinder heatup Army-ACALA-Camp Lejune 12-00722-06 02/26/98 H-3 contamination event - 5 people contaminated Clayton Lab Services General Lic. 01/30/98 Two Ni-63 sources lost in shipment Allied Signal, Inc. SUB-526 02/28/98 Standby diesel failed to operate Detroit Macomb Hospital 21-01190-05 07/14/97 Possible medical Ir-192 underdose m?sadministration Paducah GDP GDP-1 03/01/98 Partial loss of facility process gas lead detection safety system alarm Soil Consultants, Inc. 24-20039-01 03/09/98 Undamaged Humboldt gauge involved l

In traffic accident Lexalite International Corp. General Lic. 02/16/98 Lost Po-210 static eliminator i Corydon Crushed Stone Co 13-26644-01 03/14/98 Troxler gauge damaged by fire l

l Detroit Macomb Hospital 21-01190-05 01/06/97 Medical Ir-192 under dose misadministration

• Paducah GDP GDP-1 03/19/98 Steam blowdown testing creating very loud noise to drown out audible alarm Grandview Hospital SNM-1603 03/19/98 Pu-239 in cardiac pacemaker

inadvertently incinerated Army-ACALA-Schofield 12-00722-06 03/19/98 H-3 source rupture Barracks, Hi Harper Hospital 21-0412-02 03/23/98 Medical HDR misadministration l Portsmouth GDP GDP-2 03/27/98 Autoclave isolation valve found to be l operating backward l United Hospital 22-01914-02 03/02/98 Missing 1.1 mCl Pd-103 seed Paducah GDP GDP-1 04/07/98 Criticality accident alarm system inop in Bldg. C-720 18 l

_ . _ . ~ _ _

Date of Licensee Name. License No. Incident Type of incident Allied Signal, Inc. SUB-526 04/08/98 Seven-band weather radio failure Univ.of Michigan 21-00215-06 04/08/98 Stuck 20,000 Cl Co-60 source in panoramic wet irradiator Portsmouth GDP GDP-2 04/09/98 Autoclave containment valves failed test Army-ACALA-Ft. Lewis, WA 12-00722-13 04/17/98 Lost Am-241 source in CAD Portsmouth GDP GDP-2 04/27/98 Smallleak of UF6 from tails vdthdrawal Army-ACALA-Ft. Campbell, 12-00722-13 04/17/98 Lost Am-241 source in CAD KY.

Paducah GDP GDP-1 05/02/98 Autoclave isolation during UF6 cylinder feeding to cascade Portsmouth GDP GDP-2 05/02/98 Autoclave isolation during UF6 cylinder heat up Paducah GDP GDP-1 05/03/98 Autoclave isolation during UF6 cylinder heat up Paducah GDP GDP-1 05/11/98 Criticality accident alarm system inop Paducah GDP GDP-1 05/12/98 Criticality accident alarm system inop Eljer Plumbing Ware 34-12906-02 05/12/98 Shutter for Cs-137 source on fixed l gauge failed to close Allied Signal, Inc. SUB-526 05/15/98 HP vacuum pump not powered by ,

standby diesel generator Army-ACALA-Ft. Riley, KS 12-00722-13 05/13/98 Lost Am-241 CAD Paducah GDP GDP-1 05/14/98 Criticality accident alarm system inop Paducah GDP GDP-1 05/15/98 Autoclave isolation during UF6 cylinder heat up Paducah GDP GDP-1 05/19/98 Criticality accident alarm system inop Army-ACALA-Germany 12-00722-13 05/13/98 Two lost Am-241 CADS KTl Construction Services Reciprocity 04/11/98 Troxler Gauge damaged Paducah GDP GDP-1 05/21/98 Criticality accident alarm system inop

, Paducah GDP GDP-1 05/26/98 Small UF6 release 19

Date of Licensee Name License No. Incident Type of incident a

Pelton Cast Steel 48-02669-02 05/31/98 Permanent radiographic facility received > $1,000 damage Brucker Engr. Company 24-32076-01 05/29/98 Lost / stolen Humboldt scientific gauge Paducah GDP GDP-1 06/02/98 Failure of C-310 high voltage release detection safety detector head Paducah GDP GDP-1 06/06/98 Criticality accident alarm system inop Paducah GDP GDP-1 06/07/98 Autoclave isolation I Army-ACALA-Germany 12-00722-13 06/10/98 One lost Am-241 CAD Nosag Products Corp. None 06/10/98 Steel contaminated with Co-60 Geotechnical Consultants 34-26022-01 06/13/98 Stolen & recovered CP gauge Ohio Dept. of Public Health None 06/18/98 Co-60 container found in deceased father-in-law's estate Lexallte International Corp. General Lic. 06/25/98 Lost Po-210 static eliminator Paducah GDP GDP-1 06/27/98 Criticality accident alarm system inop William Beaumont Hosp. 21-01333-01 01/29/98 Potential generic implications event -

malfunction of HDR unit Paducah GDP GDP-1 07/06/98 Autoclave isolation during UF6 cylinder heat up Univ.of Wisconsin 48-09843-18 07/13/98 Medical P-32 underdose misadministration Univ.of Wisconsin 48-09843-18 07/14/98 Missing 4.5 mCl of C-14 NTH Consultants 21-04206-01 07/20/98 Damaged moisture density gauge i Allied Signal, Inc. SUB-526 07/20/98 Alert declared due to UF6 release offsite j Medi-physics, Inc. 34-26239- 07/21/98 Delivery truck involved in an accident 01MD Guardian Automotive General Lic. 07/06/98 Lost 2 Po-210 static eliminator guns Radarium Foundation 24-19486-01 08/10/98 Medical Co-60 teletherapy over dose Hosp. misadministration Paducah GDP GDP-1 08/10/98 Thirty pounds of chlorine gas released inside waste treatment bldg.

Army-ACALA-Ft. Stuart, GA 12-00722-13 08/17/98 Lost 2 Am-241 CADS 20

=

Date of Licensee Name License No. Incident Type of incident Paducah GDP GDP-1 08/27/98 Exceeded pressure safety limit Garden City Hospital 21-04072-01 09/01/98 Medical brachytherapy underdose misadministration Cleveland Clinic 34-00466-01 08/11/98 Medical Y-90 underdose misadministrations Riverside Methodist Hosp. 34-01055-01 08/12/98 Missing one 1-125 seed Portsmouth GDP GDP-2 09/06/98 Small UF6 release Army-ACALA-Toole, UT 12-00722-06 09/09/98 H-3 contamination event Army-ACALA-Picatiny, NJ 12-00722-06 09/09/98 Two alming post lights (H-3) missing Army ACALA-Korea 12-00722-13 09/21/98 Lost 3 Am-241 CADS Univ.of Michigan 21-00215-04 09/22/98 l-131 contamination event Combustion Engineering SNM-33 09/24/98 Site contamination event Detroit Water & Sewage 21-23397-01 09/29/98 Stolen (& returned) CPN gauge Dpt.

Huffy Sports General Lle. 10/02/98 Missing Po-210 static eliminator Army ACALA-Germany 12-00722-13 08/25/98 Missing Am-241 CAD St. Joseph's Med. Ctr. 13-02650-02 10/06/98 Missing an 1-125 seed l

Army-ACALA-Ft. Irwin, CA 12-00722-13 10/06/98 Missi.,9 an Am-241 CAD Wayne State Univ. 21-00741-08 10/06/98 Missing two Ni-63 sources U.S. Steel - Gary Works 13-26104-02 10/12/98 Damaged 2.0 Cl Am-241 thickness gauge American Engineering 22-20271-02 10/13/98 Radiography source would not fully Testing, Inc. retract due to dented guide tube Paducah GDP GDP-1 10/15/98 Incoming shipping container with external contamination Paducah GDP GDP-1 10/17/98 Exceeded pressure safety limit NTH Consultants 21-14894-01 10/19/98 Troxler gauge run over & damaged Sinal Hospital 21-00299-06 10/19/98 Medical misadministration - Incorrect treatment dose l William Beaumont Hospital 21-01333-01 10/19/98 Medical 1-131 misadministration underdose 21 i

r Date of Licensee Name License No. Incident Type of incident Paducah GDP GDP-1 10/23/98 Autoclave isolation during UF6 cylinder feeding to cascade Paducah GDP GDP-1 11/01/98 UF6 cylinder valve failed to close NE Ohio Reg. Sewer Dist. General Lic. 10/29/98 Lost Cs-137 compensating cell Community Hospital 13-06009-01 11/04/98 Missing three I-125 seeds St. Joseph Health Center 24-02704-01 11/04/98 Unplanned overexposure to fetuses H.C. Nutting 34-18882-01 11/13/98 Damaged Troxler gauge /.run over)

Cleveland Clinic 34-00466-01 11/17/98 Source stuck during bra:hytherapy treatment with experimental after loader Paducah GDP GDP-1 11/19/98 Power lost to CAAS beacons Portsmouth GDP GDP-2 11/23/98 Autoclave leaking steam during UF6 cylinder heat up Army-ACALA-Honolulu, HI 12-00722-06 12/01/98 Missing 1.6 Cl H-3 source Indiana Univ. Med. Ctr. 13-02752-08 12/01/98 Medical gamma knife misadministration - wrong site Qualitech Steel Corp. 13-32086-01 08/09/98 Co-60 source damaged during molten steel spill Bothwell Reg. Health Ctr. 24-16275-02 11/12/98 Medical teletherapy misadministration Portsmouth GDP (3 ens) GDP-2 12/09/98 Fire causing loss of cell integrity Portsmouth GDP GDP-2 12/10/98 Safety equipment failure in X-330 bldg.

Portsmouth GDP GDP-2 12/13/98 Safety equipment failure in X-326 bldg.

Mid West Testing 24-24609-02 12/14/98 CPN gauge stolen from licensee Army-ACALA-Ft. Irwin 12-00722-13 12/14/98 Lost Am-241 CAD Marquette University 48-02931-00 01/0649 Loss of a 2 uCl Am-241 source Army-ACALA-Anniston, AL 12-00722-06 ' 01/12/99 Shipment received with excessive surface contamination Army-ACALA-Ft. Campbell, 12-00722-06 01/21/99 H-3 contamination event KY Army-ACALA-Ft. Shafter, HI 12-00722-06 01/21/99 H-3 contamination event  !

Army-ACALA-Korea 12-00722-13 01/07/99 Missing Am-241 CAD 22

Date of Licensee Name License No. Incident Type of incident Array-LOC 12-00722-07 01/19/99 Stolen LAW Detroit Macomb Hospital 21-01190-05 01/28/99 Medical misadministration Research Medical Center 24-17998-02 02/05/99 Medical gamma knife underdose misadministration Army-ACALA-Kuwait 12-00722-06 02/10/99 Lost H-3 source Paducah GDP GDP-1 02/17/99 UF6 cylinder received with removable surface contamination

• - Identified during an inspection, subsequently reported to NRC as required.

21. During this review period, did any incidents occur that involved equipment or source failure or approved operating procedures that were deficient? If so, how and when were other State /NRC licensees who might be affected notified? For States, was timely notification made to NRC7 For Regions, was an appropriate and timely PN generated?

Calumet Testina Services. Incl During a radiographic operation with an Amersham 660B gamma camera, the source assembly separated from the control cable after an exposure. The source was subsequently retrieved in i accordance with the ilcensee's procedures and NRC and the manufacturer (Amersham) were notified regarding the incident. A PN was issued.

Washinaton University School of Medicine: During an experimental clinical trial protocol approved by the FDA, the strontium-90 sources failed to retract back into the hand-held remote applicator. The licensee's investigation into this matter indicated that the cause was probably due to a kink in the treatment catheter and excessive torque to the Touhy-Bourst valve which caused the failure to retract the sources. New procedures were developed to correct the problem. The licensee notified NRC, and Region 111 notified the FDA. A PN was issued.

MQS: The licensee notified NRC that during a radiographic operation with an Amersham 660B gamma camera, the source assembly separated from the control cable after an exposure. The source was subsequently retrieved in accordance with the licensee's procedures and the manufacturer (Amersham) was notified regarding the incident. The licensee (MQS) filed a Part 21 report. A PN was issued.

Cancer Treatment Center: The licensee notified the NRC that the AECL Theratron 780 teletherapy unit failed to retract to the safe position after the termination of a treatment. The licensee notified the manufacturer (AECL) and they subsequently determined that the cord reel caused the cord to tangle when the source drawer attempted to return to the safe position.

The cord jammed and held the drawer in the open (exposed) position. The 23

cord reel was replaced and the unit functioned properly. A PN was not issued because it did not meet the PN lasuance criteria.

Harrison Steel Castinas Company: The licensee notified the NRC that while performing radiography with a AEA Technology (formerly Amersham) cobalt-60 camera with a M/N 957 automatic exposure controller, the source failed to retract to its safe (shielded) position. The licensee notified the manufacturer and it was subsequently found that the slide on the Posilock closed before the source was fully retracted. It was determined that the slide on the Posilock was not properly set before the source was cranked out to the exposed position, which was contrary to the licensee's procedures. A PN was not issued because it did not meet the PN issuance criteria.

Wisconsin Centrifuaal. Inc.: The licensee notified the NRC that during radiography with a Picker Cyclopc unit, the source failed to retract into the safe (shleided) position. It was subsequently determined that the cause of the failure was due to a broken shutter spring. A PN was issued.

Cleveland Clinic Foundation: The licensee notified the NRC that during a Manual Brachytherapy Remote After loader (MBRA) treatment setup with a U.S. Surgical Corp. MBRA unit the source failed to retract to the safe (shielded) position. NMSS and FDA were notified regarding the device failure. A PN was not issued because it did not meet the PN lasuance criteria.

l Ohio State University & Veterans Administration. Iowa City: The licensee's have implemented a blind protocol using Sn-117m that could result in patient's being released from the hospital and exposing members of the ,

patient's family to radiation doses in excess of regulatory limits. NMSS l was immediately notified and coordination has occurred between NMSS,  !

Region lil, and FDA to address the deficiencies in the protocol. Also, a list  ;

of all hospitals participating in the protocol was obtained and forwarded to all NRC Regions for followup.

22. For incidents involving failure of equipment or sources, was information on the incident provided to the agency responsible for evaluation of the device for an assessment of possible generic design deficiency? Please provide details for each case.

As noted above, in all cases the manufacturer was notified concerning each event. In addition, regarding the events at Calumet Testing and MQS (described above), special inspections were performed in Regions I and 111 l and the States of Massachusetts, Loulslana and Texas. These were coordinated with NMSS, which subsequently lasued NUREG-1631 describing the generic defect involving the Amersham Model 660 radiography system.

24 x

23. In the period covered by this review, were there any cases involving possible l wrongdoing that were reviewed or are presently undergoing review? If so, please describe the circumstances for each case.

[ Region lil's p...swer to Question #23 contains certain sensitive, predecisional Information. The Region's answer to Question #23 is omitted here.]

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24. Identify any changes to your procedures for handling allegations that occurred during the period of this review.

Region 111 revised Regional Procedure 0517A on March 5,1998. While the revision was extensive, it did not involve any changes to how allegations were to be inspected, but addressed such items as conduct of allegation j review boards (ARBS), scheduling of ARBS, correspondence with allegers (content and frequency), review of documentation submitted by 01 or allegers, data entry into the AMS system, issuance of reports from the AMS system, etc. A copy of the revised regional procedure is attached for your j use. I VI. General 1

25. Please prepare a summary of the status of the State's or Region's actions taken in response to the comments and recommendations following the last review.

NMSS conveyed the results of the 1997 National Program Review to Region 111 in a memorandum dated August 5,1997. As noted in that memorandum, Region 111 had already provided its response to Recommendations 2,3, and 4, in its comments on the draft report, and no  ;

additional information was required as a result of the final IMPEP report.

The actions described in our comments were completed as of March 10, 1999, when a specific revision to the regions allegation procedure was issued making it explicit that no allegation material was to be placed or contained in the docket files.

l

26. Provide a brief aescription of your program's strengths and weaknesses. These strengths and weaknesses should be supported by examples of successes, l problems or difficulties which occurred during this review period. I Proaram Stronaths: Our incident response effods have been numerous, prompt and through. Several routine inspections, i.e, Midwest Testing, Harper Hospital, University of Wisconsin-Oshkosh, DAS Consulting, Detroit l

Sinal Hospital, Midwest imaging Diagnostic, Inc. and Advanced Medical -

Systems, have identified significant management breakdowns and/or escalated enforcement issues.

27 2

4 l

in addition to completing our core programs in licensing and inspection, we have been able to balance special projects assigned from Headquarters as well as those assigned internally. Examples of projects which we have completed or are ongoing included: summer / spring inspections of portable gauge licensees, quarterly / semi-quarterly inspections of broadscope university licensees, and participation in the writing of several guidance consolidation project NUREGs. Other special projects included:

medical risk analysis, Part 35 guidance, inspection performance Indicators (medical), and risk and barrier analysis for numerous programs.

Self-assessments for the follow up to escalated enforcement cases and )

incidents indicated that Region lil has met the requirements for a six-month follow up inspection.

Region 111 Initiated a trial scheduling program (1997 to present) ior scheduling all core /non-core inspections, including reciprocity inspections, assist inspections and follow up inspections. This system was developed by the GG-14 Senior Health Physicists and is updated each month. Each month the inspectors meet to discuss the next months strategy and assignment of inspections to ensure that all core /non-core inspections are scheduled in a manner that is efficient and cost effective for the agency.

During this IMPEP assessment period the Region has issued several escalated enforcement cases in record breaking time. As an example, Harper Hospital was issued a Severity Level ill violation for a programmatic breakdown in its QMP within 8 days of the end of the Inspection. Other examples include University of Minnesota, a Severity Level 111 violation was issued in 37 days, and University of Wisconsin-Oshkosh, a Severity Level ill violation associated with a management control breakdown was issued in 42 days.

The Region has a continuous self-assessment program that over this IMPEP cycle include assessments of misadministration and medical events followup, compliance with MC 2800, i.e, extension / reduction of inspections, reciprocity inspections, non-escalated enforcement, etc.

The Region successfully completed development of a strong QA/QC program for the fixed laboratory, including the upgrading of several assessment instruments. Management support to the laboratory was strong, and ensured continued analytical services to the NRC were maintained while the laboratory equipment was being upgraded.

Staff experience and qualifications has been strong with very little turnover in inspection, licensing, or laboratory staff. Region Ill's staff is experienced, and includes staff with M.S. and Ph.D. degrees; one certified H.P., one certified Industrial hygienist, reactor experience as well as materials experience, and two former NRC section chiefs.

28

Our process for issuance of licensing actions was improved with the computer assisted development and issuance of licensing actions during the last half of this IMPEP cycle. It has resulted in a significant Improvement in the timeliness of issuance of licensing actions (93%

average timeliness compared to the 80% goal).

4 In the conduct of decommissioning activities, Region lil has maintained an outstanding relationship with the affected States. This included routine communications and accompaniments by State staff.

A strength of the Region 111 fuel cycle program over this period has been the ability to respond to emergent issues or events. This was best evidenced by the Region's responses to the several material release events at Allied Signal (one of which was an AIT), and the AIT response to the Portsmouth GDP fire. In addition, special team inspections were conducted at the Portsmouth GDP regarding the nuclear criticality safety program, compliance plan issues, the catastrophic failure of the onsite steam plant, and the dropping of an empty UF6 cylinder at the Paducah GDP. Another strength has been the ability to shift resources between the GDP resident and regional-based inspectors to address emergent issues.

Region 111 also supported inspections in other Regions (Ril and RIV) with reduced resources in 1998. Inspection reports were generally issued in a timely manner, identified good technical issues, and were of high technical quality. Good communications among all Fuel Cycle Branch staff has helped to identify declining performance trends between the sites.

We have developed and are implementing a structured process to ensure a coordinated transfer of licenses to facilitate Ohio's becoming an agreement state. This is done through bi-weekly phone conference calls between Region lil, Office of State Programs, NMSS, and State representatives.

Despite downsizing of our administrative staff, we have been able to improve the efficiency of operations such that we have maintained the same level of administrative support.

1 Proaram Weakness: Self-assessments conducted in the areas of report I (fleid notes) timeliness Indicated that the Division was deficient in the area of field note and report timeliness. Efforts have been implemented to improve both areas.  ;

Efforts to bring the Region ill laboratory up to acceptable QA/QC standards has required significant management involvement and has been a labor intensive effort for a long period of time.

1 The overall Agency program for site and facility decommissioning continues to evolve, so there are often situations with neither prior precedent nor clearly applicable regulatory foundation. Criteria are inconsistent between decommissioned reactors and materials facilities.

29 l

l

In addition, the conventional regulator / regulated relationship does not exist for a number of contaminated sites as they are owned by parties that have not been licensed by the NRC.

Our self-assessments determined that the Region was deficient in meeting the reciprocity inspection goals specified in MC 1220. This is partially due to the extremely short notification provided by licensees prior to initiating work (usually a day or less) and inspection scheduling difficulties. For example, in the case of one radiographer, on two separate occasions the ,

Region dispatched an inspector to the proposed location to find that the l radiographer had not shown up. On both occasions, the jobs had been I subsequently canceled after the NRC determined where the jobs were J being performed.

Another weakness has been the addressing of complex allegations in a timely manner. In addition, the GDP resident training program needs enhancements to facilitate resident development in a more detailed fashion (similar to the program in the Division of Reactor Projects for reactor residents).

B. NON-COMMON PERFORMANCE INDICATORS

1. SDMP Proaram

27. For each site listed in the SDMP where the Region has project management responsibility, provide the following information:

What is the status of meeting the milestones in SECY 97-242?

Describe the action plan th&t is in place by the responsible parties for site remediation.

Were any significant delays identified and corrective actions put in place in a timely manner?

Identify policy issues under consideration, and describe how they are being i resolved in a timely manner. j NMSS is the project manager for all SDMP sites in Region 111 except, i Advanced Medical Systems, Inc. (see the answer to Question 28). In the i case of AMS, the licensee will not actually begin any decommissioning of its active license unless the denial of its license renewal is upheld in j hearing.

28. For each site listed in the SDMP where the Region does not have project management responsibility, provide the following information:

- The information requested in question 27 above.

- Licensing and inspection support by the Region to the lead project office.

Milec tones of SECY 97-242 are on target. Chemetron was removed from the SDMP list in February 1999, and we expect two additional projects 30

(NEORSD and Elkem) in Region ill will be removed from the SDMP list later this FY.

The action plans are summarized in the SDMP database.

Significant delays which necessitated corrective action by NRC were not encountered.

Region 111 conducts essentially 100% of the SDMP inspection program, with NMSS project manager accompaniment in some cases. An integrated licensing and Inspection planning and scheduling document is used which is available for audit. Each SDMP site is inspected at least once each year, unless NMSS and Region lil agree to an exception due to site-specific circumstances. In FY 97 the only exceptions were Clevite and Horizons, where no activities meriting inspection occurred. In FY '98 the only exceptions were Elkem and Jefferson Proving Ground, where no activities meriting Inspection occurred,

11. Decommissionina

29. For each non-SDMP site where the Region has project management responsibility, provide the following information:

Status of meeting planned milestones.

Describe the action plan that is !n place by the responsible parties for site remediation.

Identify any significant delays in decommissioning progress, and describe any corrective actions put in place.

Identify any policy issues associated with the site, and describe how they are being resolved.

The following summaries address non-SDMP projects in Region lil, for which Region lit has project management responsibility.

Advanced Liahtina: Advanced Lighting is a current licensee in Coldwater, Michigan, which has made notification under the " timeliness rule" regarding plans to transfer activities involving licensed materials to another facility (in Ohio) In mid 1999 and has requested authorization to proceed with decontamination. The proposed activities are outside the normal scope of decontamination activities previously accomplished under the license. The proposalis under review, and the schedule is being followed to determine an appropriate inspection activity.

Alliant Techsystems: This is a former munitions manufactory in Minneapolis, Minnesota, and a munitions testing facility in Elk River, Minnesota. Both projects are under license, with an approved decommissioning plan at Elk River; however, a request has been made to defer submittal and Implementation of a proposed decommissioning plan for the Minneapolis site, in order to consolidate decommissioning of the radiologically contaminated portion of a major facility with the anticipated 31

shutdowe of the entire facility in about two years. The proposal in under review.

American Smeltina: This is a former foundry operation in Whiting, Indiana, for which the ORNL terminated license review project identified a lack of documentation concerning closecut. The buildings that still remain have been surveyed and no contamination found. A slag plie remains to be surveyed; it is under different ownership than the buildings and is also being regulated by the State of Indiana EPA. If significant contamination is found, slag pile remediation will be addressed jointly with the State.

Battelle Columbus Laboratories: The Battelle research facilities in West Jefferson, Ohio, are being decommissioned under contract and with primary funding by DOE. A research reactor, a spent fuel storage pool and several high-level " hot cells" are among the facilities to be demolished, lasues at this site include financial assurance, overall schedule (which is strongly controlled by DOE funding levels), and the apparent need for a possession ilmit above NRC " formula quantitles." The State of Ohio will become an Agreement State in approximately July,1999, but will not <

receive regulatory authority for Battelle if the possession limit is above

" formula."

BP America: This is a research and production facility in Cleveland, Ohio,  !

where lab-scale work was performed to develop the catalytic process i using depleted uranium which BP adopted at their Lima, Ohio, facility. The l Cleveland facility holds an NRC license for some gauges, and has l requested that this license be amended to allow continued possession of a ,

contaminated " reactor" which is still in service for nonradioactive work I and fixed materials within an electrical equipment room's walls. This request is under review.

Chevron: The Chevron company (a non-licensee) owns a building (the

" Government Building") at the Engelhard property in Cuyahoga Heights, Ohio. This buliding was contaminated by processing of uranium by the Harshaw Chemical Company, for the Manhattan Engineering District, before AEC/NRC licensing came into effect. Little progresp has been made since discovery in about 1995-6 that the levels of contamination were much higher than previously believed. Funding for cleanup is being evaluated by the DOE.

Enaelhard: Engelhard (a non-licensee) owns the entire former Harshaw Chemical complex in Cuyahoga Heights, Ohio, with the exception of the Chevron /" Government" building. The property on the South side of Harvard Avenue, which constitutes a relatively small fraction of the total, has been fully surveyed and remediated as necessary. Completion of the remainder of the work will be affected by the ultimate actions to clean up the Chevron building, since the grounds immediately adjacent to the building are the responsibility of Engelhard but can not reasonably be cleaned up until after the Chevron building is cleaned up and/or removed.

32

Mallinckrodt; Mallinckrodt owns property in St. Louis, Missouri, which became contaminated by processing various types of ores. The project is under NRC license. A final decommissioning plan is pending, with issues relating to suspected onsite intermixture of materials regulated by NRC with both high-background materials (boiler ash, bricks) and with materials from a DOE facility located immediately adjacent to the licensee's property.

McDermott-Tech: A current NRC licensee with research facilities in Alliance, Ohio, McDermott-Tech has several former 20.302 or 20.304 burial sites. One or more of these sites may not meet reevaluation criteria associated with the " Timeliness Rule." Licensee investigations are underway, with submittals expected in the relatively near future. The original approach has been abandoned in favor of a dose-based approach, using the 25 mrem criteria of the license termination rule. This has caused some delay in the evaluation.

Michiaan Chemical Co/Velsicol: Michigan Chemical (now owned by Velsicol) is a former licensee which processed ores for extraction of rare earths at a plant in St. Louis, Michigan. a shallow land burial site was used for disposal of various waste products at a 3-acre site near Breckenridge, Michigan. The integrity of the burial site was found compromised during an NRC/ State of Michigan survey in late 1996, following up on a contact from a concerned local citizen through the local State Representative.

Region 111 has been working with Velsicol's Memphis Environmental Center since early 1997 on thorough site characterization and appropriate remediation.

Shelwell Services: Shelwell is a current licensee which has requested license termination for a site in Hebron, Ohio, where a source-damage incident in 1983 resulted in widespread, low level contamination with j

Cs-137 in the form of micro spheres. A Commission Paper, an Environmental Assessment, and a public meeting have all been utilized in the termination process, to make notification about the results of detailed staff inspections and analyses of conditions at the site which the staff deems consistent with the Ilconse termination rule. The license termination is expected to be completed by about April 1,1999, pending i removal of some obsolete AmBe neutron sources by DOE, and removal of a small volume of contaminated soil.

30. Identify all licensees that initiated decommissioning during the review period (do not include those licensees that were terminated during the review period, as DWM will use the LTS to compile this information).

The only two sites that initiated decommissioning during the review period are Advanced Lighting and McDermott Technology. Both of these sites are discussed in the answer to question 29 above.

31. List the decommissioning inspections that were carried out during the review period. Please indicate if the inspection schedules required by Manual Chapter 2602 were prepared for licensed facilities undergoing decommissioning 33 1

J

and if this schedule was developed, indicate inspections that are overdue by more than 25% of the inspection due date. Indicate which inspections revealed that licensees were not conducting their decommissioning in accordance with the approved decommissioning plan and describe how these projects were managed.

l Materials decommissioning inspections are scheduled and conducted considet!ng averal factors. For SDMP projects, the integrated licensing and inspection plan senedutr?for decommissioning projects is used. For non-SDMP projects, contacts with the licensee to determine scheduled activities serve to identify the most risk-informed timing for inspection.

The reactor inspections are scheduled according to a Master inspection Plan (MIP) for each facility, which is developed pursuant to the governing Manual Chapter, MC 2561. <

No inspections were more than 25 percent overdue, in rare cases involving SDMP facilities, the normal, once-per-year inspection schedule was extended with the concurrence of the program office due to considerations involving schedule or lack of activity.

In the Summer of 1997, violations of the approved decommissioning plan requirements were identified at the BP Chemical facility in Lima, Ohio.

These related to failure to fully implement details of practices specified in the QA/QC program, which was incorporated in the license by reference.

Although the noncompliances ultimately proved primarily administrative in nature, they were sufficiently numerous and varied that Region lil, working closely with NMSS, determined the quality of information to demonstrate compliance was inadequate and placed ultimate approval of the removal of the project from the SDMP list at risk. Region 111 and NMSS confronted the licensee with a Confirmatory Action Letter (CAL), a management meeting, and enforcement. There was a temporary shut down of the project (construction of a waste cell) on two occasions while both the level of control of activities and the level of detail in the QA/QC plan were normalized to each other.

Materials decommissioning inspections conducted during the review period were as follows:

SDMP Sites Advanced Medical Systems, Inc., Cleveland, OH = 6/10-11/97; 2/25-26/99 BP Chemical, Lima, OH = 7/21-23/97; 11/12-13/97; 4/1/98; 7/15-16/98 Brooks & Perkins/AAR Manufacturing, Livonia & Detroit, Ml = 5/15/97; 8/13/98 Chemetron, Newburgh Heights, OH = 3/31-4/4/97; 7/14-17/97; 8/4-7/97; 8/11-12/97; 3/23/98; 5/8-9/98 (with mobile lab); 7/6-10/28/98 34

SDMP Sites Clevite Corporation, Cleveland, OH = Exempt FY 97; 1/14-15/98; 2/23-3/6/98; 5/14/98 (final closeout)

Dow Chemical, Midland and Bay City, MI = 5/12-14/97; 7/23-25/97; 10/28-29/97; 9/28-30/98;12/8-9/98 Elkem Metals, Inc., Marietta, OH = 8/21-22/97; Exempt FY 98; 10/14-15/98 Hartley & Hartley = 9/25/97; 8/98 Jefferson Proving Ground, Madison, IN = 8/28-29/97; Exempt FY 98 Lake City Army Ammunition Plant, independence, MO = 1/8/97; 5/11-12/98; 7/21-22/98;11/18-19/98;1/13/99;1/19/99 Lamotite (Horizons Inc.), Cleveland, OH = Exempt FY 97; 9/98 3M, Pine City, MN = 8/1/97; 9/23/98 Northeast Ohio Regional Sewer District,(NEORSD), Southerly, Cleveland, OH = 4/3-4/97; 4/8/97; 7/15/97; 3/4/98; 7/7/98 RMI Titanium Company, Ashtabula, OH = 9/29-10/1/97; 1/14-16/98; 2/4/98; 7/98 Shieldalloy Metallurgical Corporation, Cambridge, OH = 8/21/97; 5/1/98; 8/20/98; 9/21/98 Non-SDMP Contaminated Sites Alliant Techsystems, Inc. = 5/7-8/97 (MN); 7/29-8/1/97(MN); 7/8/97(IL);

9/24-11/6/98(IL)

American Metal Products = 4/1-2/98 American Smelting = 1/13-14/99 Armour Research = 3/31/98 (Gary)*; 4/30/98 (LaPorte)* (ORNL - closed, both sites)

Battelle Memorial Institute = 8/25-27/97; 4/8-10/98; 11/16-18/98 Bayer Corporation = 2/11-12/98 B P America = 11/20/98 Engelhard = 7/16/97; 8/5/97; 10/20-21/97; 12/18-19/97 (building closeout);

3/4/98 -

Ethyl Corporation = 9/98 (ORNL - pending)

Fermi 1 Nuclear Power Plant = 7/10-11/97 General Electric, Tungsten Products = 5/13/98 (final closeout)

McDermott Technologies = 9/1/98 Merril Pharmaceutical = 9/21-22/98 Mose Cohen & Sons = 9/26/98 (ORNL - closed)"

35

Non-SDMP Contaminated Sites Roof Consultants = 11/20/97 Schering Plough = 8/5-20/98 Shelwell Services = 4/29-5/1/97 St. Eloi Corporation = 9/23/98 (ORNL - pending)* .

Wellman Bronze & Aluminum = 8/13/98 (ORNL- closed)* l

- residual contamination identified, licensed.

• • residual contamination identified, NORM.

32. Identify all licenses (both terminated and otherwise) that have received in- "

process inspections of licensees' final survey programs and confirmatory surveys, in accordance with IP 87104 and IP 88104, during the review period.

Describe the inspection activities covered during inspections of these licensees.

in-process inspections of final surveys were conducted as listed below.

The inspection report listed contains the description of the inspection activities and is available for audit upon request.

1 Facilltv/ Licensee Report Number Note (s)

Dow Chemical Co. 040-00017/97001(DNMS Selected areas TRW - Port Clinton, OH 040-07855/97001(DNMS) ORNL Closeout

• Phamacia Adria 030-13645/97001(DNMS) ORNL closeout Red Wing Pottery 040-03616/97001(DNMS) ORNL closeout 3M (three sites) 070-00228/97001(DNMS) ORNL closeout AVCO/Sanyo 040-06304/97001(DNMS) ORNL closeout" AutoJumble Letter to RIV dated 9/22/97 RIV assist Ajax Magnathermic 040-02894/97001(DNMS) ORNL closeout Peskin Sign 040-02894/98002(DNMS) ORNL closeout UCAR (National Carbon) 040-02692/97001(DNMS) ORNL closeout Hoechst Marion Roessel 030-05696/97001(DNMS) Lic. term.

Battelle Columbus Labs 070-00008/97001(DNMS) Selected building (s)

Dow Chemical Company 040 00017/97003(DNMS) Selected area (s)

Bayer Corp. 030-05089/98001(DNMS) License termination American Metal Products 040-04554/98001(DNMS) ORNL closeout and letter dated 1/7/99 Armour Research 040-01007/98001(DNMS) ORNL closeout G-E Tungsten Products 040-00534/98002(DNMS) Final closeout Chemetron 040-08724/98001(DNMS) Cell construction &

closeout Clovite 070-00133/98001,02,03(DNMS) Final Closeout B P Chemicals 040-07604/98002(DNMS) Selected area Schering Plough 030-07609/98001(DNMS) Lic. term.

Wellman Bronze & Alum 040-01790/98001(DNMS) ORNL closeout St. Elol Corp. 040-02371/98001(DNMS) ORNL closeout 040-02275/98001(DNMS)

Mose Cohen & Sons 040-08081/98001(DNMS) ORNL closeout Ethyl Corporation 030-90032/98001(DNMS) ORNL closeout 36

Facilltv/ Licensee Report Number Note (s)

Dow Chemicals 040-00017/98002(DNMS) Selected area (s)

Alliant Techsystems 040-08830/98001(DNMS) Elk River area closeout Elkem Metals 040-07208/98001(DNMS) Final Closeout Battelle Columbus Labs 070-00008/98002(DNMS) Selected building American Smelting 040-06653/98001(DNMS) Buildings only

- residual contamination identified - ilcensed

- residual contamination Identified - NORM The items designated "ORNL closeout" are reports of inspection of former licensee facilities identified in the ORNL review of terminated license files as lacking documented closeout details.

33. List all appropriate staff who have not yet met the qualification requirements of Decommissioning Inspector as identified in Manual Chapter 1246. List the courses or equivalent training / experience they need to attend and a tentative schedule for completing these requirements.

All decommissioning inspection staff have met the qualification requirements of MC 1246.

34. Identify by name, license number and type all licensees with outstanding decommissioning financial assurance (DFA) reviews. Describe the outstanding issue and the plans to resolve the issue.

Dow Chemical Company 00265-06, research and development type A broadscope. Deficiencies in the licensee's latest response were provided back to the licensee by letter dated January 6,1999. We are awaiting a response from the licensee to address those deficiencies.

Battelle Memorial Institute - license number SNM-7 and the new application (will be license number 34-26608-01 If issued prior to Ohio becoming an -

Agreement State), currently licensed for everything (source material, special nuclear material in critical mass quantitles, industrial measuring equipment, hot cell operations, and research and development type A broadscope). DWM has determined that the licensee's methodology for establishing DFA was unacceptable. In a conference call with the licensee on February 18,1999, the licensee was provided with a description of the deficiencies and NRC's options regarding its renewal application and initial application for a broadscope license given that the licensee has no current viable financial assurance instruments for either.

Frontier Technology Corporation - license number SNM-1957, manufacturing and distribution type B broadscope. Deficiencies were provided to the licensee on August 13,1998. The licensee has been contacted on several occasions to provide its response, the most recent 37

being January 20,1999. We are still awaiting the licensee's response to the deficiencies.

Qual-X incorporated - license number 34-16907-02, manufacturing and distribution non-broadscope. Deficiencies were provided to the licensee on October 22,1998. The licensee was subsequently contacted to provide its response on January 20,1999. We are still awaiting the licensee's response to the deficiencies.

Quanterra - license number 24-24817-01, other service license. Deficiencies were provided to the licensee on October 1,1998. The licensee was subsequently contacted to provide its response on January 20,1999. We are still awaiting the licensee's response to the deficiencies.

35. Describe the existing status of Region Ill's analytical laboratory and mobile laboratory. Provide data on types of uses, types and amounts of analytical procedures performed, performance testing program, staffing, and capacity utilitization history during the reporting period.

Mobile laboratgry; The mobile laboratory was utilized in the field on two occasions: In May 1997 to conduct immediate analyses of samples of soll and water collected at Shelwell Services Inc., in Hebron, Ohio, where characterization and in-process remediation were being conducted on a site contaminated with many micro-spheres of Cs-137. The other use was an extended, in-process analytical assignment at the Chemetron Bert Avenue disposal site in Newburgh Heights, Ohio. About 200 samples were analyzed as the disposal cell was built, to promptly confirm ac'ceptability of disposed material. The mobile laboratory was in place in the field for about three months (summer of 1998) to conduct this assignment. '

The analytical equipment in the mobile laboratory includes a 50 percent i efficient germanium detector, which is superior to the nominal 17 percent i efficient detector which served the fixed laboratory until November 1998.

For a substantial portion of the time when the mobile laboratory was not in use, the detector system was moved into the fixed laboratory and used as a backup there. l ine mobile laboratory was taken out of service in late 1998 for periodic )

maintenance er. h setector by the vendor. The detector needs more I repair tSat contemplated and remains with the vendor. When the work is  ;

complete, the detector will be returned to service with new computer l hardware and software procured in late 1998 with the new fixed lab equipment.

Fixed Laboratory: The fixed laboratory operated under a set of Region I procedures, informally implemented, until the laboratory was removed from service in September,1998, for installation of newly-procured, upgraded gamma spectroscopic equipment and to complete many enhancements and corrective actions identified as needed to ensure complete implementation of the NMSS Quality Assurance Plan. This 38

l l

temporary shut down was consistent with a recommendation contained in a report of assessment from an " assist visit" at the end of August,1998, by staff from the Radiological Environmental Sciences Laboratory (RESL)~. l The sheer number and variety of action items identified (about 180) lent l Itself to use of a GANTT chart approach for monitoring progress and completion of actions. Weekly meetings were held to brief DNMS l management in Region til and NMSS was kept informed via weekly i

transmittal of the current GANTT chart to a contact person and periodic  ;

telephone briefings.

Detailed tracking of the number of analyses performed in the Region 111 lab  ;

is not readily available for the period of interest in FY 1997. From the i beginning of FY 1998 to date, the fixed lab received an average of about 100 samples per month, for a total of approximately 1,530 samples. Nearly all of the analyses performed by the Region lli lab were either soil (586 samples) or smears (796 samples). In addition, ORISE analyzed 133 samples on behalf of Region lli during late 1998 when the laboratory  ;

was temporarily out of service. Details are contained in Quarterly laboratory reports, which are available for audit.

One of the Region 111 performance " metrics" for Fiscal Year 1998 was 100%

{

successful performance on laboratory intercomparison samples. The  !

laboratory met this target. In at least one case, however, results were not reported timely from the Region lll lab. This was addressed by initiating a requirement that all subsequent intercomparison samples be tracked as to timeliness in the DNMS Action item Tracking System.

36. Describe the measures taken by the Region during the reporting period to improve the capabilities of the Rlli analyticallaboratory. Describe any considerations still to be resolved.  !

All aspects of laboratory capability have been improved, including quantity and quality of management oversight, counting hardware and software, staff training, procedures, etc. These actions ensured proper .

Implementation of the NMSS QA Manual for the Region 111 labs. Details of most actions taken are contained in files maintained by the Health Physics Manager (HPM); a summary is represented in the GANTT chart mentioned in item 35 above. Both sets of records are available for audit.

37. Describe Rill's plans for operation of the laboratory for the next 2-4 years.

Computer hardware and software upgrades are planned in the immediate future for the liquid scintillation and proportional counting systems, to meet Y2K considerations and to improve speed and compatibility with the Windows NT standard used throughout the NRC for reports, e-mail, etc.

Staffing will continue to be dedicated at a level of about 1.7 FTE each year, with one person dedicated full time, HPM oversight about half-time, and backup analysts for the remainder. Staff training will be a focus, to 39

Improve capability and to ensure familiarity with developments in the specialized field of radio analysis.

A " customer service" philosophy, with the inspectors and inspection programs in both Regions lil and IV being the customers, will remain a priority. Requested analyses will be promptly completed and documented in clear, accurate terms in a format useful in the preparation of inspection reports.

No major hardware purchases are contemplated in the next 2 - 4 years. We will evaluate whether the mobile lab will be replaced.

Ill. Fuel Cvele insoection Proaram Status of insoection Procram

38. List in chronological order the fuel cycle inspections (or assessments, in the case of non-licensee facilities) performed during the reporting period by facility and type (i.e., U= unannounced routine inspections, R = reactive inspections, D = decommissioning inspections, etc.). Please include the inspection procedure number (e.g., IP 88020). A sample format is shown below.

18 Licensee Number Dates Iype ABB-CE 97001 2/3 - 2/7/97 Routine Regional ABB-CE 97002 4/14 - 4/18/97 Routine Regional f ABB-CE 97003 8/4 - 8/8/97 Routine Regional ABB-CE 97004 12/1 -12/5/97 Routine Regional ABB-CE 98001 4/6 - 4/9/98 Routine Regional ABB-CE 98002 5/12 - 5/13/98 Routine Regional

[ Security]

ABB-CE 98003 7/13 - 7/17/98 Routine Regional ABB-CE 98004 9/14 -9/18/98 Routine Regional ABB-CE 98005 11/2 -11/6/98 Routine Regional

~

AlliedSignal 96007 12/16/96- Reactive 5peciaIl 1/10/97 .M' AlliedSignal 97001 01/06 - Routine Regional 01/10/97 AlliedSignal 97002 06/23 - Routine Regional 06/27/97 40

IB Licensee Number Dates _Tygg AlliedSignal 98001 01/06 - Routine Regional 01/23/98 l AlliedSignal 98002 01/28 - Reactive Special [AIT) {

02/06/98 l AlliedSignal 98003 03/02 - Routine Regional [AIT '

03/06/98 F/U)

AlliedSignal 98004 05/27 - Routine Regional 05/28/98 AliledSignal 98005 07/21/98 & Reactive & Routine ,

08/31 - Regional Integrated 09/03/98 AlliedSignal 98006 11/30 -12/4/98 Routine Regional (EP]

AlliedSignal 99001 02/16 - Routine Regional 02/19/99 Paducah 97002 3/3 - 4/21/97 Routine Resident Paducah 97003 4/22- 6/2/97 Routine Resident Paducah 97004 6/3 - 7/14/97 Routine Resident &

Regional Paducah 97005 5/5-5/9/97 Routine Security w/DFS Paducah 97007 7/15- 9/12/97 Routine Resident &

Regional Paducah 97008 8/26 -10/7/97 Routine Resident & -

Regional Paducah 97009 9/8 - 9/12/97 Routine Regional [QA)

Paducah 97010 9/19/97- Special'[dylinder ' '

2/16/98 Drop) ,

Paducah 97011 10/8 -11/4/97 Routine Resident &

Regional Paducah 97012 10/6-10/10/97 Routine Regional Paducah 97014 11/25/97- Routine Resident 1/20/98 Paducah 98002 1/20- 30/98 Routine Regional 41

IB Licensee Number Dates Tvoe Paducah 98003 1/20 - 03/9/98 Routine Resident Paducah 98004 02/23 - Routine Regional 02/27/98 [DFS]

Paducah 98005 02/23 - Routine Regional 02/27/98 Paducah 98006 03/10 - Routine Resident 04/20/98 Paducah 98007 03/16 - Routine Regional 03/20/98 Paducah 98008 03/31 - Routine Regional [EP]

04/02/98 Paducah 98009 04/20 - 06/98 Routine Resident Paducah 98010 05/18 - 22/98 Routine Regional Paducah 98011 06/09 - Routine Resident 07/20/98 Paducah 98012 06/22 - Routine Regional 06/26/98 Paducah 98013 07/21 - Routine Resident 09/01/98 Paducah 98014 08/03 - Routine Regional 08/07/98 Paducah 98015 09/08 - Routine Reg! anal 09/11/98 Paducah 98016 09/02 - Routine Resident 10/14/98 Paducah 98017 10/15 - Routine Resident 11/30/98 Paducah 98018 11/30/98 - Routine Resident &

1/12/99 Regional Paducah 99002 1/25 -1/29/98 Routine Regional Portsmouth 97002 3/3 - 4/06/97 Routine Resident Portsmouth 97003 4/7- 5/18/97 Routine Resident &

Regional 42

LB Licensee Number Dates Type Portsmouth 97004 5/19 - 6/29/97 Routine Resident Portsmouth 97005 6/30 - 8/10/97 Routine Resident &

Regional Portsmouth 97006 9/2 - 9/5/97 Routine Regional

[DFS]

Portsmouth 97007 7/29 - 8/1/97 Reactive Special

[ Steam]

Portsmouth 97008 8/11 - 9/21/97 Routine Resident Portsmouth 97009 9/11 - 9/13/97 Routine Regional (EP]

Portsmouth 97010 9/22 -11/2/97 Routine Resident &

Regional Portsmouth 97011 11/3 -11/7/97 Routine Regional Portsmouth 97012 11/3-12/14/97 Routine Resident Portsmouth 97013 12/8/97 - Reactive Special [NCS) 1/9/98 Portsmouth 97015 12/15/97- Routirn Resident 1/25/98 Portsmouth 98002 1/6 - 1/16/98 Routine Regional Portsmouth 98003 1/26 - 3/8/98 Routine Resident Portsmouth 98004 3/2 - 3/6/98 Routine Regional Portsmouth 98005 3/9 - 5/8/98 Routine Resident &

Regional -

Portsmouth 98007 4/20 - 6/8/98 Routine Resident Portsmouth 98008 4/27 - 5/8/98 Routine Regional Portsmouth 98009 6/8 - 11/98 Routine Regional (Security]

Portsmouth 98010 6/1 - 6/5/98 Routine Regional Portsmouth 98011 6/8 - 7/20/98 Routine Resident Portsmouth 98012 7/27 - 7/31/98 Routine Regional Portsmouth 98013 7/20 - 8/30/98 Routine Resident 43 )

i j

IB Licensee Number Dates Tygg Portsmouth 98014 8/31 - 9/4/98 Special[ Compliance Plan]

Portsmouth 98015 8/31-10/13/98 Routine Resident Portsmouth 98016 10/19- Routine Regional 10/23/98 Portsmouth 98017 10/13- Routine Resident 11/23/98 Portsmouth 98018 11/23 - 1/12/99 Routine Resident Portsmouth 98019 12/9/98 - Reactive Special [AIT l 1/8/99 Fire).

INSPECTION PROCEDURE BY REPORT NUMBER FOR 1997-1999 l

[ Requirements Dictated in MC2600 (Fuel Facilities) & MC2630 (GDPs)]

COMBUSTION PROCEDURE FREQUENCY ALLIEDSIGNAL ENGINEERING PADUCAH PORTSMOUTH 88100 MONTHLY . WA WA 97002 97003 97002 97003 GDP Operations 97004 97007 97004 97005 97008 97011 97008 97010 98003 98006 97012 97015 98000 98011 98003 980C5 98013 90014 98007 98011 98016 98017 98013 98015 98018 98017 98018 88101 ANNUAL WA WA ' 97002 97003 97003 97004 GDP 97004 97007 97008 97010 Configuration 98013 98014 97012 97015 Control 98003 98007 98011 98013 98015 98017 98018 88102 ANNUAL WA WA 97002 97003 97002 97003 GDP 97004 97007 97004 97005 Surveillances 97008 97011 97008 97010 98003 98006 97015 98005 98009 98011 98011 98013 98013 98016 98015 98017 88103 ANNUAL WA WA 97002 97003 97003 97004 GDP 97004 97007 97005 97008 Maintenance 97008 97011 97010 98003 98003 98017 98011 98013 98018 98015 98018 44

COMBUSTION PROCEDURE FREQUENCY ALLIEDSIGNAL ENGINEERING PADUCAH PORTSMOUTH 88105 ANNUAL N/A N/A 97002 97003 97002 97003 GDP Mgmt. Org.

97004 97007 97008 97010

& Cntrl.

97008 97011 98003 Tl2600/003 SEMIANNUAL 97001 97002 97001 97002 97012 98002 97011 98012 FF Operations 98001 98002 97003 97004 98012 98018 98016 Safety Review 98003 98004 98001 98003 98005 98006 98004 98005 88005 ANNUAL 97001 98004 97001 97002 97010 98005 97011 98002 98004 FF Mgmt. Org. 98005 98006 97003 97004 and Controls 98005 98008 98010 98001 98003 98012 98004 98005 88010 ANNUAL 97001 97002 97001 97002 97009 97010 97007 97011 98002 Operator 98004 98005 97003 98001 97012 98002 98004 98005 98008 Training & 98006 98004 98005 98005 98007 98012 98016 Retraining 98010 98012  !

98015 88020 ANNUAL buA 97001 97002 97002 97003 97002 97003 97004 Regional 97003 97004 97004 97010 97007 97010 Criticality Safety 98001 98003 97012 98002 97011 97012 97013 98004 98005 98018 97015 98003 98012 98016 88025 ANNUAL 97001 98003 97001 97002 97012 98002 97007 97008 97011 FF Maint. and 98004 98005 97003 97004 98005 98010 98002 98004 98005 Survelliance 98006 98004 98005 98012 98015 98008 98010 98012 Testing 98014 98018 98016 83822 SEMIANNUAL 97001 97002 97001 97002 97008 98012 97005 97010 98002 Radiation 98003 98005 97004 98003 98015 98018 96008 Protection 98006 98004 88035 & 84850 ANNUAL 97001 98003 97001 97004 97007 97008 97003 97005 98002 Rad. Waste 98005 98006 98003 98004 98010 98015 98008 Mgmt. & Waste Generator Req.

88045 ANNUAL 97001 97002 97002 98001 97007 98010 97003 97005 98002 Environmental 98001 98008 Protection 88050 ANNUAL 98002 98003 97002 98003 97004 98008 97008 97009 97010 Emergency 98005 98006 98012 99002 97015 98010 Preparedness 86740 ANNUAL 97001 98001 97001 98005 97002 98005 97008 98004 Rad. Material 98003 98005 Transportation 81401 ANNUAL N/A 98002 97005 97008 97006 98009 Security Plans 98004 81402 ANNUAL hUA 98002 97005 97008 97006 98009 Rpts. Of 98004 Safeguard Event 45 l l

COMBUSTION PROCEDURE FREQUENCY ALLIEDSIGNAL ENGINEERING PADUCAH PORTSMOUTH 81531 ANNUAL N/A 98002 97005 97008 97006 98009 PP of Low SNM 98004 81820 AS NEEDED N/A N/A 97005 98004 97006 Phys. & Ntn!.

Security Protection 92702 AS NEEDED 97001 98004 97004 98001 97004 97007 97004 97012 98007 F/U on Vlos. 98005 98006 98003 98005 97008 97011 98009 98010 98011 97014 98002 98012 98015 98016 98003 98004 98017 98006 98009 98010 98011 98015 90712 AS NEEDED N/A N/A 97002 97003 97003 97004 Inoffice Review 97004 97007 97008 97012 of Events 97008 97011 97015 98007 97014 98003 98011 98013 98006 98009 98015 98017 98011 98016 98018 98017 98018 92703 AS NEEDED N/A N/A 97002 97003 N/A Confirmatory Action Letters 40500 AS NEEDED N/A N/A 97009 98014 Self Assessment 35701 AS NEEDED N/A N/A 97009 97010 N/A Quality 98002 Assurance Program Rev.

39. Please identify any individual licensees with planned inspection frequencies different from the normal frequencies listed in Table 1 of the Appendix to inspection Manual Chapter 2600, and indicate the inspection procedure (s) so affected.

Planned inspection frequencies were documented and approved by both regional and headquarters management on the Master inspection Plan.

The minimum inspection frequency for the various inspection procedures has been met for all facilities in the Region lli inspection program. The only deviation is that in several instances the Region 111 fuel cycle inspection goals were exceeded as a direct result of the Region's response l to events and emargent issues. The following table is a list of the l reactive /special inspections conducted which were not planned on the MIP and those inspections which had a significant change in the content of the inspection (as defined in the MIP) due to emergent issues:

46 I

. 1

(.

18 Licensee Number Dates Description L

AlliedSignal 96007 12/16/96 - Special Inspection conducted due to 1/10/97 declaration of an ALERT on 12/16/96 Portsmouth 97007 7/29 - 8/1/97 Special inspection regarding the loss of onsite steam supply Paducah 97010 9/19/97 - Special inspection conducted due to the 2/16/98 dropping of an empty UF, cylinder Portsmouth 97013 12/8/97 -1/9/98 Specialinspection of the nuclear criticality safety program initiated because of extensive issues with NCS program AlliedSignal 98002 01/28 - 02/06/98 Reactive AIT inspection due to the declaration of an ALERT and injury of three onsite personnel Paducah 98005 02/23 - 02/27/98 Routine inspection, however content was changed to all training due to recent training issues AlliedSignal 98005 07/21/98 & Reactive inspection conducted due to the 08/31 - 09/03/98 declaration of an ALERT Portsmouth 98014 8/31 - 9/4/98 Specialinspection of the implementation and completion of the Compliance Plan Portsmouth 98019 12/9/98 - 1/8/99 Reactive AIT Inspection due to fire in the purge cascade and subsequent breach of containment systems Technical Quality of Inspections

40. With reference to the inspections described in item 1 above, please indicate the supervisory accompaniments made during the review period, and by whom.

Also, briefly describe the way the accompaniments were conducted and documented.

Inspector Supervisor Licensee Date O'Brien/Jacobson G. Shear Paducah GDP 1/8-10/97 Cox/Hartland G. Shear Portsmouth 1/20-22/97 O'Brien/Jacobson G. Shear Paducah 2/10-12/97 O'Brien/Jacobson P. Hiland Paducah GDP 6/11 & 13/97  ;

Jacobson/Reidinger P. Hiland AlliedSignal 6/12/97 i Cox/Hartland P. Hiland Portsmouth GDP 6/16-17/97 O'Brien/Jacobson P. Hiland Paducah GDP 7/21-25/97 Cox/Hartland/ P. Hiland Portsmouth GDP 7/31-8/1/97 Reidinger/Blanchard 47

Inspector SuDervisor Licensee Date Hartland P. Hiland Portsmouth GDP 8/25-27/97 O'Brien/Jacobson P. Hiland Paducah GDP 12/4/97 Jacobson P. Hiland AlliedSignal 12/5/97 O'Brien/Krsek P. Hiland Portsmouth GDP 12/11-12/97 Hartland P. Hiland Portsmouth GDP 12/15-17/97 Jacobson P. Hiland AlliedSignal 1/28-30/98 Jacobson P. Hiland Paducah GDP 2/5/98 Jacobson P. Hiland AlliedSignal 2/6/98 Hartland P. Hiland Portsmouth GDP 3/11-14/98 Hartland/Krsek P. Hiland Portsmouth GDP 4/8-9/98 Hartland/Krsek P. Hiland Portsmouth GDP 4/20-22/98 Hartland P. Hiland Portsmouth GDP 6/1-5/98 Hartland/Blanchard P. Hiland Portsmouth GDP 7/6-10/98 Hartland/Blanchard P. Hiland Portsmouth GDP 11/2-3/98 Jacobson K. O'Brien (Acting) Paducah GDP 11/2-6/98 Jacobson/Bisischard T. Reidinger(Acting) AlliedSignal 11/30-12/14/98 Hartland/Blanchard K. O'Brien (Acting) Portsmouth GDP 12/7-11/98 Hartland/Blanchard K. O'Brien (Acting) Portsmouth GDP 1/6-7/99 Hartland/Blanchard/ P. Hiland Portsmouth GDP 2/5/99 O'Brien [AIT Exit]

Supervisory accompaniments of inspectors were conducted through direct field observations of onsite inspection activities and through directly observing inspectors' communications with licensees and certificatees. Accompaniments were routinely scheduled to coincide with inspection exit meeting.

Documentation of some supervisory accompaniments is contained in the associated inspection report's " contact list." in addition, the Division tracks supervisory accompaniments monthly using the Management Information Statistics Report (MISRE) in the section entitled " Branch Chief Site Visits."

Results of inspector accompaniments are routinely discussed with Division management during the monthly " Branch Update Meeting."

Technical Staffina and Trainino

41. Please list the professional (technical) personnel assigned to perform inspections in the fuel cycle facilities inspection program, and the fractional amount of  ;

person-years of effort to which they are normally committed in the program. l Also, include the general inspection areas of responsibility (e.g., E=

environmental protection, N= nuclear criticality, O= operations, P= physical security, R= radiation protection, T= other). For those who joined the program since the last review, and any others who have not yet met the quahfication  :

requirements of fuel cycle facility inspection staff, please indicate when they joined the staff, the degrees they received, the years of experience in the general areas they inspect (e.g., health physics, engineering, etc.), and the extent to which they are qualified as NRC inspectors. A sample format is shown below.

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Name Qualification Level of Effort inspection Area (s)

Courtney Blanchard Fuel Cycle Safety 100 % E,N,0,R,T David Hartland Resident inspector 100 % E,N,0,R,T  ;

John Jacobson Fuel Cycle Safety /R 100 % E,N,0,R,T Jim Kniceley Physical Protection l 80 % P,T Rob Krsek Fuel Cycle Safety 100 % E,N,0,R,T Ken O'Brien SRl/Ri 100 % E,N,0,R,T Tim Reidinger Senior Fuel Cycle Safety 100 % E,N,0,R,T

[E= Environmental Protection, N= Nuclear Criticality Safety, O= Operations, P= Physical l Security, R= Radiation Protection, T=Other; RI = Resident inspector, SRl = Senior  !

Resident inspector] )

Since the last review, the following individuals in the Fuel Cycle Branch have assumed new positions and have not yet met the current position's training qualification requirements:

Courtney Blanchard: Mr. Blanchard joined the fuel cycle staff in October 1996 and has a B.S. In Mechanical Engineering, certification as a Professional Engineer (PE), and 17 years of work experience from a Naval Shipyard. Mr. Blanchard was qualified as a Fuel Cycle Safety inspector in September 1997. In 1998 Mr.

Blanchard was selected to fill the vacated resident inspector position at the Portsmouth GDP. Mr. Blanchard reported on site in July 1998 and has completed about 30 percent of the training requirements for certification as a resident ,

inspector. Training includes system walkdowns, review of applicable SAR, TSR, l and NRC requirements, and oral discussions with the Portsmouth SRI. Below is Mr. Blanchard's schedule for completion of his resident inspector training:

Activity Completion Activity Completion Date Date Llquid Cylinder 2/99 Cranes and Scales 5/99 Operations Feed / Transfer 3/99 Plant Utilities 7/99 Stations Uranium Recovery 3/99 TSR Admin. Controls 8/99 Ops.

CAAS Operation 4/99 Site Emergency Plan 8/99 UF Leak Detection 4/99 G.L. 91-18 /10 CFR 9/99 76.68 Fire Protection 5/99 Final Qualification 10/99 Systems 49

David Hartland: Mr. Hartland joined the fuel cycle staff in August 1996 and has a B.S. In Nuclear Engineering, a Masters Degree in Business Administration, and 15 years related work experience. Mr. Hartland is a qualified resident inspector for both reactor plants and the gaseous diffusion plants. Mr. Hartland was selected for the vacated senior resident inspector at the Portsmouth GDP in November 1997 and has completed approximately 98% of the requirements toward full qualification as a senior resident inspector. Below is a tentative schedule for the completion of Mr. Hartland's qualifications as a senior resident inspector.

Completion Completion Activity Date Activity Date Personal Management 5/99 EEO Information for Course Date Practices (Req'd Mgrs. & Supvs. TBD Course) (Req'd Course)

42. Please identify any professional or technical staff who left the fuel facility inspection program during the review period, and if possible, describe the reasons for their departures.

In August 1997, Charles Cox was selected to fill a position as a mechanical engineer, in the Special Projects Branch, NMSS/FCSS at NRC Headquarters. In January 1999, Rob Krsek was selected to fill the position of Resident inspector at the Palisades Nuclear Power Plant, Division of Reactor Projects, Region 111. Mr. Krsek will report to Palisades in approximately May 1999.

43. Describe what plans and procedures are in place to assure full coverage of the specified fuel cycle inspection procedures, as specified in inspection Manual Chapter 2600, in view of the possible impacts of retirements and other turnover on a small inspection staff. Also, please describe the extent to which current fuel cycle inspection program goals have been achieved, and the reasons for any differences between the goals and the actualimplementation of your program as the result of such personnelissues.

Manual Chapter 2600 is reviewed prior to the development of the MlP to assure that allinspection modules are addressed as required. The MIP, developed each fiscal year, is the primary tool to assure full implementation of the fuel cycle Inspection procedures. The MIP provides the inspection procedures to be used by each assigned inspector during a planned inspection. Additionally, the branch maintains a calender which tracks personnel planning and scheduling.

Regarding personnel turnover, succession planning within the Fuel Cycle Branch has included qualification as a fuel cycle inspector with subsequent assignment as a Gaseous Diffusion Plant (GDP) resident.

Both of the Fuel Cycle Senior Residents were also previously qualified as reactor resident inspectors. The net result is that the branch has a diverse and experienced inspection staff. The last two open fuel cycle inspection 50 l

positions were filled from candidates within the branch. During the time positions were vacated, required inspections were conducted by quallfled staff, i.e., both GDP residents are qualified to perform routine inspections at all fuel facilities. Turnover of Fuel Cycle staff is anticipated to remain at manageable levels, and any vacancy will be filled in accordance with the Region lli personnel guidelines.

Regarding the frequency of inspections performed at the fuel cycle facilities over the past two yeas, the Region 111 fuel cycle inspection goals have been bettered. The added inspections were a direct result of the Region's response to events and issues. Currently, the operating plan quarterly metrics review is used to track performance goals.

44. How are you managing available resources based on the overall safety / safeguards risk posed by each facility (i.e., matching available expertise to areas of greatest risk and weak licensee performance)?

I Resources are dedicated as required for each licensee in response to the results of the licensee performance review (LPR) process. The LPR process identifies functional areas that require additional NRC inspection resources to focus attention on areas with of perceived performance problems. Annual senior management screening meetings have been conducted for each licensee to discuss overall performance.

Inspection resources were initially assigned in the MlP based on identified risk. Adjustments in the inspection process are continuous based on performance issues. Several special inspections, including two AITs, have been conducted following significant events. Another method utilized to manage branch resources to perceived needs is the " task-assignment" of experienced inspection staff to supplement inspection resources. Task assignments typically are of short duration and assure the branch matches the available expertise to the area of greatest risk. Also, the branch utilizes NMSS and DNMS resources when specific inspection findings or perceived problems require expertise that is not available within the branch. Any request for assistance is discussed at the branch level both for NMSS and DNMS.

45. How are you managing inspection resources based on projected licensee activities (new system startups, etc., to assure that the right technical expertise will be available when needed)?

The on-going activity or schedule of Region 111 Fuel Cycle licensees does play a part in our scheduling of resources. For the most part, inspections of unique activities such as an emergency exercise are coordinated far in advance to assure available resources. Other "special inspections" are managed utilizing resources from the Region's DNMS and NMSS (e.g.,

AlliedSignal AIT follow-up). Where practical, routine inspections are modified by adding necessary resources to encompass both the routine inspection requirements as well as any needed special inspection initiatives (Paducah QA inspection).

51

46. How are you managing available inspection resources to assure adequate agency emergency response to credible fuel facility events / accidents? 1 The branch has continued to manage the emergency response aspect of the program by utilizing regional and re';ldent staff resources to respond to significant fuel facility events. The branch has maintained a diverse grouping of expertise 6 snong the inspectors, which provides resources for both ongoing inspectlaa activities and effective response to fuel facility events. When additional resources were needed to respond to an event, the branch has requested assistance from DNMS (Paducah dropped cylinder), NMSS/FCSS (AITs), and Rlil Division of Reactor Safety (Portsmouth Steam Plant and Paducah QA). The branch ensures adequate technical response to the emergencies through active participation in site emergency exercises and through inspection of the applicable site emergency preparedness program.

At both the GDPs, where NRC resident offices are established, the Region maintains continuous coverage through the use of the resident inspectors.

In instances where neither resident inspector is in the immediate area of the plant, the Region utilizes either regional or NMSS/FCSS resources to provide site coverage, or ensures that an NRC inspector is no greater than six hours away from the respective plant to respond to an event. In addition, the Paducah resident inspectors, who reside in close proximity to AlliedSignal, have promptly responded to several events at AlliedSignal over the past two years.

A response tabletop exercise was conducted with NRC resident staff, Region 111 management, and Environmental Protection Agency management to better define roles and responsibilities in response to a hypothetical event at a Gaseous Diffusion Plant involving an offsite release of UF6.

The following are examples of the management of resources which ensured agency response to significant accidents and events. Resident and regional staff at the Paducah GDP were dispatched to AlliedSignal to monitor recovery activities regarding events and accidents in December 1996, July 1997, January 1998, and, July 1998. In December of 1998, an NMSS/FCSS staff member was providing site coverage at the Portsmouth GDP and promptly responded to a significant fire. Region Ill's Division of Reactor Safety and NMSS/FCSS resources were utilized over the past two years in special inspections and augmented inspection teams at both the AlliedSignal and Portsmouth plants.

47. How do you assure that all licensee events are promptly reviewed and appropriate response taken, commensurate with the safety / safeguards risk?

(This includes event evaluation for generic implication, adequacy of licensee immediate corrective actions, compensatory actions, and completion of long term actions.)

52 l

l

For all Region 111 event notifications, the branch chief is notified by the Region til Duty Officer. If the event is being reported from one of the GDPs, the resident staff is generally Informed of the event in parallel with the licensee's report to the NRC Operations Center or Regional Duty Officer. For an event reported from a GDP, the resident staff performs an initial assessment of the significance and discusses proposed inspection follow-up with the branch chief. For the other Fuel Cycle facilities, an initial dialogue within the branch is conducted to evaluate the significance and propose follow-up activities. During these initial discussions, additional NRC staff consultations occur (e.g., NMSS/FCSS) dependent on the specific event.

All Region til events are discussed at the daily DNMS "0745 meeting" with divisional management and a representative from NMSS. Following the division's meeting, all events are then briefed by the Fuel Cycle Branch Chief at the Region's "0815 meeting." Attendees at the 0815 meeting include senior regional managers, regional council, and representatives from the Region's Public Affairs Office, State and Government Affairs Office, and the Office of Investigation. The daily event briefings assures at the earliest stage in the event review process that each event is communicated to a broad audience to solicit insights regarding significance, trends, or generic implications.

The division maintains an event notification log which is used to track all event reports. This tracking system provides a method to monitor the branch's follow-up actions regarding the review of licensee corrective actions, compensatory actions, and long term actions. For the GDPs, the Inspection staff's initial review of each event is documented in their routine !

Inspection report or memorandum as appropriate. For all significant events, the follow-up of the written licer'see event report is conducted as a routine inspection activity, and the reaults are documented in an Inspection report. Inspections are scheduled based upon safety and safeguards risks. The event notification log is reviewed on a weekly basis by the divisional management team.

48. What do you feel is/will be your greatest challenge for the next year?

Training and implementation of the new enforcement policy will be a challenge. In addition, replacement and training of future fuel cycle inspectors may be a challenge due to budget constraints.

49. What has been your greatest unexpected challenge over the past year?

Over the past year, the greatest challenge for the Fuel Cycle Branch has been to complete all assigned routine inspections and respond to significant events or issues with reduced resources. During this past year, the normal staff complement for the Fuel Cycle Branch was affected by temporary rotational assignments for the branch chief, senior fuel cycle inspector, and senior resident inspector. In addition, early in the year, the 53

time required to replace a vacated resident position required close monitoring of available resources.

i

50. If you were given any additional resources, where would you put them or what would you focus them on (include things that you are, or would like to do)? I Additional resources would permit better succession planning, particularly with resident inspectors. As currently exists, there is no defined pathway for development of future Fuel Cycle resident inspectors. Based on the lack of interest for two vacated Fuel Cycle resident positions over the past two years, the need for a pipeline to recruit and train replacement inspectors is evident.

Additional staff would be devoted to addressing LPR identified  !

weaknesses at the various licensees. The added staff would also assist  !

the GDP inspection program and conduct allegation reviews as assigned. l l

51. What was your most significant accomplishment of the past year? Greatest disappointment?

The most significant accomplishment over the past year was effectively implementing the MlP and performing necessary reactive inspections with I reduced resources. Of particular note were the inspection findings at l AlliedSignal and the performance assessments for the GDPs. l The greatest disappointment over the past year was the slow rate of performance improvement at the Portsmouth facility despite our efforts to

" add value."

IV. General l

52. Summarize any significant reprogramming actions taken during the review period, and the basis for these actions (e.g., moved 2 budgeted FTE from non-core materials inspections to materials licensing to eliminate a backlog). List any major program accomplishments or initiatives not cited in other answers.

Indicate any areas in which DNMS did not meet its Operating Plan goals.

Debble Piskura was temporarily reassigned from materials inspection to materials licensing to reduce the pending backlog of licensing actions.

This temporary assignment lasted 6 months and had minimal impact on the core inspection program.

B. J. Holt was reassigned from Chief, Materials Licensing Branch, to Director, Division of Resource Management and Administration. For several months during this review period senior license reviewers assumed the duties of the branch chief. During the period before a permanent selection was made, the Materials Licensing Branch completed over 93 percent of all licensing actions timely, and the licensing backlog remained approximately at the level it was at prior to the re-assignment.

54

Monte Phillips was reassigned from Chief, Materials inspection Branch 2, to the allegations staff to reduce the backlog of allegation cases, develop the regional allegation procedure, and provide oversight to allegation activities. During this period one of the senior inspectors assumed the duties of the branch chief. This temporary assignment lasted 6 months and had minimal impact on the core inspection program.

In the decommissioning branch, signifit: ant reprogramming occurred in

]

two areas: assumption of responsibility for conduct of the inspection program at the Zion nuclear plant in June 1998, and implementation of a special initiative to upgrade the Region 111 laboratory at the start of FY 1999. The Zion inspection effort involved assignment of a " lead" inspector, to whose existing duties this responsibility was added, and performing an ongoing, every-week inspection activity utilizing a rotating cadre of five personnel, including the " lead." The FTE utilization rate amounted to almost one full FTE. The laboratory special initiative involved temporary (about three months) assignment of the health physics manager, and the Decommissioning Branch Chief, on an all-day, every-day basis to join with the full-time assigned laboratory operations specialist in completing more than a hundred specifically identified and tracked " action items." A senior radiation specialist took on many of the normal branch chief duties during the period from September 1998 into December 1998 while this initiative was performed.

Over the past two years the Fuel Cycle Branch has effectively utilized available resources to complete the inspection program responsibilities.

Significant program accomplishments included support to the NRC's performance evaluations for the GDPs, and the conduct of LPRs for .

AlliedSigtsal and Combustion Engineering. Also during the last two years,  ;

the branch has been effective at identifying areas of concern which warranted special inspections, including the steam plant failure at  ;

Portsmouth, dropped cylinder at Paducah, criticality safety inspections at '

Portsmouth, compilance plan inspections at Portsmouth, corrective action program inspection at Portsmouth, AIT and follow-up inspection at I AlliedSignal, and the AIT and follow-up Inspection at Portsmouth. Other major accomplishments were the significant inspection findings which '

included Portsmouth's failure to maintain mechanical components, programmatic breakdown of the criticality safety program at Portsmouth, failure to properly implement certain compliance plan issues at Portsmouth, and the identification of procedural adherence problems at Combustion Engineering. In addition, the branch was very effective at evaluating the risk significance of safety limit violations at Paducah, and the branch was an effective team member during NMSS' resolution of Paducah seismic deficiencies.

Region til met all operating plan goals but two for the first quarter of 1999.

Specifically, the Fuel Cycle Branch was late with three inspection reports, although all inspections required to be performed were completed. In one 55 .

case, the report was three days late, and the other two late reports were the result of unplanned illness of the inspector.

53. Provide any comments and recommendations regarding the effectiveness of Headquarters support to regional activities and the Region /He adquarters interface. Identify any regional interaction with Headquarters and licensees to improve the quality of your licensing / inspection program.

Overall, Headquarters support to regional activities has been excellent in certain areas. The interface between 3egion 111 and Headquarters is very good, and has been consistently improving. The implementation of the regional coordinator position and the daily call have been useful in conveying information between the staff. This has resulted in an increasingly more timely response to inost of our questions.

Headquarters support and effectivenoss of the Region / Headquarters Interface in the decommissioning area were outstanding and were identified as a " Strength" in response to question 26, above. The integrated licensing and inspection plan for decommissioning was a particular Initiative which, while still relatively new in use, is considered a significant advance in resource planning and management. Support for the laboratory upgrade was critical in the successful completion of the project and took the form of senior management attention, resources (contracted substitute services and consulting, equipment purchases) and technical direction and advice.

The interface with Headquarters regarding complex, major, or unusual regulatory questions has been invaluable to the Region and has served to improve the quality of our licensing and inspection programs, and improve the timeliness of enforcement actions.

As noted above, the Region ill initiatives to inspect major broad scope licensees and portable gauge licensees have resulted in significant improvements to the inspection program. As a result of these initiatives, inspections have been performance based and focused on observing licensees' use of material, and radiological work practices rather than a review of licensee records.

Headquarters should strive to improve communications with other program offices, e.g., Office of General Council and Office of Enforcement, to ensure a timely response to TARS and regional requests regarding change of ownership and bankruptcy cases. As an example the Region has had a longstanding TAR on two licensees (UCAR and Gelman Sciences) regarding disputed violations related to change of ownership.

When the Region received the response regarding these issues it appeared to contradict the guidance in the " draft" NUREG which was in the final stages of being published. Further communication with OGC was necessary to resolve the issues in these cases.

56

The quality of licensing actions has shown improvement with the issuance of the consolidated guidance documents (NUREG-1556 series). However, there are areas where improvement could be made. For example the quality of many of the cur. ently active standard review plans (SRPs) that have not been supercedcil by a NUREG-1556 document is not good (e.g.,

the checklist for reviewing HDRs and medical applications differs from the SRP). TARS submitted to NMSS need to be processed and the results issued to the Regions in a more timely manner to allow the Regions to complete the associated licensing action within the timeliness goals.

In the area of fuel cycle licensees, support to the Region, and the Interface by headquarters staff has been very effective. Headquarters has provided timely evaluation of technical and licensing issues, needed resources, and has served as a partner in developing the Region's inspection strategies.

The headquarters staff consistently fosters an open dialogue on significant

. issues at all levels, which has resulted in a team approach to resolving inspection findings. Some examples over the review period include, the inspection and management of criticality program issues at Portsmouth, the AlliedSignal AIT follow-up inspection findings, and more recently, the full participation on the NRC response to the Portsmouth fire.

One suggestion to improve the quality of the fuel cycle inspection program is to expand our existing program of inspection accompaniments between regional inspectors (e.g., Rlli to Ril and Ril to Rlll) to also include headquarters staff. These inspections could be preplanned and easily integrated into the MIP with input and feedback from both regional and headquarters management.

54. In which areas of licensing and inspection guidance do you need the most training? Please provide a list by priority, highest first.

A policy should be developed and training provided to the Regions on how licer aing actions will be handled from malling by the licensee through fasuance by the license reviewer in the new " electronic" environment of ADAMS. For example, we have heard that NMSS is considering a centraliacd receipt for all license action requests, rather than the current practice of licensee's wr.d!:'g the request to the Region. As major NUREG-1556 volumes become final, training should be provided to the licensing and Inspection staff on how the two roles (inspection and licensing) will complement each other in determining an adequate level of safety as new licenses are issued under the new guidance. Finally, training should be provided to license reviewers on the " streamlined renewal process."

in both the inspection and licensing arena, additional training is needed in the areas involving the new Part 35 requirements and handling of change of control / ownership and bankruptcy cases.

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REGION lli MANUAL REGIONAL PROCEDURE 0517A MANAGEMENT OF ALLEGATIONS A. Scope ,

This document prescribes the regional procedures and policy for the implementation of the NRC allegation management policy in accordance with NRC Management Directive (MD) 8.8, " Management of Allegations", and those portions of NUREG/BR-01g5, Revision 1. "NRC Enforcement Manuaf", applicable to the handling of 01 reports or allegations. Users of this procedure shall famlGadze themselves with MD DirecGve and Handbook 8.8.

B. References NRC Management Diracuve 8.8, " Management of Atad~ts" NRC Management Diracuve 7.4, " Reporting Suspected Wrongdoing and Processing OlG Refe: Tats" NUREGIBR-0195, Revision 1, "NRC Enforcement Manual" NUREG-1600, "NRC Enforcement Polic/

NRC Manual Chapter 1007, " interfacing AcGvities Between Regional Offices of NRC and OSHA" Regional Procedure 0518, "Handhng Fitness for Duty Matters" Regional Procedure 1007A, " Interface Adivities Between Regional Office and OSHA" Regional Procedure 1215, "HandEng Office of Investigation Reports and infonnation" Regional Procedure 1460, " Working Arrangements for implementing the Memorandum of Understanding with the Department of Labor" Emergency Preparedness and Environmental Health Physics SecGon Policy & Guidance Procedure 002-C. _SM_Remonsit2dr ,

Specific responsibilities for all personnel are specified in Attachment 3. They are broken down by responsibiliGes of the Regional Administrator (RA) and Deputy Regional Administrator (DRA), technical Division Directors, technical Branch Chiefs, technical & .

the Senior Office AN-a~t Coonlinator (SOAC), Office AM-8~i Coordinator (OAC),

Enforcement Officer (EO), Enforcement and investigation Coordination Staff Administrative Assistant (EICS-AA), Regional Counsel, Field Director for the Office of Investigations, division and branch Secretaries, State Liaison Officer, Regional ,

1 Agreement States Officer, and the receptionist.

CONTACT: J. A. Hopkins _

Revised 3/05/98 Senior Office Allegations Coordinator i

b

RP 0517A D. _ General Information i

' Alleastion: A declaration, statement or assertion of impropriety orinadequacy associated with NRC-regulated activ Ges, the validity of which has not been established. This term is further defined in Attachment 5.

Confidentiality: In Recion Ill. confidentiality can be offered only by the Raaianal Administratet. This authonty may be delegated. If at any time, for any reason, confidentiskty is breached orJeopardu:od, the Regional Administrator must be informed l and the concemed individual (Cl) should be advised, the reason explained and remedal measures taken, if possible, to reduce the impact of disclosure.

Confidentiskty is not to be granted as a rouhne matter, rather con 6dentiakty should be granted only when necessary to acquire information in the best interest of the agency. It may be offered to those Cis who by their actions would not readily make the desired information available or where there are other circumstances that might warrant it. The offerof a confidentiskty agreement should be contingent upon an assessment of the usefulness of the information provided if sus a determination can be made in a timely manner. For the majorky of individuals, confidentality need not be provided. The details on granting of confidentishty, as well as the specifics of the confidentiakty agreement, are addressed in Management DirecGve 8.8, Handbook Section Ill.

As a general rule, however, the "need to know" principle should be implemented where the identity of any Cl is conoemed. For those Cis with a confidentiality agreement this means that the identity of the source must be protected by not referring to the Cl or other idenGfying information in discussions unless absolutely necessary and by expurgatmg the name and other identifying information from documents before disseminating these to the staff. For those Cis without a confidentiskty agreement, this means avoidance of unnecessary use of the identity of the source and other identifying information in discussions and in documents, it must be made clear to all concemed if, and on what terms, the anonymity of a person making an :":M= is to be released. A clear record should be maintained for the files to preclude later misunderstanding. AWM files cordaining the identity of Cis must be protected to prevent the identity of Cis fmm being disclosed.

E. Procedure 1.0 ReceMna Alleastions 1.1 Allegations or conoems may be received in Region lit by one of four ways:

1. A direct call to one of the allegation coordmators (such as over the allegation hotline);

2. A contact by an inspector or other technical staff with a Cl, either by phone or in person;

3. A document is left with an inspector or mailed to the Region lit office; or ,

2 Revised 3/05/98

RP 0517A

4. The allegation is referred to the region by an NRC Headquarters office, another region, or another agency.

With the exception of the latter two, either of the OACs should be involved, jf possible. In the receipt of the allegation. Inspectors should use good judgment when attempting to involve the OAC sta# and should take an allegation K involving the OAC sta# would be detrimental to receipt of complete and canded information or K no member of the OAC sta# is immediately available f_o assist in taking the allegation. Delays in taking an allegation or discussing the issues with a Cl, solely because the OACs are not available, may leave a Cl with the wrong impression and delay our assessment of the safety significance of a CI's issues.

1.2 If neither OAC is available, the inspector should, at a minimum: (1) take the allegation (see the following section for the information to obtain from and provide to the Cl); (2) obtain the Crs name, address, and telephone number; and (3) document the ":;=hn in as much detail as possible and forward the information to the immediate supervisor or cognizant Branch Chief and EICS via E4nall(address: OAC3) within three workdays. DO NOT include the Cl's name, address, or telephone number in the E mail. Provide that information to the OAC through the mall in an " addressee only" envelope or by telephone. The OACs will contact the Cl if a follow up callis needed. Attachment 1 provides sta# guidance in taking allegations. The information to be obtained is described in detailin Section 2.1.

1.3 Individuals wanting to report safety concems or violations of NRC requirements can contact the Rlli Office Allegation Coordinators by calhng 1800695-7403

(:"::=*n hotline) as shown on NRC Form 3, Notice to Employees, or through the Region lil Switchboard at 1800-522-3025, 1.4 OK-hours allegation calls made to the allegation hothne are forwarded to the Headquarters Duty Officer, Operations Center, and then to the Regional Duty Officer. The information should be given to one of the OACs the next working day.

1.5 Drop-in Visits by Allecers: N an individual appears in person at the Regional Office and wants to speak with one of the OACs, the individual should be referred to EICS. The individual SHAl.L NOT sign in at the NRC recephon area. The receptionist shall call the ElCS AA and inform her that an individual is in the waihng area who wishes to speak with one of the OACs. The ElCS-AA shall noufy one of the OACs, or K none are available, the Enforcement Officer, who will escort the individual to the EICS conference room, where the individual will sign in as a visitor. The information to be obtained is described in detail in Sechon 2.1 below.

2.0 Information to be Obtained from/Provided to the Cl 2.1 Any eir@p contacted by a Ci should attempt to refer the Cl to' one of the OACs, K possible; however, K an OAC is not immediately available, then the e r@y:: should obtain the following essentialinformation:

l n r% , *,. J A 9A ,* ,hD

1 t

RP 0517A

a. Full name.

b. Home mailing address.

c. Whether the Cl objects to having his/her identity revealed.

d. Whether the Cl objeds to having the conoems forwarded to the licensee for follow up (consistent with protecting his/her identity),

e. Telephone number where the individual may be contaded (both home and work N possible). Ask what is the best method to contad them.

f. Position or relationship to facNity or activity involved.

g. Nature of allegation (s) (who, what, when, where, why, how)

h. Any documents?

1.

Have you told your management or Employee Concems Program? What was their response?

j. Does the Cl believe there is an immediate threat to public health and safety or to plant equipment? If so, why?

Restate each of the concems to the Cl to ensure you clearly understand. If the Cl is alleging employment discrimination, remind the Cl that he must file a written complaint with DOL OSHA within 180 days of the alleged discriminatory act to obtain personal relief.

2.2 If the Cl dedines to provide the above information, attempt to estabEsh the reason (s) using the following guidance: Inform the individual that Public l.aw 95601 affords protection to the Cl by prohibiting an employer from '

discriminating against an employee for contading the NRC. If the individual says that they wul provide the information if their name is kept confidential, inform the person that k is NRC policy to proted indsvidual identities when possible whether confidentialsty is granted or not. However, if the person wants a con 6dentiality agreement, it wlR have to be coordinated through the Regional Office (see Section 2.9 on the process for granting confidenhalsty). The Ci should be informed that only the Regional Administrator is authorized to grant confidentiality, and if the Ci still persists in requesting confidentiality psior to giving the information, the Ci should be told to contad one of the OACs, who will handle the CI's request.

2.3 Consistent with MD 8.8, the Cl must be informed of the degree to which their identity can be protected.1his is necessary since some Cis may incorrectly assume that the NRC can or wHl protect their identity under aR circumstances.

Therefore, individuals to whom the NRC has not granted confiden6ality should be informed that the NRC intends to take au reasonable efforts not to disdose their identity and of the circumstances under whid their identity may be revealed (see ,

MD 8.8, Part 1(A)(2). The information contained on the laminated card provided '

to aR technical staff entitled "Disdosure of AY% Identity" (NRC Form 613)  !

shat be provided to the Cl after obtaining as mud informahon as possible. If at any time k becomes necessary to release the identNy of an alleger for the reasons  !

described on the laminated card, with the excepGon of einr icymein discrimination orwrongdoing investigations, the Regional Administrator or Deputy Regional Administratorwig be consuNed and approve the release. Reasonable efforts will be made to contad the Cl and explain the need for disclosure unless k is docasmented in the AMS file that the Cl has dearty indicated no objection to being ' l identified. ,

4 Revised 3/05/98 j

s RP 0517A 2.4 in the event a Cl provides information which may be safeguards or classified information, the Ci should be advised that he/she will be contacted to arrange a personal interview. Exceptions apply if the information involves an immediate health and safety matter.

2.5 The Ci should be informed that the NRC employee with whom he/she is in contact with cannot at the time evaluate the information, determine follow-up action, or establish NRCJurisdection. It may be necessary that sonwone else contact the alleger for additional information.

2.6 The Cl may be informed also, that unless an objection is registered he/she will receive written notification within 50 days regarding the :":;EE ,, at an address designated by the Cl, which will also =*rc;e f-;= the receipt of the :":;sh.

This process will permit the C1 an opportunity to review the infonnation and provide some assurance that the information has been correctly translated by the NRC.

2.7 ff the Cl persists in not providing their identification after the above explanations, document the aRegation in as much detail as possible and advise the Cl that follow up information related to the conoems wiu not be available.

2.8 For allegations of discrimination that fan under Section 211 "C&+ic,=

Protection", of the Energy Reorganization Act, advise the aNeger that a written complaint must be filed with the Department of Labor within 180 days of the occunence of the discrimination event to assure personal employee rights and remedies are protected (such as reinstatement, back pay, etc.). (Also see Regional Procedure 1460, " Working Arrangements for implementing the Memorandum of Understandmg with the Department of Labor.")

2.9 For those cases where the Cl wul not provide the concem to the NRC without obtaining confidentiality, a discussion between the Cl and OAC will be held to determine the following: .

(a) has the Cl provided the information to anyone else (for example, is the I information already widely known, with the Ci as its source);

(b) does the NRC already know of the informatson, obviating the need for a particular confidential source;  ;

(c) does the Cl have a history that would weigh either in favor of or against granting confidentiality in this instance (for example, has the Cl abused grants of confidentialityin the past);

(d) is the information that the Cl is offering within the jurisdiction of the NRC; (e) why does the Cl desire confidentiality (what would be the consequences to i the Cl if his or her kientity was revealed?);

c n .. .: - , , me ma

RP 0517A (f) does it appear that the Cl caused the condsbon or committed the violation and could likely be subject to civil or aiminal prosecubon (MD 8.8, Sechon 111.B.1).

Based on the information provided, the OAC will consuh with the Regional Administrator on whether confidentiality should be granted using the guidance provided in Management Drective 8.8. If the decision is not to grant confiderdiality, the Cl wlN be so informed. If the decision is to grant confidentiality, two copies of the ' Confidentiality Agreement"(Exhibit in Management Directive 8.8) will be signed by the regional administrator and provided to the Cl with instructions to sign both copies and retum one to the region. Upon receipt of the Tonfidentiality Agreement" signed by the Cl, the Cl wlN then be treated as a Confidential Source per Management Directive 8.8.

3.0 Alleastions Received by Mag 3.1 A'N oorrespondence that appears to contain anegation material, induding intemal NRC memoranda addressing allegations, should be forwarded promptly.to the SOAC for handhng and coordination. To avoid the distribubon of material that may tend to identify individuals as Cis, the complete cordents of sud conospondence and the envelopes should be forwarded to the SOAC. No copies should be made.

4.0 initial Review of Allenstions 4.1. The individual ihtig the anegation shaN documerd the information (normaNy, this will be one of the OACs). Clearly list each concem. Provide any other information that will help clarify the concems and aid in the inspection. The information should be documented in a memorandum and provided to tlw SOAC in hani copy and by E-mail within three working days of receipt. The E-mail  ;

version shaN not include the name of the Cl, and wlR be transmitted electronically to E4nall address OAC3. This memo should be concurred in by the individual's supervisor and no copies of the memo including the Cl's name should be made.

This wNl help control the identity of the Cl and minimize inadverterd disclosure. .

4.2. Upon receipt of the :":; :-5, one of the OACs wlN review the :":;:: to  !

identify the specific conooms and whether an emergency ARB is necessary. The t

. OAC wlN then cordad the appropriate divisional managemord (DRS and DRP for reactors, DNMS for materials) If the OAC determines that an emergency Allegation Review Board (ARB) is necessary orif there is a question as to which Branch should be assigned the lead. If an emergency ARB is necessary, it will be scheduled as soon as possible (normany within the next two hours).

4.3 As necessary, the OAC win coordinate allegation information with the assigned te$nical staff and determine whether a valid allegation exists. if necessary, the OAC (with divisional support, as needed) wlR re contact the Cl to otdain any adddional information. In some cases, the Cl may call bad to discuss the status of an allegation, or to obtain adddionalinforma6on from the Cl. In either case, if a '

phone caN occurs between a member of the Region H1 staff and a Cl, the call must 6 Revised 3/05/98

RP 0517A be documented in a conversation record or memorandum and provided to ElCS I for inclusion in the allegation file.

4.4 Technical issues in the allegation that involve an individual's failure to meet requirements have the potential for being willful or deliberate violations. However, in the absence of specific allegations of willfulness or deliberateness, such issues will normally be tracked separately as tedmical issues and resolved using program resources.

4.5 Due to their potential impact on safety, au matters involving potential wrongdoing wul be handled on a priority basis. Potential wrongdoing identified through the allegation process win be promptly brought by the OAC to the attention of the ,

Field Director of the Office of Investigatsons (01), in addition to the appropriate Division Director. Potentialwrongdoing identified through the inspedion process win be promptly raised through the inspectors' management diain and to the OAC who wlN then notify the 01 Field Office Director.

4.6 ."-tions regarding suspected improper conduct by NRC employees and NRC contractors wRt be brought to the attention of the Deputy Regional Administrator for possible referral to the Office of Inspedor General (OlG). Allegations of this nature are not entered irdo the AMS. (

Reference:

NRC Management Diredive 7.4.)

4.7 AllegaGons that faR within the purview of OSHA are to be tumed over to OSHA through the Region til state Watson Officer, and are not to be entered in the AMS.

(

Reference:

Regional Procedure 1007A, NRC Manual Chapter 1007 and MD 8.8,Section I.D.1.g).

4.8 Allegations that involve agreement state matters should be coordinated with the Regional State Agreement Officer. In those cases where the :": en , involves wrongdoing on the part of Agreement State personnel or deals with the adequacy of the Agreement State's regulatory oversight, the guidance in ARegation '

Guidance Memorandum g702 wNl be implemorded. Namely, the case win be referred to the Office of State Programs allegation coonlinator for follow up.

5.0 Initial Documentation and Development of Alleoation File 5.1 The OAC wlE enter the allegation information irdo the Allegation Management System (AMS), listag eadi conoom and facility for the specific Cl. This wiu be done as soon as possble, but no later than 30 days after receipt of the allegation.

If related conoems are identified that can be traced to other allegations already in the AMS system, a cross-reference for that conoom wiu be included under the "related allegation" tab identifying the conoom and auegation number where the related conoom can be found. The conoom for that allegati m numberwill also be annotated with a "related ausgation" action tab showing the new allegation number and concom. Specific edion tabs to be ordered include " Initial ARB Meetmg" (planned date is 30 days from receipt date), '644onth ARB Meeting" (planned date is 6 months from receipt date), and if a spedfic Cl is identified.

. " acknowledgment letter" (planned date is 30 days from receipt,date) and "dosure letter"(no planned or assigned dates).

7 Das,;end '3 Int; ton

RP 0517A 5.2 The OAC entering data into AMS will establish an allegation file including the following specific serial items: 1) Identification Sheet (identifies the Cl with address and phone numbers); 2) Ust of Spedfic Concems (specifies each concem in the allegation and its regulatory basis if known); 3) documentation received or developed that identifies the adual text of the allegation and specific concems, in addition, records of any conversations with the Cl, related documents, etc. shall be included in the case file.

5.3 For those allegations where a specific Cl is identified, the OAC entering the data into AMS shall at the same time prepare the Acknowledgment Letter to the Cl using the boilerplate letter provided in the G:EICS\ BOILERS %CKNOWLBOL file.

The specific concems placed in AMS should be electronically cut and pasted into the letter to the Cl to ensure that the AMS file is accurate. The Acknowledgment Lmiter to the Cl must be developed to address whether the Cl has objected to identity release or referral to the licensee, and whether the allegation involves discrimination or not. The a&ccid-;;-ment letter should show the sender to be the OAC, with a copy to the appropriate AMS file. There are no concurrences for the acknowledgment letter. The acknowledgment letter will be sent to the Cl by certified mall, with a retum receipt request, and will not be mailed in an envelope carrying an NRC logo or label, or NRC metered postage.

5.4 After entering the allegation data into AMS, the OAC shall prepare a

• Receipt of New Allegation" memo to the cognizant Branch Chief that specifies the upcoming date for the ARB and specifies what is to be decided at the ARB conoeming that allegation. A copy of the badtground information, and "Ust of Specific Concems" (which documents the concem and regulatory basis, if krwn) will be included with the "New AHegation" memo. The ElCS.AA wW provida copies of the "New Allegation" memo with attachments as follows: the D'< Mon Director / Deputy (DRS for reactor cases, DNMS only for materials cases). Of Regional Fudd Office, and Regional Counsel will receive copies of the memo, tst of Specific Conoems",

and background information only (with the allegers identity conced). The Deputy Regional Administrator wiu receive a copy of the memo and "Ust of Specific Conoems". The original of the memo wHI be placed in the case file, and .

will indude an attendance and approval sheet for the upcoming ARB with a preliminary description for the basis of safety significanoe for the auegation. The addressee wW receive the memo, ust of Spedfic Concems", ba4wnd information (with the auegers identity concealed), and an ?N-*% Action" page for each conoem, and a recommended action by the OAC.

5.5 All documents containing the identity of the aNeger, other than publidy available information, wiu be handled as NOT FOR PUBUC DISCLOSURE.

5.6 At the 8:15 moming meeting, a member of the ElCS staff (usually the Enforcement Officer) wlH brief the Division Directors and other attendees by providing the name of the facility where the concems are alleged to have occurred i and the date when the ARB will be held to discuss the concems for those j conoems received the previous day.  !

1 I

8 Revised 3/05/98

RP 0517A 6.0 Initial Alleaation Review Boards (ARB) 6.1 Regular ARBS are held every Monday in the ElCS conference room as follows:

Materials cases from g:30 until 10:30 a.m.; and Reactor cases from 2:05 p.m.

until 3:30 p.m. The ARB will include all cases received and processed into the AMS during the seven day period between Thursday aftemoon and the following Thursday moming. In no case should the initial ARB be delayed more than 30 days from the date of receipt of the allegation. The purpose of the initial ARB is twofold; namely, to ensure that all concems have been identified in the allegation package, and that an appropriate course of action is specified to close out each of the concems.

6.2 The following individuals or their deputies / actors shall attend ead ARB: Regional Counsel, Of Field Of5ce Director, SOAC or OAC, the cognizant te&nical Branch Chief, the DRP Branch Chief with responsibility for the facility, and the ARB Chainnan. The ARB Chairman is the Director of Reactor Projects or Reactor Safety, as designated by the Regional Administrator, for reactor cases; and the Director of Nudear Materials Safety for matedals cases. These individuals should come prepared to discuss (1) the safety significance of the allegation, (2) the rationale for the safety significanoe, (3) the prionty of the auegation (immediate inspection, inspection within 30 days,60 days, etc.) assuming that the aNegation is true, and (4) the priority for an Of investigation, if warranted.

6.3 Each Thursday, the ElCS AA wul distribute the ARB pack ges as noted in Section 5.4 above and 12.5 below. The ElCS-AA win also prepare and distribute the ARB agenda via E-mau to su technical divisional management and their secretaries. It is the responsibuity of technical division secretaries to ensure that individuals acting for the Branch Chief are provided a copy of the ARB agenda Monday moming. If the cognizant Branch Chief wlN not be prepared to discuss the case by the scheduled ARB date, he should contact the OAC, responsible Division Director, and the Board Chairman and have the case rescheduled to the following week. Sud re-scheduling requires ARB Chairman approval. ,

6.4 Prior to the ARB, the cognizard technical Branch Chief shaR review the background information provided with the 'New MT'%" memo and verify that au conoems of the Ci have been listed on the "tJst of Specific Concoms". If this review identifies conoems that were not previously listed, one of the OACs should be contacted immediat?; to ensure that the concems list is updated, AMS is updated, and the radi4%.;;T,ed conoems are discussed at the upcoming ARB.

6.5 Also prior to the ARB, the cegni .ent technical Branch Chief for the concem will review the recommended course of schon from the list provided on the "ARegation Action" page and either concur or revise the recommended action. Just pdor to the ARB, the Branch Chief will provide the marked page to the OAC in attendance at the ARB.

)

6.6 The ARB will dedde IF there is an issue requiring NRC fouow up, and if so, then l WHO:T,hould follow up to close the issue. Normally, this will be one of the l following three options: refer it to the licensee, perform an inspechon, or refer the O OnuicaA 'afMIOR

RP 0517A concem to the Office of Investigations. This latter option will be the normal choice for cases where wrongdoing is likely or employment discrimination has occurred.

NOTE: When refening cases to 01, the cognizant Branch Chief must be prepared to do the following:

clear 1y identify what specific requirement was violated; provide a copy of the procedure or technical specificah that has been violated; provide a copy of any problem report or other documents related to i the concem; and j 1

provide a basis that would show that the violation was likely to l have been wilful as opposed to inadvertent or based on a lack of  !

knowledge of the requirement.

Cases should not be referred to 01 unless thir ' x aas been established.

In some cases, the NRC may chose to close the concem without taking any action because the concem is too vague to be followed up, the conoom lacks merit, or the concem is outside NRC's regulatory responsibilities. Things the ARB should consider in assigning responsibikties and edion dates are described in  !

Management Dwecove 8.8,Section I.E.2.c, and include the following-Safety concems requiring immediate regulatory action Feedback to the Cl i Technicalissues Wrongdoing concems and the prioritization of investigations Potential forchilling effects .

Potential for the allegation being generic Appropriate actions to close the concems Referrals to licensees or other organizations Significanoe and status of allegation as it retaks to ongoing licensing or escalated enforcement actions '

Wmdow of opportunity to observe the alleged activity opportunity for coverg Startup or continued operations decisions if the allegation were true Scope of potential conochve actions if the :":;st':-a =

were true 6.7 ARBS should refer as many allegations as possible to the licensee for schon and response unless any of the following factors apply (see MD 8.8, Sedion I.C.1):

the information cannot be released in sufficient detail to the lioensee without compmmising the identity of the C1 (unless the Cl has no objection to his or her name being released) or the release of the information could bring harm to the Cl; 10 Revised 3/05/98

RP 0517A the licensee could compromise an investigation or inspection because of knowledge gained from the referral; the concem is made against the licensee's management or those parties who would normally receive and address the concem; or the basis of the concem is information received from a Federal agency that does not approve of the information being released in a referral.

In determining whether to refer concems to a licensee, provided the above four situations do not apply, consideration should be given to the following (see MD 8.8,Section I.C.1.b):

What is the licensee's history of allegations against it and past record in deshng with allegations, including the likelihood that the licensee will effectively investigate, document, and resolve the concom?

Has the Cl already taken this conoom to the licensee with unsatisfactory results? If the answeris yes and the conoom is within NRCjurisdiction, then the concem should normally not be referred to the licensee.

Are resources to investigate available within the region? and Has the ci voiced objection to the release of the conoom to the license? l l

6.8 The deliberations of the ARB will be documented by the OAC in attendance. This l documentation will be approved at the ARB by the ARB Chairman. The  !

documentation must contain the following per MD 8.8, Sec6on I.E.3:

f:;em number; date of ARB; attendees; pu@ose of the ARB; plants affected (induding generic applications);

applicable action items and schedules for the action office or Ol; ARB assessment of the safety significanoe of each concem; priodtylevel for 01 inv::4;#m (if Of assigned the action);

proposed inspec6ons and investigations; rationale for referrals to licensees; and the basis for the ARB decisions regarding safety significance, Ol pdority, and proposed inspections or investigations.

The minutes of the ARB will be provided by the attending OAC to the ElCS-AA for entry of acGons into the AMS system and inclusion of the minutes in the ;":;4m file. Assigned technical branches will be informed of specific actions assigned to them via the bhveeldy reporting system of open allegation ac6ons. If the ARB determines that a concem will be referred to the licensee, the OAC shall ensute that the Cl does not object and that he is informed, if possible, of the referral.

This will preferably be done via the issuance of the acknowledgment letter to the CI (see Section I.C.1.d of MD 8.8 and Se&on 5.3 of this procedure).

.. ,, . . . . , m c on o

RP 0517A 6.9 ff the ARB concludes that a conoem has generic implications, should be referred to another govemmental agency, or an Agreement State, the actions assigned for that concem will be implemented by the OAC as follows:

6.9.1 Alleaation involves Generic Implications:

The OAC will contact the affected Offices which should result in a mutual agreement as to which Office or Region should have the lead. If agreement cannot be reached at the OAC level, then the Deputy Regional Administrators or Office Directors will resolve which Office or Region should take the lead. Unless Region ll1 is the lead office, the OAC will document transfer of the allegation to the lead Office or Region for follow up. The Rill allegation wlN be closed when the Cl has been informed that the concem has been transferred to the other Region or Office.

6.9.2 Alleaation to be Refened to an Aareement State:

The OAC will prepare a transfer letter to be sent to the Agreement State transferring the concems. The letter will be signed by the Director, DNMS, and concurred on by the cognizant DNMS Branch Chief and Agreement State Programs Officer. The a#egation wlR be closed with the transfer of the concem to the Agreement State if the Cl has agreed to the release of theiridentity to the State. However, if the Cl does not agree to the release of theiridentity to the State, the allegation must remain open until a copy of the response from the State j is received and provided to the Cl. The anegation wiu be dosed when the closure letteris issued to the Cl. If the Cl does not agree to release of theiridentity to the State, the referral letter wGl be treated in accordance with Section 8 below, except the referral will be to a State, and not a licensee.

6.9.3 AReaation to be Referred to Another Govemmental Aoency (ete as OSHAh Referrals to OSHA shall be done in socordance with NRC Manual Chapter 1007.

Specificauy, the OAC shaN document the conoems on the OSHA referral form and forward it to the Region l11 State Liaison Officer. A copy of this document will be used to dose the actior. tab foi OSHA reformt. Referrals to other govemment agencies shall be drafted by the OAC for issuance by the Enforcement Officer after concummoe by the Region 111 State t.laison Officer. The concem may be dosed in AMS when the closure letter is issued to the Cl informing him that the conoom is not under NRC jurisdiction and that the conoom has been forwarded to the appropriate govemmental agency for follow up. A copy of the referral letter should be attaded to the closure letter to the Cl.

As noted above, the ARB will normauy assign one of three actions to address each concem. These actions are conduct an inspedion, referral of the aRegation to the licensee for follow up, or referral of the concem to 01 for investigation. The following sections of the procedure address the handling of the conoem based on which of these three op6ons is. chosen by the ARB.

12 Revised 3/05/98

i RP 0517A 7.0 Condud an Inspection to Close Concems  !

l 7.1 in cases where the ARB has decided that the assigned technical branch will perform the follow up, the achvity assigned (contact Cl, perform inspection, obtain headquarters assistance, etc.) should be completed well within the time frame, i usually 30 or 60 days, specified by the ARB. The closure memo fmm the assigned technical branch will be issued within the time frame assigned at the  ;

ARB.

7.2 If an inspection is performed sudt that an inspection report is issued that involves the review of one or more of a CI's concems, it should be written in a style that does not contain the name of, or material that could be used to identify, the Cl or that the issue was prompted as a result of an allegation. Normally, a report should be written only for those cases where a violation is identified (either cited or normited). If an inspedion report is to be written, it should be written in Manual Chapter 0610 format and a signed copy of the report must be forwarded with the closure memo to ElCS.

7.3 If an inspection is performed, the inspedor must ensure that each of the concems identified by the ARB for follow up by inspedion is specifically addressed in the inspection. The inspection may include a contact with the CI (which must be documented), to ensure that the inspector dearfy understands the concems and any background information that may be related to the concem. For example, the concem may be that the Cl was not property trained, when the specifics are that the pradical exam given to the Cl was in fad a coadiing session and not an examination. A review of licensee records in this case would not be capable of establishing whether the conoom was substantiated. The inspection must determine not only the validity of the concem (substantiated / unsubstantiated), but also the regulatory significance. For example, the concem that a test was not performed may be substantiated, but there may be no requirement for the test.

i honee no regulatory violation.

7.4 Upon completion of the adion assigned by the ARB, the assigned tedinical branch shall always prepare a closure memo desenbing the NRC's conclusions.

This memo is a stand alone docurnent and should clearfy identify each conoom identified on the itemized list of concems that is maintained in the :"aeh file, the details of what was done to resolve the conoom ('w iciuding who was taked to, what was reviewed or observed and where it was observed, etc.), the NRC's condusions regarding the concem (e.g., whether it was substantiated, partially substantiated, or unsubstantiated), and the safety significance of the finding. The memo must also clearty provide the basis for the NRC's conclusion. Any documentation should be wdtten in a style that does not belittle or disparage the Cl, orthe significanoe of the concems idenDfied to the NRC. Both documents (dosure memo and inspedion report) will then be sent under the Branch Chief's or higher signature to EICS, both eledronically (E-mail address OAC3) and hard Copy.

n n . .:. ., o wuon

RP 0517A 8.0 Referrals of Concems to the Ucensee for Follow up 8.1 Referral letters to the licensee request the licensee to perform the follow up to the concem ensuring that the follow up is independent and addresses the concem.

They are mailed out under the signature of the Enforcement Officer, with the licensee's response to be sent to the Enforcement Officer. Concurrences for the referral are the OAC, Branch Chief of the branch assigned to do the review of the licensee's response, and the Enforcement Officer. Referral letters are not docketed and contain no distribuuon. The only copy other than that mailed to the licensee will be placed in the AMS case file. The referral letter will contain the AMS case no. and will request that the licensee's response indude the AMS case no. foridentifying purposes.

8.2 Normally, the OAC will prepare the standard referral letter to the licensee using the concem as the basis for the referral. The referral letter will normally request a response in 45 days. However, if the ARB elects to request additional information, the referral letter will be drafted by the lead technical Branch within seven days of the ARB and provided electronically to e4 nail address OAC3.

One of the OACs will then finalize the referral letter within the next seven days.

The goal shall be to issue referral letters to the licensee within 14 days of the decision to refer the concem to the licensee. Upon issuance, the " referral letter" action tab will be dosed with the issue date, and a new action tab " response to referral" (or awaiting licensee response) will be opened and assigned to ElCS for closure with a planned completion date of the date the response is due to be received by the region imm the licensee.

8.3 When the licensee's response is received in ElCS, the ElCS-AA will make a copy of the response and forward it to the assigned branch with a forwarding memo; place the original in the AMS case file, update the AMS to close the " response to referral" action tab with the date received, and assign a new action " Review Submittal" to the assigned branch responsible for the review of the referral response. The planned coiT+;stion date will be 30 days from the date the response is forwarded to the assigned branch.

8A Upon receipt, the assigned branch will evaluate the response to verify the accuracy of the details. The evaluation should first be made to detennine if the licensee conducted an independent review of the issue (s) and compare the response with any known fads. The evaluation should then determine if the licensee's review discussed the appropriate issue (s) as well as comprehensiveness of the response. Upon completion of the review, a closure memo shall be completed synopsizing the licensee's and NRC's conclusions.

This memo is a stand alone document and should clearly identsfy the concem, the details of what was done to resolve the concem (m' duding the fact that it was refened to the licensee), and the NRC's condusions regarding the concem (e.g., whether it was substantiated, partially substantiated, or unsubstantiated).

The memo must also dearly provide the basis for the NRC's conclusion. If the response indicates that a violation may have existed that warrants enforcement (e.g., not a candidate for enforcement discretion), then the closure memo should indicate that enforcement is under consideration. (NOTE: In this case, the ~

closure letter to the Ci should indicate that the concem was substantiated, is a j 14 Revised 3/05/98 ,

l

RP 0517A violation, and that enforcement action is under consideration.) Any documentation should be written in a style that does not belittle or disparage the Cl, or the significance of the conoems identified to the NRC. Both documents (closure memo and inspection report) will then be sent under the Branch Chief's signature to EICS, both electronically (E-mail address OAC3) and hard copy.

8.5 in those cases where the assigned branch concludes, after review of the licensee's response, that there is insufficient information available to close the conoem, the assigned branch shall develop a course of action to obtain the necessary information. This proposed course of action shall be discussed with the cognizant Division Director, and upon agreement, an e-mail or memo should be sent to OAC3 or EICS, describing what adion wGl be taken and when it will be completed. If the decision is to re-refer the concem to the licensee, the assigned branch will write the letter to the licensee to be issued under the cognizant l Division Director's signature, otherwise, steps 8.2 through 8.4 will be repeated for the re-referral.

{

9.0 Referrals of Concems to 01 for Conduct of an inva=hahn f 9.1 in cases where the ARB suspeds wrongdoing, such as cases of employment discrimination or winful violations, the concems will be refened to the Office of investigations for follow up at the ARB. Of wiu open a case file and conduct its investigation based on the priorky established for the case (high, normal, and low). Guidance for establishing investigation priorities is outEned in Part IV of Management Directive 8.8. Examples of various pnorities are as follows:

HIGH: (1) Ucensee or contrador managerret (second line supervision or above), Reador Operator, or Radiation Safety Officer directing, performing, or condoning any deliberate violation, including providing false information to the NRC or creating false licensee records; (2) any individual directing, performing, or condoning a deliberate violation where, without consideration ofintent, the underlying violation is at least equivalent to a Severity Level I,11, or 111 violation; .

(3) discrimination issues where the alleged discrimination is, as a result of providing information direcoy to the NRC, or caused by a licensee or contrador manager above first level supervisor, or where a history of findings of discrimination or DOL setuements suggests a pivgis.n.nWJc rather than an isolated issue, or alleged blatant or egregious discrimination appears to have occurred; (4) en individual knowingly provides incomplete and inaccurate information to the NRC or a licensee with the purpose ofinfluencing a significant regulatory dedsion, issuance of a license amendment, or not proceeding with an escalated enforcement action; (5) an individual willfully covered u' p a matter so that a required report to the NRC was not made where it would have been likely for the NRC to have promptly responded to the report; (6) an individual willfully provided inaccurate or incomplete information to the NRC or a licensee that resulted in the NRC or licensee making a wrong decision; (7) an individual tampered with vital equipment at a power reador indicating a potential act of sabotage; or (8) any case which would otherwise be classified at a normal priority '

but, there is a need for an immediate investigation to ensure evidence is not lost I or tampered with.

l l

RP 0517A I

NORMAL: Cases that are not of high or low priority, including discrimination not l

amounting to a high priority, relatively isolated deliberate failures to file an NRC Form 241 (" Report of proposed Activities in Non-Agreement States"), and cases where an individual directed, performed, or condoned a deliberate violation that without consideration of intent would be categorized at Severity Level IV.

LOW: (1) situations in which, without consideration, the underlying violation would be characterized a's a minor violation; (2) relatively isolated falsification of a record or falsification of records that are not significant; (3) violations caused by careless disregard not covered in higher priorities; and (4) licensee- or contractor-identified willful violations of limited safety significance committed by individuals holding relatively low level positions.

g.2 Of will provide a copy of the " investigation Status Reconf to EICS. The ElCS-AA will create an entry in the 01 Case Log form (G:\EICS\ TRACKING \Ol_STA1) identifying the AMS file number and the Of case number. In adddion, the BCS AA will file the " investigation Status Reconf in the allegation file, mark the outerJacket of the allegation file to show the Of case number, and update AMS to show the appropriate concem as being under 01 investigation with the appropriate priority.

g.3 Normally, Of will conduct or schedule an irderview of the Cl within 30 days of ace.pGug the case. In those cases, a copy of the interview transcript wiH be provided by Of to ElCS. Upon receipt, the BCS-AA wHl prepare the forwarding I memo to the assigned technical branch (G:\EICS\ BOILERS \Ol_INTRV.LTR),

create an action tab for the concem entitled " Review Of Transcript" to the assigned brandi with an assigned date of the transmittal date of the irderview, l and a due date of 30 days after the assigned date.

g.4 Upon receipt of the transcript and memo from BCS, the assigned Division should issue an AITS item to complete the transcript review and forward the results to ElCS by the assigned due date in the memo from ElCS. The transcript shall be reviewed by the assigned technical branch to determine if any new concoms have been described and to determine if any change should be made to the 01 priority for the case originaNy established at the ARB. Upon complebon ofits review, the assegned technical branch will issue a memo to ElCS with a copy to 01 indicating, if any new technical concems were identified, and if so, what they are, and whether the of investigation priority should be changed or if the investigation should be terminated (i.e., no indications that wrongdoing was reaNy aNeged or '

that a discrimination case can be pursued).

g.5 Upon receipt of the 01 interview response memo from the assigned technical brandt, the ElCS AA win place the memo in the i;;-"~t file and update AMS to indicate that the brandi review was completed as of the date of the memo. The AMS action tab "Of investigation" wiu not be modified. If the memo indecates a change in priority, the existence of new concems, or a proposal that the investigation be terminated, the memo wiu be~ provided to one of the OACs to schedule a follow up ARB (proposal to terminate investigation or change 01 priority) or create a new allegation case file (existence of new concems). .

16 Revised 3/05/98

RP 0517A 9.6 Upon receipt of the Ol investigation report, the EICS-AA will provide one copy to the Enforcement Officer and the other copy to one of the OACs for forwarding to the assigned technical branch. The ElCS-AA will also update the 01 Case Log form (G:\EICS\ TRACKING \OI , STAT). The OAC will first review the synopsis to determine which of three categories the report falls under: willful violation identified, no willful violations identified, or case closed based on resource considerations. Depending on which category, the following steps will be taken to close the allegation file:

9.6.1 Case Closed - Investication Completed: The OAC will prepare a forwarding memo for the report dependmg upon the results of the investigation (G:\EICS\ BOILERS \Ol-REPOR.YES or.NO) requesting the assigned technical branch to review the report, determine K there are any new technical concems identified from the exhibits, and determine if they agree with the condusions in the report. The results of this reviewwill be provided via a closure memo to ElCS within 15 days of receipt of the report for review. The AMS will be updated by

, closing the "Of investigation" tab with the date of report issuance; creating a

" Review 01 Report" tab assigned to the appropriate technical branch with a 15 day due date from the date of the memo transmitting the report; and creating an

" Awaiting OE Memo" tab assigned to EICS with a due date of 21 days after receipt of the Of report.

9.6.1.1 The assigned Division, upon receipt of the report from ElCS, will assign an AITS item for completion of the retiew with a due date as specified on the memo transmitting the report. The assigned technical branch will review the report to determine what enforcement should be taken orif they disagree with Ol's conclusions AND determine if any unresolved technical issues exist. Upon completion of the review a closure memo shall be completed providing the NRC's conclusions, and, if appropriate, the basis for disagreeing with Ol's conclusions. This memo is a stand alone document and should clearty idenbfy the conoem, the details of what was done to resolve the concem (induding the fact that it was referred to OI), .

and the NRC's conclusions regarding the conoem (e.g., whether it was substantiated, partially substantiated, or unsubstantiated). The memo must also dearfy provide the basis for the technical division's condusion if it disagrees with Ol's conclusion, and whether there are any unresolved I tedmical issues, and if so, what they are.1he memo should be written in a style that does not be'ittle or disparage the Cl, or the significance of the conoems identified to the NRC. The memo shall be sent to the Enforcement Officer, with copies to Of and the SOAC under the Branch Chief's or higher signature both elodronically (E-mail address OAC3) and hard copy.

9.6.1.2 Upon receipt of the closure memo from the assigned technical branch by ElCS, one of the OACs will close the assigned action tab " Review Of Report" using the date of the memo. The case file will remain open until receipt of the three week OE memo. Upon receipt of the OE memo, the EICS AA will make a copy and place it in the allegation file as well as provide a copy to the Enforcement Officer. AMS will be updated to close

4 RP 0517A the action tab

• Awaiting OE Memo" based on the receipt date of the memo. The allegation file will be provided to one of the OACs to review and determine if the OE memo is in agreement with the conclusions reached by the assigned technical branch, i.e. no enforcement action is necessary. If so, the case can be dosed (proceed to Section 10 of this pmoedure). If not, an assigned action tab " Enforcement Action" will be j created for the concem with the assigned technical branch being '

responsible for closure. The assigned date will be the date of review of l the allegation file, and the due date will be 30 days after receipt of the I Ol report. Also, if the case involves a determination that the licensee or contractor discriminated against an employee for raising safety concems, a " chilling effect" letter will be issued to the licensee as described in Sections 11.1 and 11.2 of this procedure.

9.6.1.3 For those cases where the region disagrees with OE or Oi, or the region agrees that enforcement action is appropriate, an Enforcement Panel will be held within 4 weeks of the issuance of the Of report (per  !

Section 7.5.4.4 of the Enforcement Manual) to resolve the course of action j for the issue. The conclusions of the enforcement panel will be documented in an "OE Understands" memo, which will be provided to ElCS by OE. Upon receipt, the ElCS AA will make a copy of the memo for the allegation file and provide both the allegation file and memo to one of the OACs for review. The OAC will determine if enforcement is being taken, if not, the " Enforcement Action" tab can be closed with the completion date being the date ofissuance of the "OE Understands" memo. If enforcement is being taken, the dosure of this tab will occurwith the issuance of the enforcement action (EXCEPTION - if there is no Cl or the Cl does not wish to be informed of the results of the NRC's review of his concems, the closure of the tab, the allegation, and AMS files will occur with the reoelpt of the "OE Understands" memo).

9.6.1.4 Upon issuance of the enforcement action, a copy will be made by the ElCS-AA and placed in the allegation file. The " Enforcement Action" tab ,

will be closed based on the issuance date of the enforcement action. The i

" Closure Letter" tab will receive an assigned date of the issuanoe date, l

'with a due date of 30 days after the issuance date. The allegation fi;e will then be provided to one of the OACs for completion of the closure letter (see Section 10.3 of this procedure).

9.6.2 Case Closed -Investiaation Not Performed due to Hiaher Priority Woric The OAC will prepare a forwarding memo (GAEICS\BOILERSOi-ADMIN. LOW) for the 01 report requesting the assigned tedmical brarxh to review the report and determine if there are any new technical concems based on a review of the exhibits and determine if further resources should be expended to resolve the concem. The AMS will be updated by closing the "Oi investigation" tab with the date of report issuance; creating a " Review Of Report" tab assigned to the appropriate technical branch with a 30 day due date from the date of the memo transmitting the report; and creating an " Awaiting OE Memo" tab assigned to ElCS with a due date of 30 days after receipt of the Ol report. ,

18 Revised 3/05/98

RP 0517A 9.6.2.1 The assigned technk.al branch willissue a memo to ElCS stating whether there are any new technical conoem(s), and if so, what those conoem(s) are. In addition, the memo will also pmvide a recommendation regarding the expenditure of further resources to resolve the onginal conoem(s).

The memo will be pmvided to ElCS both by hard copy and via e-mail (e4 nail address is OAC3).

9.6.2.2 Upon receipt of the technical branch memo by ElCS, one of the OACs will close the assigned action tab " Review Of Report" using the date of the memo. The allegation and AMS filer, will remain open until receipt of the OE memo. Upon receipt of the OE memo, the ElCS-AA will make a copy and place M in the kliegation file as well as provide a copy to the Enforcement Officer. The AMS file will be updated to close the action tab

" Awaking OE Memo" based on the receipt date of the memo. The action tab " Follow up ARB" will be opened and assigned to ElCS with an assigned date, of the date of receipt, of the brarx#s memo, and a due date of 10 days after receipt of the memo.

9.6.2.3 Regardless of the poshion taken in the technical branch memo, a follow up '

ARB is necessary to obtain regional management agreement to resolve the concem(s), with or without additional expenditure of resoumes (see MD 8.8,Section IV.F.2 and Enforcement Manual Section 7.5.3). One of 1 the OACs will schedule a follow up ARB within 10 days of receipt of the memo imm the assigned tedmical Branch. A copy of the OE and technical branch memos will be included in the padage provided to the board members forthe follow up ARB.

9.7 ff any of the above-specified assigned technical brand reviews idenkfy new technical concem(s), one of the OACs will initiate pmcessing them into the allegation system in accordance with Section 4 above. New concems should not be added to an existing case file unless the concems are a subset of those concems already in the file. For example if the "new" concem is that the root .

cause evaluation for a diesel generator failure to start event was inadequate, but the original concem is that the diesel generator is inoperable, this could be considered a subset of the original concem, since ensuring the diesel was operable would necessitate ensuring that a failure event had been adequately evaluated and conected. Co,nW/, if the "new" conoom were that the diesel generator testing records were inappmpriately descarded, this would not be a subset of the original concem, and would be entered into the system as a new allegation.

9.8 Following issuance of the 01 report in which 01 finds that there was not sufficient evidence to substantiate the alleged wrongdoing, OE issues a memo stating that M does not appear that enforcement is warranted and providing three weeks for addressees to review the report and provide dissenting views. j 9.9 At the point where a closure letter can be written to the Cl, (e.g., after the OE memo discussed in Section 9.8 has been issued and the three weeks have elapsed or the apparent violations, if appropriate, have been issued to the '

licensee) a copy of the synopsis of the 01 report will be provided as an enclosure

_ _ . .. ._,_ j

8 RP 0517A to the closure letter sent to the Cl. (NOTE: In those cases where enforcement action was taken, the synopsis will not be sent to the Cl until the letter to the licensee enclosing the synopsis has been sent). IN ADDITION, a copy of the synopsis will normally be mailed by the OAC directly to the licensee or contractor informing them that the Of investigation has been closed for those cases where the licensee has not otherwise been informed in writing (i.e., cases where wrongdoing is found and enforcement action is proposed). The synopsis will not be provided to the licensee or contractor if the OAC's review of h determines that the synopsis contains information that would disclose the identity of the Cl. In that case, the letter to the licensee should summarize the Of conclusions without I providing a copy of the synopsis. The letters can be sent provided the approving ofHcial of the Ol report and the Diredor, OE, concur in the letter to the licensee.

{'

Their concummoe indicates no dissenting views were received or the dissenting views were resolved, DOJ declined the case or completed hs adion, and the NRC does not intend to take enforcement action on the wrongdoing issue. Copies of the letter to the licensee or contractor will be placed in both the allegation file and l in the public document room, and a copy of the letter to the Cl will be plaed in the allegation file.

I 10.0 Closure of Alleaation and AMS Files J 10.1 Upon receipt of the closure memo (with attached inspection report, if appropriate) fmm the assigned branch, the ElCS-AA will place the hard copy of the memo in the allegation file, close out the action tab in AMS assigned to the branch based on the receipt date of the elodronic e-malled letter, and place an assigned and planned completion date on the " closure letter" action tab. The assigned date is the date of recolpt of the dosure memo, and the planned completion date is 30 days thereafter. In addition, if the '64Aonth ARB Meeting" achon tab is still open, this tab will be deleted from the required actions. The ElCS-AA willinform the SOAC that the tile is ready for review and issuance of a closure letter.

10.2 in those cases where there is no need for a closure letter to the Cl, such as anonymous, inspector-identified, licensee-identified, or cases where the Cl .

refuses additional contact, the anegation and AMS files win be dosed. The AMS file will be updated to show that the allegation file is closed effectrve with the

!ssuance of the closure memo. If the '644onth ARB Meeteg" adion tab is still open, this tab will be deleted from the required edions. The ElCS-AA will inform the SOAC that the file is ready for review. Upon completion of the review, if all conoems were propedy addressed, the :":g"!:- i file will be marked " CLOSED" on the front outside Jadtet of the file and retumed to hs appropriate file location.

If concems were not property addressed, the technical branch will be contaded to provide appropriate information to dose the concem.

10.3 in cases where escalated enforcement is proposed to address one of the CI's concems as noted in the branch's dosure memo to EICS, one of the OACs shall update the AMS file by opening the " enforcement" action tab and assigning the hem to ElCS for completion. A best estimate of the expected enforcement action issue date should be placed in the "due date" field, and the assigned date should be the date of the closure memo. Upon issuance of the adion, the adion tab will ,

20 Revised 3/05/98

RP 0517A be dosed and a copy of the enforcement adion induded as an endosure to the closure letter sent to the Cl.

10.4 in those cases where a Cl exists and has not refused additional contad from the NRC, a closure letter will be issued to the Cl describing the results of the NRC's review of all of the Cl's concems, if a status leNer has previously been issued that dosed one or more of the CI's concerns, a reference to the status letteris acceptable in the closure leNer for the speci6c concem being closed. One of the OACs will review the file to ensure all concems were properly closed. If so, the dosure letterwill be prepared using the appmpriate portions of the boilerplate contained in the G:\EICSBOILERSELOSURE.BOL example. The closure letter must describe how each concem was evaluated, and results of the NRC's review, includmg any enfomement that may have been taken. In those cases where the results of the foHow up to the concem results in escalated enforcement or where an 01 investigation concluded that a willful violation occuned, he closure leNer must include documentation of the results. This means, in the cases where enforcement results, the closure leNer shall include a copy of the enforcement action issued to the licensee (induding Of cases resulting in enforcement).

Addstionally, for of investigation cases, the synopsis of the 01 report should be induded as an enclosure to the dosure letter to the Cl. In cases where the information in the file is insufHcient to support closure of a conoem, the technical branch wiu be contaded to provide appropriate documentation to support dosure of the concem.

10.5 The closure leNer will be prepared by one of the OACs to be signed by the assigned Division's Director. Concurrences wiH include the ElCS of5cer, assigned Branch Chief, appropriate Projects Branch Chief, Regional Counsel, and the assigned Division Director. The closure leNer win be sent to the Cl by certified mail, with a retum receipt request.

10.6 Prior to mailing the closure letter to the Cl, the SOAC will determine, on a case by case basis, whether the Ci should be contacted prior to mailing of the closure .

leHer. If so, one of the OACs will make reasonable anempts to contad the Cl, with technical assistance as necessary, by phone prior to issuanoe of the closure leNer. As always, if the Cl is contaded, the phone conversation win be documented andincludedin the ":ffe fue.

10.7 Upon mailing of the closure letter, the EICS-AA shau make a copy of the letter, place it in the allegation file, and make an entry in AMS indicating the date the closure letter was mailed. The AMS file will be dosed with the dosure date being the malling date for the closure letter. The allegation file will be ' marked

" CLOSED" on the front outside Jacket of the file and retumed to its appropriate file location.

11.0 Special Considerations for Cases involvino Discrimination (DOL Involvement) 11.1 Allegations concoming employment discrimination have an additional potential to cause an environment at a licensee's fadlity where empcy::s fail to bring up safety concems for resolution. This %illing effect" must be addressed by the NRC. For concems involving " chilled environment", the ARB must decide whether

f  !

RP 0517A the licensee should be issued a "chiliing effect" letter in addition to any other acGvities the NRC may perform to resolve the concem. If an employment discrimination concem has been substantiated either by NRC or DOL or if the ARB decides that a " chilling effect" letter is to be issued, the action tab in AMS

" chilling effect letter" will be assigned to EICS with a due date of 30 days from the date of the ARB. One of the OACs will prepare a chilling effect letter to the licensee to be signed by the assigned technical Division Director or Regional Administrator. The letter will request the scensee to respond to the NRC with what actions it is taldng to eliminate the potential that employees will not raise safety conoems.

11.2 Allegations conoeming employment discriminate, in addition to the above process, also include the potential for a duplicate investigation to be performed by the Department of Labor, Occxspational Safety and Health Administration (DOL-OSHA) as required by Secdon 211 of the Energy Reorganization Act. The NRC may become aware of these concems directly from the Cl, orindirectly imm DOL in these cases, it is important that the allegation file contain the required information regarding both the NRC's and DOL's investigative efforts. In cases where the alleged concem involves employment discrimination, the OAC will ensure that the AMS shows the allegation as a "Secdon 211 - yes" and the concem will show the "211 box" cluw:ked. If the NRC does not have a copy of a DOL complaint for this conoem, an medon tab " check DOL status" will be assigned to EICS with a due date of 185 days after the date of the alleged discriminatory act. The case will remain open until 185 days even if 01 has closed its investigation to ensure that the 180 days allowed by law for the Cl to file a

, complaint has expired.

11.3 If no subsequent filing is received from DOL-OSHA specific to the concem, one of the OACs will contact the appropriate DOL-OSHA field offices to determine if a complaint was filed on the assigned due date for the " check DOL status." If a complaint was not filed, the " check DOL status" action tab will be dosed as of the date of the phone call, and a record of the conversaGon documenting "no DOL case was filed" will be placed in the allegadon file. It is imperative to wait for the due date prior to making the call to allow the clock for filing a DOL complaint to expire. A call earlier than the due date could lead to false information, as the Cl could stilllegally file a valid complaint after the call. If the Cl did file a discrimination case with DOL-OSHA, the OAC will request a copy of the complaint be provided dwectly to the NRC Region 111 Enforcement Officer, and request that any future documentation concoming the case (AD Decision, field investigator's l narraGve report, appeal of AD decision) also to be provided direcey to the NRC Region 111 Enforcement Officer upon issuance. l 11.4 Upon receipt of the discrimination complaint from DOL-OSHA, the ElCS-AA will make a copy and indude it in the applicable allegation file, and update AMS to show a completed date for the " DOL Complaird Filed" adion tab of the date the complaint was received. The original will be provided to the Enforcement Officer.

If it exists, the " Check DOL Status" action tab will be closed effective with the date of receipt of the complaint. In addition, a new action tab " DOL AD Decision" will be entered into AMS and assigned to ElCS with a 6;e date of 45 days from the 22 Revise'd 3/05/98

RP 0517A date of the filing of the complaint by the Cl. The ElCS-AA will update the file "G:\EICS\ TRACKING \DOLTRACK.TBL" to show the appropnate information.

11.5 Unless the Area Director's (AD's) decision and field investigator's narrative report have already been received, one of the OACs will contact the appropriate DOL-OSHA Area Director on the due date in AMS to determine the results of the DOL-OSHA investigation into the discrimination complaint. The AMS will be updated to reflect the new schedule for issuance of the decision, if one has not yet been issued. If the decision has been issued, the OAC will request a copy of the AD decision and field investigator's narrative report be sent to the NRC Region lIl Enforcement Officer as soon as possible. The OAC will also request that a copy of all future correspondence regardmg the case be sent to the NRC Region til Enforcement Officer. .

11.6 Upon receipt of the AD Decision and field investigator's narrative report from DOL-OSHA, the ElCS-AA will make copies and provide one to 01. The original will be provided to the Enforcement Officer. Also, a copy will be placed in the applicable allegation file, and AMS will be updated to show a completed date for the "AD Decision" action tab of the date the AD Decision was received. A new action tab

• DOL Appeal Filer will be assigned to ElCS with a due date of 15 days from the date of the decision. The EICS,AA will update the file "G:\ElCS\ TRACKING \DOLTRACK.TBL' to show the appropdate information.

11.7 Unless the " Request for Appeal" has already been received, one of the OACs will contact the DOL Administrative Law Judge (AIJ) Office on the due date in AMS to determine the status of an appeal of the AD's dedsion. It is imperative to wait for the due date pdor to malJng the call to allow the clock for filing an appeal to expire. A call earlier than the due date could lead to false information, as the Cl or licensee could still legally file an appeal after the call. The AMS will be updated to reflect either that the AD's dedsion is final (e.g., the " DOL Appeal Filed" action tab wSI be deleted and the AD decision annotated as being final), or that the appeal has been requested from the ALI Office. If an appeal has been filed, the ,

OAC will request a copy of it be sent to the NRC Region 111 Enforcement Officer as soon as possible. The OAC will also request the ALJ Office to include the NRC Region lit Enforcement Officer on the service list for all issuanoes pertaining to the case in those cases where the appeal is filed by the licensee or contractor, a chilling effect letter will be issued per Section 11.2 above (See enforcement manual Section 7.7.3.2.b) If one was not already issued.

11.8 Upon receipt of the DOL appeal filing domsmentation, the ElCS-AA will make a copy and place it in the applicable allegation file. The original will be provided to the Enforcement Officer. In addition, the EICS-AA will annotate the DOL case

, number on the cover of the allegation file, and AMS will be updated to show a completed date for the " DOL Appeal Filed" action tab of the date the appeal was received. Two new action tabs, " DOL Hearing Scheduler and "At.J Decision" will be assigned to ElCS. No due date will be assigned for ALI decision, however, the DOL Hearing tab will show an assigned due date of 45 days from the date of .

receipt of the appeal. The ElCS-AA will update the file "G:\EICS\ TRACKING \DOLTRACK.TBL" to show the appropriate information.

n, n. . . .n c an o

RP 0517A 11.9 Unless the hearing schedule has already been received, one of the OACs will contact the DOL Administrative Law Judge (ALI) Office on the due date in AMS to determine the status of the hearing. If the ALl's Office pmvides a hearing date, the OAC will enter that date into AMS as the due date for the action tab. If the hearing has been held, the AMS action tab will be closed with the completion date being the date the hearing was completed.

11.10 Upon receipt of the ALI Recommended Decision, the EICS-AA will make copies and pmvide one to 01. Also, a copy will be placed in the applicable allegation file, and AMS will be updated to show a completed date for the "ALI Decision" action tab of the date the ALI Recommended Decision was received. The original will be provided to the Enfomement Officer. A new action tab " DOL ARB Decision" will be assigned to ElCS with no due date. The ElCS-AA wiu provide the allegation file to one of the OACs and update the file "G:\EICS\ TRACKING \DOLTRACK.TBL" to show the apprGpriste information. Of note, the ALl's Decision is only a reccine,endation and does not constitute final action by DOL However, NRC willinitiate enforcement at this point if the ALI decides that discrimination occurred. In addition to direct receipt, copies of the ALI Recommended Decision can be obtained over the intemet at the DOL address"http /www.oalj.

1 dol. gov /public/wblower/refmc/wblistm.htm". '

11.11 Upon receipt of the Administrative Review Board's final decision, the ElCS-AA will make copies and pmvide one to 01. Also, a copy wHl be placed in the applicable allegation file, and AMS will be updated to show a completed date for the

• DOL ARB Decision" action tab of the date the f inal Decision was received. The original will be provided to the Enforcement Officer. At this point the DOL proceeding has concluded and the Final Dodsion constitutes DOL's final decision on the case. The ElCS-AA wiu update the file "G:\EICS\ TRACKING \DOLTRACK.TBL" to show the appropriate information.

Final decisions can also be obtained over the Intemet at the address shown above. If this was the only concem remaining open in the allegation, the closure letter can be issued to the Cl as described in Section 10 of this procedure.

11.12 in many instanoes, the DOL proceeding is settled at some stage between the CI's' submittal of a complaint and the Administrative Review Board's final decision. In those cases, there is usuauy no conclusion to establish whether discrimination occurred. Upon loaming of a settlement agreement, the OAC will close all DOL-related action tabs and assign the " DOL Settlement" action tab to ElCS with a completed date of the date the settlement was approved by DOL (either the Area Director or Administrative Review Board may appmve the settlement). The OAC wul ensure that the allegation file contains a copy of the Settlement Agreement and DOL approval documentation. The concem may be closed at this point only if the NRC has already reached its own decision on the validity of the concem via an Of investigation. If this is not the case, a follow up ARB must be held to determine what action will be taken to resolve the conoem. The follow up ARB will be scheduled within 30 days of receipt of the Settlement Agreement, and a copy of the agreement will be provided as background for the ARB meeting.

11.13 in those instances where Of completes theirinvestigation of a discrimination concem with a finding on the merits prior to coiTp;etion of a hearing before the --

24 Revised 3/05/98

RP 0517A DOL Al.J on the same discrimination concem, the Ol report will be evaluated by OE, who will determine if it is to be released to both parties in the DOL proceeding, regardless of the findings. He OAC will contact OE and advise them I that a DOL proceeding is ongoing - OE will determine when the parties to the DOL  !

proceeding will be infonned of Ol's conclusions. OE will inform the region of its l dedsion during the weekly conference call or in the three week memorandum. '

Once OE has approved releasing Ol's findings to the parties to the hearing, one of the OACs will prepare the transmittal letters to the parties. The letters will inform both parties of Ol's conclusion and note that the conclusion is under review by the staff and is not the final agency position. The synopsis will be included as an attadiment. If a predecisional enforcement conference is to be held for a discrimination concem, the Director, OE will decide whether the licensee will be provided a redacted copy of the Of report (to be provided by OI) rather than the synopsis, if the redacted. report is provided to the licensee, the redacted report will be placed in the PDR and the Cl will also be provided a copy of the redacted report. The letter should also inform both parties that the complete report may be requested under the Freedom of information Ad if the synopsis only is sent to the parties. The letter to the licensee or contractor will be concurred in by the Director, OE and the approving official of the 01 report. A copy of both letters will be placed in the allegation and enforcement files.

11.14 Information developed by DOL or obtained from DOL, which was not made available to the public by DOL, will be processed in accordance with 10 CFR 2.7g0(a). Examples of the DOL information which is EXEMPT FROM PUBUC DISCLOSURE are DOL Investigation Reports and Settlement Agreements. Any request for this information under either the Freedom of Information or Privacy Acts must be identified to DOL through the OAC and FOIA Contdinator.

12.0 raiodic Statusina of Open Alleoation Files: De agency goal for complebon of allegatson cases is 180 days from the date of receipt of the allegation to the date the Cl is provided feedback on the results of the NRC's evaluation of his/her concem(s). However, there are cases that may not be ceiv+leted within the goal l due to the need for Of or DOL involvement, or complexity of the issues. Bis section addresses actions taken to manage those cases where the allegation may i not be completed within the spedfied agency goal.

12.1 Once each month, or as requested by the Division Diredor, the ElCS-AA will generate the fur set of status reports for aR open allegation cases. He titles of the reports, distribution, and content are as described in Attachment 4 to this procedure. Bi-weekly, the ElCS-AA will generate status reports 5,6, and 10 as described in Attadiment 4 for distribut'on to the technical branch chiefs.

12.2 Once each month, normally the first Friday o'the month, the Regional Admin!strator will meet with au technical Division Diredors, the Enforcement Officer, and the OACs to discuss the status of all allegations open greater than 180 days from the date of receipt. This meeting is routinely scheduled by the ElCS-AA, who will also prepare the " Allegation Briefing Sheet" as described in Attadiment 4. This sheet is distributed two days prior to the meeting with the Regional Administrator. De purpose of the meeting is to discuss what adions are preventing the file from being closed and establish priorities and schedules to 25 Revicad 3/05/98

RP 0517A expedite completion of the case. For those cases involving 01, the discussion will also include whether the Ol priority should be raised during the next 01 monthly status meeting.

12.3 Once each month, normally the third Friday of the month, the Deputy Regional Administrator will meet with all technical Division Directors, Regional Counsel, the Enforcement Officer, and the OACs to discuss the status of all allegations open greater than 120 days from the date of receipt. This meeting is routinely sdeduled by the ElCS-AA. The meeGng has a two-fold purpose, namely, to serve as the follow up ARB for those cases whose technical concems remain open and the last ARB was more than four months previous, and to allocate resources to address those concems not involving DOL or 01 fonow up to resolve issues prior to them becoming greater than 180 days old. For those cases where this meeting serves as the follow up ARB, the OAC shall document the results of the discussions for the case in the auegation file and update the AMS system to incorporate the' decisions made at this meeting.

12.4 Once each month a status briefing is held between of and the technical Division Drectors to discuss the status of all currently open Of cases. One of the OACs will attend this status briefing. The primary purpose of the ,T.;;Og is to ensure the 01 priorities are appropriate, given the safety significance and age of the case and obtain a projection on when the investigation will be completed. '

12.5 in addition to the follow up ARBS described in Sec6on 12.3 above, the OAC will include cases requiring fogow up ARBS based on the information developed during Of report or transcript reviews or inspec6on activiGes (for example, where the inspection determines that the violation may have been wluful) determine that a follow up ARB is needed. These followmps will be included in the next regularty-scheduled weeldy ARB. The OAC shall prepare a " Follow up ARB" memo to the cognizant Branch Chief that specifies the upcoming date for the ARB, why a follow up ARB is being held, and specifies what is to be decided at the ARB rs,r.cerrJr,g that allegation. A copy of the background info mation will be included with the memo. The ElCS-AA will provide copies of the memo with .

attachments as follows: the DRS Division Duector for reactor cases, DNMS Division Dwector only for materials cases, Ol Regional Field Office, and Regional Counsel. The original of the memo win be placed in the allegation file (which will be provided to the DRP DMSION Duector prior to the ARB), and willindude an attendance and approval sheet for the upcoming ARB. The ElCS AA wiu also update AMS by putting a " Follow up ARB" schon tab in if one does not already exist with a due date of the date of the scheduled follow up ARB.

12.6 Prior to the ARB, the cognizant technical Branch Chief for the concem will review the recommended course of ac6on based on the additional background infomution obtained from the list provided on the *Anegation Actior:" page and either concur or revise the recommended action. Just prior to the ARB, the Branch Chief will provide the marked page to the OAC in attendance at the ARB i meeting. Documentation of the results of these follow up ARBS.will be done in accordance with Section 6.8 above.

26 Revised 3/05/98

RP 0517A 12.7 When follow up ARB information is placed in the AMS System by the OAC, a check will be made to determine if the Cl has been contacted with a status to the concems. If not, the OAC will prepare a status letter using the "G:\EICS\ BOILERS \ STATUS.BOL" draft This letter will indicate which, if any, concems have been resolved and their results. The letter will have the same concuirences and signature as a closure letter if there are examples of concems being closed; otherwise, it will have the signature for an acknowledgment letter (See Sechons 5.3 and 10.4 above).

12.8 Each Monday moming prior to the ElCS 8:00 a.m. meeting, the ElCS-AA shall print out the following reports imm the AMS system: Initial ARBS Due, Referral Letters Due, Acknowledgment Letters Due, Closure Letters Due, Days Since Last Contact,6-Month ARBS Due, and 10-Month ARBS Due. Copies of these reports will be provided to both of the OACs and the Enforcement Officer for review.

The OAC shall evaluate each report and implement the action necessary to prevent the item from exceeding the overdue date.

12.9 in cases where follow up ARBS are required, the OAC will ensure they are scheduled within the following three weeks, but prior to exceeding the required time frame for follow up ARBS (180 days after initial, subsequently every 120 days).

12.10 !n cases where referral or acknowledgment letters have not been issued, the OAC l will ensure that they are drafted and pmvided for signature within the following two weeks. Similarty, if the last contact with the Cl has been in excess of 150 days, a status letter will be pmpared and issued to the Cl within the following three weeks.

Attachments: 1. Guidance for Handling incoming Allenations

2. AMS Action Tab Usage

3. Assignment of ResponsibiliGes

4. Reports Generated from AMS

5. Glossary of Terms 97 n . .b A O ft%10 A

i RP 0517A INSPECTOR GUIDANCE FOR HANDLING INCOMING ALLEGATIONS The following guidance is provided to ensure that a Region 111 OAC is involved, to the extent possible, in receiving an allegation.

Method of Allegation Receipt Appropriate NRC Staff Response

1. Cl goes to the resident office or other 1. Attempt to get one of the OACs on the phone, private office space to speak to an inspector. to take the allegation. If one of the OACs is not immediately available orif the Clis unwilling to participate in the call, take the allegation, document R, and fward it to one of the OACs.

The inspector should provide a copy of NUREG/BR-0240, " Reporting Safety Concems to the NRC," to the Cl.

2. Cl calls an inspector (Resident orRegion 2. If the phone has 3rd party add on capability, try Based) on the phone. to get one of the OACs on the phone to take the allegation, otherwise, take the allegation. If one of the OACs is not immediately available or if the Cl is unwilling to participate in the call, take the allegation, document R, and forward it to the OAC.

3. Ci speaks to an inspectorin the field. 3. (a) Invite the Cl back to an appropriate office space (e.g. the resident's office) and try to get one of the OACs on the phone to take the

' allegation. If an OAC is not immediately available orif the Cl is unwilling to participate in the call, take the allegation, document it, and forward R to the OAC . The inspector should provide a copy of NUREG/BR-0240, " Reporting Safety Concems to the NRC", to the Cl. J I

(b) If the Cl is unwilling to go with the inspector to an office space, take the allegation in the field, document it, and forward it to the OAC .

4. Inspector receives an anonymous 4. Take the allegation, document it, and forward message via answering machine or voice it to the OAC.

mail.

Note. If the OAC is unavailable, the inspector should, at a menemum: (1) take the allegation; (2) obtain the Cl's name, address, and telephone number; (3) determine if the Cl will allow follow up of the concem by the licensee and whether he refuses to have his identity disclosed; and (4) document the allegation and forward the infomation to the Branch Chief and OACs via E-mail whhin three workdays. Do not include the CI's name, address, or telephone number in the E-mail. Provide that information to the OAC through the mail in an " addressee only" envelope or by telephone. The OACs will contact the Cl if a follow-up call is needed.

NOTE: If employment discrimination concem, remind Cl they have'180 days to file with DOL OSHA.

w %.o 1

RP 0517A ALLEGATIOff MANAGEMENT SYSTEM ACTION TAB USAGE The AMS system utilizes action tabs to assign actions for each concem identifimi in an allegation file. The use of the action tabs is as specified in the procedure, and is summarized in the following table:

ACTION TAB ASSIGNED DUE DATE COMPLETED USE DATE , DATE Acknowledgment Allegation 30 days after Date letter Acknowledges receipt of concems

' Letter receipt date allegation mailed from Cl, advises DOL rights, and receipt describes identity protection status (Section 5.3).

Status Letter Upon 6 months Date letter Provides Cl with periodic feedback determining after ack. mailed on the status of NRC's review of the need based on letter issued concems. Per MD 8.8, required status report every 6 months (Sections 12.7 and 12.10).

wre I.etter Date of receipt 30 days after Date letter Provides Cl with results of NRC's of closure assigned 03te mailed review of the concems (see memo for last Section 10.3). I open concem l Initill ARB Meeting Allegation 30 days after Date of ARB Determines NRC's actions to resolve I receipt date allegation meeting the concems (see Sections 5.1, 6.1, i receipt and 6.8).

6 Month ARB Upon 5 months Date of ARB Required for all allegations still open Meeting determining after initial meeting after 180 days from receipt,that do need based on ARB (delete if not involve DOL or 01 (see status report not'needed) Section 12.3).

Follow up ARB Upon As required by Date of ARB Required for every case open Meeting determining ARBS, or meeting beyond 10 months and where initial need based on every 4 ARBS recommend follow-ups, except status report months after for Of or DOL cases (see 6 month ARB Section 12.5).

01 investigation Date accepted Leave blank Date report Used when Of takes a concern for at ARB (Of allowed with a follow up review (see Section 9.1).

18 months for synopsis of closure) conclusions provided to EICS I

1 RP 0517A ACTION TAB ASSIGNED DUE DATE COMPLETED USE DATE DATE Rsview 01 Report Date forwarding 15 days after Date of receipt Used to assign review of the 01 memo sent to forwarding to of memo from report to the assigned technical technical assigned assigned division to determine next course of branch technical technical action upon Of completion (see branch branch Section 9.6 and subparts).

Revi3w Of Date 30 days after Date of receipt Used when Of conducts an initial Tr:nscript forwarding forwarding to of memo from interview with Cl prior to continuing memo sent to assigned assigned investigation (see Sections 9.3,9.4, technical technical technical and 9.5).

branch branch branch Refttral Letter Date of ARB 30 days after Date letter Used to refer concems to the that assigned ARB decides mailed to licensee, OSHA, or other agencies the action letter to be licensee for follow up (see Sections 6.9.1, issued 6.9.2, 6.9.3, 8.1, and 8.2).

Response to Date letter Date specified Date response Used to track receipt of the Refztral mailed to in letter for received from response from the licensee (see licensee licensee to licensee Sections 8.2 and 8.3).

send response Revisw Submittal Date response 30 days after Date of receipt Used to track review of the received from response of closure licensee's response by the assigned licensee forwarded to memo from technical division and receipt of a assigned technical closure memo for the referred technical - branch concems (see Sections 8.3 and 8.4).

branch Letter from Alleger Date of receipt I. eave blank Same as Used when a document is received of letter assigned date from the Cl.

Phone Call Date assigned Leave blank Date call Used when a phone callis assigned w/ alleger -

by ARB or date completed by the ARB or occurs between a call occurs member of the NRC staff and the Cl.

Check DOL Status Date 185 days Date telecon Used to determine if a DOL case discrimination after date of with DOL ,

was filed (see Sections 11.3, 11.4 concem placed alleged made , and 11.5).

~

In AMS discrimination confirming status DOL Complaint Date of filing Leave Blank Same as Used when a DOL complaint of Filed Discrimination assigned date discrimination for raising safety-complaint with concerns is filed with DOL (see DOL Sections 11.4 and 11.5). .. '

Attachment

......~.

2

RP 0517A ACTION TAB ASSIGNED DUE DATE COMPLETED USE DATE DATE DOL Appeal Filed Date AD 10 days after Date of call to Used to determine if an appeal of Decision issued assigned date AU or date of the AD decision has been made, or appeal filing to record appeal date (see Sections 11.7,11.8, and 11.9).

DOL Hearing Date Appeal Date Hearing 1.ast date of Used to track in AMS the date of Scheduled filed with AU is scheduled hearing the hearing (see Sections 11.9 and ,

11.10).

AU Decision Date Appeal Initially - 60 Date AU Used to trackissuance of AU l filed with Au days after Recommended decision (see Section 11.11). Due i hearing, (see decision issued date is updated every 30 days after uses) reviewing AU issued Decisions via l the Intemet. l

- DOL AD Decision Date OAC 45 cays after Date decision Used when a complaint of determines a DOL issued by DOL discrimination is being invesGgated by cr,6@t was Complaint filed Area Diredor DOL (see Sec6ons 11.6 and 11.7). I filed with DOL l 1

udL ARB Dodslon Date AU initially - 45 Date DOL ARB Used to track DOL case closure. I Recommended days after Final Order The ARB decision is final (see decision issued hearing, (see issued Sections 11.11 and 11.12).

uses)

Issue Chilling Date assigned 30 days fmm Date letteris Used to specify issuance of a letter to EffGct Letter by AR8 assigned date issued to the licensee when the ARB licensee determines a chilled environment exists or enforcement for discrimination has been proposed (see Sections 9.6.1.2,11.1 and 11.2).

AWSm Assign N/A N/A N/A Not Used.

Form ARB Meetmg N/A N/A N/A Not Used.

Other Date placed in Normallyleft Upon Used to specify actions not currently AMS blank completion of available in the AMS system ac6on the ac6on tabs. As such, it is rarely used.

spedfied in the descrip6ve text Summary N/A N/A N/A Not Used.

I RP 0517A ACTION TAB ASSIGNED DUE DATE COMPLETED DATE USE DATE Ar "hg OE Memo Date 01 report 21 days after Date memo received by assigned date Used to track OE concurrence in received from investigation condusions (see ElCS OE Sections 9.6.1, 9.6.1.2, 9.6.2, 9.6.2.2, and 9.8)

DOL Settlement Date of receipt Leave Blank Same as of DOL Used to track settlement of DOL assigned date cases, indicating NRC must still make settlement a separate determination of whether agreement.

discnmination occurred (see Sedion 11.13).

NA At Conversion N/A N/A N/A Not Used.

kispecuen Date assigned as specified Date of receipt Used to track issuance of the by ARB by ARB of closure closure memo by the assigned memo from technical branch upon completion of branch its inspection efforts (see Section 7.1).

Rel;ted Allegation Date entered in Leave Blank. Same as Used when a Ci has provided AMS assigned date. concerns in more than one allegation, or the same concem is identified in more than one allegation for the same facility.

Enforcement Date of review Due date per Date Used to track issuance of the Action of AMS file enforcement enforcement enforcement action when there is a after OE memo manual for action issued. Clin need of a closure letter (see received. Issuance. Sections 9.6.1.2, and 9.6.1.3).

Attachment 2

RP 0517A I

AMMIGNMFRT OF RF3tPOMMARILITIFR

1. Bealonal Administrator (RA): Appoints the SOAC and OAC as specified in Management Directive 8.8, Sechon 0311(C); grants confidentiality, and conducts monthly meetings with Division Management to discuss allegation cases open 1180 days. Specific sections addressing Regional Administrator adivi6es are 2.9,11.1,12.1, and 12.2.

2. Docuty Realonal Administrator (DRA): Conducts monthly meetings with Division Management to discuss allegation cases open 1120 days and grants con 6dentiality in the absence of the Regional Administrator. Specific sec6ons addressing Deputy Regional Administrator activities are 2.9,4.6,12.1, and 12.3.

3. Division Directors or Deputies (DRP. DRS. DNMS): Attends ARBS (DNMS chairs materials ARBS, DRP chairs reactor ARBS), dism**ae :":;fri cases open 1120 days '

with RA and DRA, determines need for emergency ARBS, signs correspondence to Cls discussing the closure of conoems, and oversees activities conducted by the technical branches. Specific sections addressing Division Director activities are 4.5,4.6,5.5,5.6, 6.1,6.2,6.3,6.6 through all of 6.9 and its parts, 8.1, 8.2, 8.4, 8.5, 9.1, 9.4, 9.6.1, 9.6.1.1, 9.6.1.3,9.6.2,9.6.2.3,10.5,11.1,11.14,12.0 through 12.5, and 12.7.

4. Technical Branch Chiefs (DRP. DRS. DNMS): Recommend course of acGon to address each concem at ARBS, attend ARBS, potentially take allegations from Cis, issue dosure memos for each conoom assigned, and oversee activi6es assigned to the branch to dose out 2":;:r,s. Specific sections addressing Brandi Chief ac6vities are 1.1 through 1.5, 2.1 through 2.9,4.1,4.3,5.5,6.1 through 7.4,8.1 through 8.5, 9.1, 9.4, 9.6.1, 9.6.1.1, 9.6.1.3,9.6.2,9.6.2.1,12.0,12.5,12.6, and Attachment 1.

5. Enforcement Officer (EO): Provides oversight to ensure the proper *,,,Ne,T,6,,"etion of this procedure and MD 8.8 for the Regional Administrator, signs refenal letters to licensees, and coordinates enforcement activities associated with 01 and DOL findings. Specific secuons addressing Enforcement Officer activi6es are 5.5, 8.1, 9.6, 9.6.1.1 through .

9.6.1.4, 9.6.2.2, 9.8,10.3,11.3 through 11.8,11.10,11.11,11.13,11.14,12.1,12.2,12.3, and 12.8.

6. Realonal Counsel fRC): Attends ARBS, provides legal advice to ARB on potential for violations or wrongdoing, and evaluates closure and status letters to ensure they clearty address concem and are understandable to Cf. Specific sections addressing Regional Counsel adivities are 4.5,5.5,6.1,6.2,6.3,6.6,6.7,6.8,6.9 and all of its subparts,10.5, 11.1,11.14,12.3,12.5, and 12.7.

7. Field Diredor. Offige of Investica' ions (O!): Attends ARBS and oversees the condud of investigations performed to address conoems that involve wrongdoing or discrimination.

Specific sedions addressing 01 activities are 4.5,5.5,6.1,6.2,6.3,6.6,6.7,6.8,6.9 and allits subparts,9.1 through 9.4,9.6,9.8,9.9,11.1,11.6,11.10,11.11,11.13,11.14,12.4, and 12.5. ,

RP 0517A 8.

State Liaison Officer: Serves as the region's interface with the Occupational Safety and Health Administration (OSHA) in the referral of industrial safety concems to OSHA, in accordance with Regional Procedure 1007A " Interface Activities between Regional Offices and OSHA". Specific sections addressing State Liaison Offar activities are 4.7 and 5.5.

9. Realonal State Aoreement Officer (RSAO): Serves as the region's interface with the Omce of State Programs and the Agreement States within Region 111. Specific sections addressing RSAO achvities are 4.8 and 5 5.

10. Senior Office Apaa=Han CWnator fSOAC): In addihon to the actMties specified below for the OAC, the SOAC is also responsible for oversight of the allegation program, developing training matedals and conducting annual training of Region til personnel on the i;=%n program, and serves as the primary point of contact with the Department of Labor, the Agency?N-aan Advisor, and is the principalinterface between Region lit and the OACs of NRR, NMSS and other regions. The specific sections addressing the activities of the SOAC are identical to those listed below for the OAC.

11. Office Alleoation Coorditwar(OAC): Serves as the focal point for mceipt and processing of all allegations. As such, is normally involved in every aspect of the allegation process, including initial receipt, case file d=Op eeat, attendance at the ARB, assignment of tasks in AMS, issuance of all cormspondence to the Cl, issuanoe of referral letters to licensees and other agencies, and advisor to the technical staff on allegation program matters. The specific sections addressing the activities of the OAC i are all of the steps in the procedure except sections 1.2,7.1 through 7.4,10.7,11.4,11.6, 11.8, and 11.11.

12. Technical Staff (DRS. DRP. DNMS): Receives allegations, performs inspections or reviews of licensee /OI reports to determine if all concems have been identified, and documents results of resolution of concems in closure memos. Specific sections addressing technical staff activities am 1.1 through 1.4,2.1 through 2.9,4.1,5.5,7.1 through 7.4, 8.4, 8.5, 9.4, and 12.0.

13. Eniwas,ent and inva#'==Hans Staff-Administrative As?Mant (EICS-AA): Provides administrative support to the OACs. Specific sec6ons addressing ElCS-AA activibes are 1.6, 3.1, 5.5,6.1, 6.2, 6.3, 6.8, 8.1, 8.3, 9.2, 9.3, 9.5, 9.6, 9.6.1.2, 9.6.1.3, 9.6.1.4, 9.6.2.2, 10.1,10.2,10.7,11.4,11.6,11.8,11.10,11.11,11.14,12.1,12.2,12.3,12.5, and 12.8.  ;

14. Division and Brand Secretaries: Ensures documents sent from ElCS for technical review are ordered into AITS and promptly processed. Specific sections addressing division and brand secretary activities are 3.1, 5.5, 9.4, and 9.6.1.1.

15. Omce ReceoGonist: Identifies visitors that wish to meet with OAC personnel and ensures they are property routed to ElCS without signing the normal visitor log (see Section 1.6).

Attachment 3

l RP 0517A 4

REPORTS GENERATED BY AMS Each month or as requested by the Division Dwedors, the BCS-AA generates the following reports for distribution. The reports generated and their distribution are as follows:

TAB TITLE SORTED BY REPORT CONTENT DISTRIBUTION NO.

1 All Reactor Anegations Alpha by site Facility Name, Allegation No., Deputy Regional Received on Date, Days Old, Administrator, DRS Assigned Division, Conoom Division Director, DRP Descrip6on, Assigned Action, Date Division Dredor, SCS.

Assigned, Planned Comp!stion Date, Division, Branch Assigned.

2 ReactorAllegations Days Old Atd!m No., Received On Date, Deputy Regional Open1180 Days Days old, Assigned Division, Facility Administrator, DRS Name, Concem Description, Dwector, DRP Dwector, Assigned Action, Date Assigned, sCS.

Planned Comple6on Date, Division, Smndi Assigned, Action Assigned Descriptive Text.

3 ReactorAtd!ss Allegation No. At-"M No., Received On Date, Deputy Regional between 120 and 180 Days Old, Assigned Division, FaciRty Administrator, DRS days old Name, Concem Descrip6on, Dwedor, DRP Diredor, Assigned Adion, Date Assigned, EICS.

Planned Completion Date, Division, Branch Assigned, Action Assigned Descrip6ve Text. -

4 EICS Open Days Old Facility Name, Allegation No., Days Deputy Regional Allegations Old, Assigned Division, Concem Administrator, DRS Description, Assigned Acdon, Date Director, DRP Director, Assigned, Planned Completion Date, DNMS Dwector, SCS.

Division, Branch Assigned, Action Assigned Descriptive Text.

5 Allegations by Branch Branch / Site Facility Name, AM-am No., Days Deputy Regional (DRP) then Days Old Old, Assigned Division, Concem Administrator, EICS, Desaiption, Assigned Acton, Date DRP Division Director ,

Assigned, Planned Completion Date, (who should have copies Division, Brarxh Assigned, Action distributed to individual Ascigned Descripuve Text. DRP Branch Chiefs for their selected sites).

l l Attachment 4

< n,...s~,,< nonsuon c

i RP 0517A TAB TITLE SORTED BY REPORT CONTENT DISTRIBUTION NO.

6 AllegaGons by Branch Branch then Facility Name. Allegation No., Days Deputy Regional (DRS) Days Old Old, Assigned Division, Concem Administrator. ElCS, Description, Assigned Ac6on, Date DRS Division Director Assigned, Planned Completion date, (who should have copies Division, Branch Assigned AcGon distritxded to individual Assigned Descripuve Text.

DRS Branch Chiefs).

7 AR Materials Alpha by site Facility Name, Allegation No.,

Allegations Deputy Regional Received On Date, Days Old, Administrator, DNMS Assigned Division, Concem Division Director, ElCS.

Descriptm, Assigned Action, Date Assigned, Planned Completion Date, Division, Branch Assigned.

8 Materials Allegations Days Old Allegation No., Received On Date. Deputy Regional Open1180 days Days Old, Assigned Division, Facility Administrator DNMS Name, Concem GescripGon, Division Director, ElCS.

Assigned Action, Date Assigned, Planned Completion Date, Division, Branch Assigned, Acdon Assigned Descripuve Text g Materials Allegations Days Old Allegation No., Received on Date, Deputy Regional between 120 and 180 Days Old, Assigned Division, Facility Administrator, DNMS days old Name, Concem Description, Division Director, ElCS.

Assigned Action, Date Assigned, Planned Completion Date, Division, Branch Assigned, Action Assigned Descriphve Text.

10 Materials Allegations Alpha bysite Facility Name, Allegation No., Days Deputy Regional by Bmndi Old, Assigned Division, Conoom Administmtor, EICS, Description, Assigned Action, Date DNMS Division Diredor Assigned, Planned Completa date, (who should have @s Division, Branch Assigned Acuon distributed to individual Assigned Descriphve Text. DNMS Brandi Chiefd.

In addi6on to the above, once each month, the EICS-AA wiu prepare the " Allegation Briefing Sheet". This sheet is distrbuted at the 8:15 a.m. meeting on the Wednesday prior to the RA Briefing to an attendees, and gives the total number of open allegations, total received during the year, total dosed during the year, total number of cases open greater than or e# to 180 days (both for reactors and materials), the number outside of the region's immediate control and why (Oi, DOL, etc.); and the number within the regions' control. For this last group, the briefing sheet will itemize the allegation number, site, and assigned Technical Division responsible for the allegation. Finally, the briefing sheet wlN specify how many cases are greater than 120 days old and the breakdove between reactors and materials for this group.

Attachment 4 2 Revised 3/05/98

RP 0517A GLOSSARY OF TERMS ffrom MD 8.8)

Action Office: The NRC program office or region tint is responsible for reviewing and taking action, as arpropriate, to resolve an allegation. For the purpose of Management Directive (MO) 8.8, the Office of Investigations (OI) and Offee of the inspector General (IG) are not considered action offices.

Administrative Review Board (DOL's ARB): The Secretary of Labor's authonzed representative to review the decisions of Administrative Law Judges and issue Orders finalizing the determination for the Department of Labor. ARB decisions are final actions, subject only to appeal to the Federal Court system.

l Agency Allegation Advisor (AAA): A designated staff memberin NRC headquarters who  ;

develops and oversees the agency wide implementation of the NRC ANegation Management '

Program, manages the allegation management system (AMS), and conducts periodic program reviews of endi action office's suegation program, as set forth in MD 8.8 and related documents.

Allegation: A declaration, statement or assertion of impropdety or inadequacy associated with NRC4egulated activities, the validity of which has not been established.1his term includes all ,

conoems identified by sources such as individuals or organizations, and technical audit efforts l from Federal, State or local govemmerd offices regarding activities at a licensee's site.

NOTE: Exduded from this deimition are inadequacies piovided to NRC staff by licensee managers acting in their official capacity (for example, A concem(s) brought to NRC by the A manager in describing how they were being addressed), matters being handled by more formal processes such as 10 CFR 2.206 petitions, misconduct by NRC eivpky::s or NRC contractors; non radiological occupational health and safety issues; inspection findings, and matters involving law enforcement and other Govemment agendes. Also exduded from this definition are findings identified by luinois Department of Nuclear Safety (IDNS) resident inspectors as part of the '

inspections they implement to assist in completion of NRC's inspection program. These .

exclusions apply to inadequacies discussed during official routine conversations between licensee managers and NRC staff members unles: tin information provided conoems a wrongdoing issue. .

Allegation File: An OE% file is estabkshed for documentation conoeming the allegation, induding conospondence, memorandums to file, interviews, and summades of telephone conversations, discussions, and meMings, inspection reports, and 01 Irr;W'l=, reports (all other 01 investigative documerdation will be retained in the Of case file). This nie must be maintained by the office al%gation coordinators (OACs) in the official fiscs of the adion office in an officiaNy designated location. AN documentation must be mainte:ned in this file and clearty marked with the aNegation number. Only the aNegation number, name of facNity, cormsponding Of case number, or conesponding DOL case number, may be placed on the outside of the file; neither the CI's name nor any otlier personal identifier may be placed on the outside of the file.

Records portment to IG referrals should not be kept in the allegation file, but forwarded to the Regional Counsel.

Allegation Management System (AMS): A com%dzed information system that contains a summary of significant data per; , sat to each allegation.

Attachment S

. n . .: ., o ,nc roa

RP 0517A Allegation Review Board (ARB): A board established by the regional administrator consisting of the Regional Counsel; 01 Field Office Director; SOAC; the cognizant technical Branch Chief; the DRP Branch Chief with responsibility for the facility; and the ARB Chairman, who is the Director of Reactor Projects for reactor cases, or the Director of Nuclear Materials Safety for materials cases; to determine the safety significance and appropriate NRC follow up for each allegation.

The ARB permits expeditious resoluuon of allegations. Staff from the OfHce of Enforcement and the Office of the General Counsel participate, as necessary.

Chilling Effect: A term that refers to the negative effect a hostile environment (e.g., an '

e.7+;cy= being terminated for being involved in protected activi6es) may have on employees raising concems to the NRC, or those who may want to raise conoems.

Concerned Individual (Cl): An individual or organization who makes an allegation. The individual or organization may be a concemed private citizen, a public interest group, the news modsa, a licensee, a current or former employee of a licensee, vendor or contractor, or a representative of a local, State or Federal agency.

Confidentiality: A term that refers to the protection of data that directly or otherwise could identify an individual by name or the fact that a confidential source provided such information to the NRC.

Confidential Source: An individual who requests and is granted confidentialityin sooordance with Management DirecGve 8.8 and who usually signs a ' Confidentiality Agreement".

Inspection: For purposes of this procedure, a special activity usually conducted by an inspector and used to evaluate and resolve an allegation.

Investigation: An activity conducted by the Office of Investigatsons (01) to gather and evaluate testimonial, documentary, and physical evidence to assist the staff, the Office of Enforcement, or the Department of JusGce in resolving wrongdoing allegations. -

Office Allegation Coordinator (OAC): A designated staff memberin the region who serves as -  !

one of the points of contact for that region regarding the processing of r":7"'3s. This person  ;

is normally appointed by the Regional Administrator or his designee per Management '

Directive 8.8.

Overriding Safetyissue: Immediate threat to public health, safety, or security, wammting immediate acGon by the NRC or leensee to evaluate and address the issue.

Protected Activities: ActMties protected within the meaning of Sec6on 211 of the Energy Reorganization Act and the Conunission's regulations, for example,10 CFR 50.7. C.T.Wcyn; of Imensees anchheir contractors are engsgod in protected activities when they are raising safety concems to 4 eir management, as well as when they raise these concems to the NRC.

Receiving Ofth: The office or region that ini6 ally receives an :": Em. In some cases, the ac6on office and the swc.e;&q office will be the same if the allegation falls within the functional responsibility of the rece;#4 office.

Attachment 5 2 Revised 3/05/98

RP 0517A Redact: The process of removing any proprietary, safeguards, or 10 CFR 2.700 information from a document prior to Ms being issued to an individual outside of the agency.

Regional State Aeroement Officer (RSAO): A designated staff member in a region who serves

. as the point of contact for the region and the Office of State Programs, regarding Agreement State radiation control programs, and who conducts technical reviews of Agreement State radiation control programs. .

Sanitime: The process of ensunng that any NRC document developed as a result of an allegation does not reveal the identity of the alleger.

Secure Files: Files that are locked when not in use and for which access is controlled on a need4o4 mow basis. '

Senior Office Allegation Coordinator (SOAC): A designated staff memberin the region who serves as one of the points of contact for that region regarding the processing of i;"':-ss, and is also responsible for the oversight of the allegation program within the region. This person is normally appointed by the Regional Administrator or his designee per Management Directive 8.8.

Staff: NRC technical, investigauve, and other staff members.

Wrongdoing: Wrongdoing consists of either (a) an intentional violation of regulatory requirements or (b) n violation resuhing from careless disregard of, or recidess indifference to regulatory requirements, or both (See Part IV of Management Direchve 8.8).

t Attachment 5 3 o...i..a 2,ncroa

i DIVISION OF NUCLEAR MATERIALS SAFETY FISCAL YEAR 1999 INSPECTION PROGRAM STATUS-MONTN ENDING JANUARY 31,1999 INSPECTIONS COMPLETED INSPECTION STATUS - ALL PRIORITIES

,. ( kbfb )

TOTAL BUDGETED 52 208 [630]  ;

TOTAL DUE 34 152 [612]

TOTAL COMPLETED 66 193 CORE 27 81 [377] I REACTIVE 1 13 NON-CORE 38 98 [235]

RECIPROCITY:

Against Goal 0 0 Assists 0 0

)

FISCAL YEAR 1999-MATERIALS INSPECTIONS -

EB Ex.H QQI MQM DE.C JAM EF& M6B APR MAY dQM 1QL 6Mfa EE.P

{111}

DUE 55 34 29 34 38 46 41 40 41 42 36 65 CPL 52 45 30 66 BR.1 32 18 16 36 BR. 2 20 27 14 30

Contact:

Marcia Pearson, DNMS, X9840 Data is Through January 31,1999 in'o Compiled / Extracted from LTS and Matrack

OVERDUE COREINSPECTIONS CIf[ "{"g"gh,g:.::.g . . ..

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RECIPROCITYFILINGS/ INSPECTIONS (CALENDAR YEAR 98)

Yearto Date (Roundedto Nearest Tenth)

Goal 2.0 Completed Against Goal 0 Assist inspections 0

INSPECTION DOCUMENTATION AND TIMELINESS FY1999

" ROUTINE REPORTS" EM lM ljkh I$df.bkIkkY 9 TOTAL ISSUED 69 226 591's 57 158 LeMem 12 68 TIMELINESS (DAYS) including 591's 2.8 4.7 Excluding 591's 16.1 15.7

" TEAM INSPECTION REPORTS" TOTAL ISSUED TIMELINESS (DAYS) 0 l 0

" FIELD NOTESE**

$. .\ ti \ hy ,

e.h ll TOTAL ISSUED 33 175 TIMELINESS (DAYS) 12.8 12.8

MATERIALS LICENSING PROGRAM STATUS FOR MONTH ENDING JANUARY 31.1999 LICENSING ACTiCMS COMPLETED LICENSING ACTIOH STATUS- ALL ACTION TYPES ,

E [EId E COMPLETED ACTION TYPE MONTH YTD FY MONTH YTD CORE (NEWS / AMENDMENTS) 110 440 1320 110 410 NON-CORE (RENEWALS) 1 4 13 0 3 TOTAL 111 444 1333 110 413

{

1 PENDING ROUTINE MATERIALS LICENSilNG CASEWORK CORE APPLICATIONS (lyg}&'S AND AMENDMENTS)

OVERDUE DOUBLE OVERDUE

, TOTAL CORES PENDING > 90 days but < 180 days > 180 Days ,

169 6 10 i NON-CORE APPLICATIONS (RENEWAL 21 l NON-CORES OVERDUE DOUBLE OVERDUE TOTAL PENDING 7180 days but < 365 days > 365 Days 3 0 2 I i

STATUS OF EXPIRED LICENSE CLOSEOUTS AVERAGE CLOSED CURRENT CLOSED YEAR TO TIMELINESS PENDING CASES MONTH DATE YTD 0 0 0 0 EXPIRED LICENSE CLOSEOUTS PENDING > 120 DAYS LICENSEE LICENSE NO. EXPIRATION DATE ACTION STATUS STATUS OF SUSPENDED / REVOKED LICENSE CLOSEOUTS UCENSES CLOSED UCENSES CLOSED PENDING SUSPENSIONS CURRENT MONTH YEAR TO DATE 2 0 0 -

SUSPENDED / REVOKED LICENSE CLOSEOUTS PENDING > 120 DA YS UCENSEE UCENSE NO. SUSPENSION DATE CLOSEOUT STATUS Stack Licensee Engineering 24-24708-01 5/9/96 reinspected 1/99 Ucensee contacting Roof 24-26009-01 11/7/97 LFMB for payoff Consultants figure. Final disposition pending.

ORNL Terminated Sites Program Closeout Progress JANUARY 1999 Number of Site inspections / Evaluations Completed Loose Scaled Material Sources FY 1992 6 1 FY 1993 15 1 FY 1994 30 0 FY 1995 22 7 FY 1996 26 14 FY 1997 24 6 FY 1998 7 31 FY 1999 October 2 0 November 1 2 December 0 0 Januant 1 4 February March April May Juno July August Total FY99 4 6 Sites inspected 134 66 Sites Pending 2 8

i DMSION OF NUCLEAR MATERIALS SAFETY INTERNAL TRACKING EDE e INSPECTION REPORT STATISTICS BY BRANCH

• FIELD NOTE STATISTICS BYBRANCH

• TIMELINESS OFACTIONITEMS

• STAFF ACCOMPANIMENTS BYBRANCH 4

l I

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INSPECTION REPORT TIMELINESG BY BRANCH Materials Insoection Branch 1 ROUTEINSPECTION REPORTS CURRENT MONTH YEAR TO DATE TOTAL ISSUED 36 100 591'S , 32 85 NON-591'S 4 15 TIMELINESS (DAYS)

INCLUDING 591'S 1.9 1.8 EXCLUDING 591'S 17.5 12.0 PERCENT TIMELY (NON-591'S) 50% 87%

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. Routine Reports Over 21-Day Goal Licensee No. of Days Community Hospitals of Indiana 35 Indiana University School of Medicine 25 TEAM INSPECTION REPORTS l

CURRENT MONTH YEAR TO DATE I TOTAL ISSUED 0 0 TIMELINESS (DAYS) 0 0 Team Reoorts Over30-Dav Goal Licensee No. of Days NONE i

T FIELD NOTE TIMELINESS BY BRANCH Materials insoection Branch 1 FIELD NOTES CURRENT MONTH YEAR TO DATE 1

TOTAL ISSUED 13 88 TIMELINESS (DAYS) 9.9 9.5 l

PERCENT TIMELY 92 % 97 %

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Licensee No. of Days Community Hospitals of Indiana 35

r-INSPECTION REPORT TIMELINESS BY BRANCl3 Materials Insoection Branch 2 ROUTEINSPECTION REPORTS CURRENT MONTH YEAR TO DATE TOTAL ISSUED 27 87 591'S 25 73 NON-591'S 2 14 TIMELINESS (DAYS) i INCLUDING 591'S 1.2 2.4 i EXCLUDING 591'S 15.5 14.8 PERCENT TIMELY (NON-591'S) 100 % 100 %

El 0 0 Routine Reoorts Over 21-Dav Goal Licensee No. of Days NONE l

TEAM INSPECTION REPORTS l CURRENT MONTH YEAR TO DATE TOTAL ISSUED 0 0 TIMELINESS (DAYS) 0 0 Team Recorts Over 30-Dav Goal Licensee No. of Days NONE L

r e FIELD NOTE TIMELINESS BY BRANCH Materials insoection Branch 2 FIELO NOTES CURRENT MONTH YEAR TO DATE TOTAL ISSUED 19 G5 TIMELINESS (DAYS) 14.0 16.0 PERCENT TIMELY 100 % 88 %

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r INSPECTION REPORT TIMELINESS BY BRANCH Materials Decommissionina Branch ROUTEINSPECTION REPORTS CURRENT MONTH YEAR TO DATE TOTAL ISSUED 3 25 TIMELINESS (DAYS) 10.0 12.8 PERCENT TIMELY 67% 80%

N EElllllE 1 5 Routine Recorts Over 21-Day Goal Licensee No. of Days Battelle 26 TEAMINSPECTION REPORTS CURRENT MONTH YEAR TO DATE i

TOTAL ISSUED 0 0 TIMELINESS (DA'YS) 0 0 Team Routine Reoorts Over 30-Day Goal Licensee No. of Days NONE

FIELO NOTES CURRENT MONTH YEAR TO DATE TOTAL ISSUED 1 2 TIMELINESS (DAYS) 27 21 PERCENT TIMELY 0% 50%

$hhwe !JAmma ng i hk 1 1 Field Notes Over 21-Day Goal Licensee No. of Days Battelle Memorial 27

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1 INSPECTION REPORT TIMELINESS BY BRANCH FuelCvcle Branch ROUTEINSPECTION REPORTS CURRENT MONTH YEAR TO DATE TOTAL ISSUED 3 14 TIMELINESS (DAYS) 21.6 25.5 PERCENT TIMELY 67% 50%

@ '.. fslb79 . E. i . .. . ....' 1 7 Routine Renorts Over 21-Dav Goal Licensee No. of Davs Allied Signal 32 TEAMINSPECTION REPORTS CURRENT MONTH YEAR TO DATE TOTAL ISSUED 0 0 l TIMELINESS (DAYS) 0 0 Team Routine Reoorts Over30 Dav Goal Licensee No. of Days NONE 1

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r, i BRANCH CHIEF ACCOMPANIMENTS OF TECHNICAL STAFF FY 1999 NUCLEAR MATERIALS INSPECTION BRANCH 1 PURPOSE (ESC. ENF. EXIT, ACCOMPANIMENT, -

INSPECTOR LICENSEE DATE OR OTHER) l GATTONE i

GO LAFRANZO NULL PARKER PISKURA WlEDEMAN l

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BRANCH CHIEF ACCOMPANIMENTS OF TECHNICAL STAFF FY 1999 NUCLEAR MATERIALS INSPECTION BRANCH 2 PURPOSE (ESC. ENF. EXIT, ACCOMPANIMENT, INSPECTOR LICENSEE DATE OR OTHER)

CAMERON HAYS JC 3 Sinal Detroit Hospital 11/9/98 Exit Meeting Veterans Admin. 1/13-14/99 HQ Meeting MULAY YOUNG ,

F BRANCH CHIEF ACCOMPANIMENTS OF TECHNICAL STAFF FY 1999 NUCLEAR MATERIALS LICENSING BRANCH PURPOSE (ESC. ENF. EXIT, ACCOMPANIMENT, REVIEWER LICENSEE DATE OR OTHER)

CASEY Calumet Testing 10/16/98 Accompaniment FRAZIER l

GILL HUETER American Biotech 11/30/98 Accompaniment MULLAUER PELKE RElCHHOLD WATSON

r PURPOSE (ESC. ENF. EXIT ACCOMPA iMENT,

' DATE p REVIEWER WEBER Calumet Testing 10/16/98 Accompaniment 1

k-

r BRANCH CHIEF ACCOMPANIMENTS OF TECHNICAL STAFF FY 1999 DECOMMISSIONING BR/ NCH PURPOSE (ESC. ENF. EXIT, ACCOMPANIMENT, INSPECTOR LICENSEE DATE OR OTHER)

OTHER HOUSE Battelle 12/15/98 Accompaniment KULZER LANDSMAN Point Beach 1,2 10/01/98 Accompaniment LEE MCCANN Battelle 12/15/98 Accompaniment NELSON >

SNELL Dresden 1 12/18/98 Accompaniment (BIG ROCK POINT) 1/12-13/99 Site Visit LEEMON (ZION) 1/21/99 Site Visit O

e L. ,

1 BRANCH CHIEF ACCOMPANIMENTS OF TECHNICAL STAFF FY 1999 FUEL CYCLE BRANCH P'.8RPOSE (ESC. ENF. EXIT, ACCOMPANIMENT, INSPECTOR LICENSEE DATE OR OTHER)

KNICELEY NO SIGNIFICANT INSPECTION ACTIVITIES l

KRSEK 1

l l RElDINGER NO SIGNIFICANT INSPECTION ACTIVITIES l

)

(PADUCAH)

O'BRIEN .

1

)

JACOBSON 1/11-15/99 Accompaniment j (O'Brien)  ;

l l

l (PORTSMOUTH)

~

HARTLAND 167/99 Site Visit (O'Brien)

BLANCHARD 1 & 7/99  :

Site Visit (O'Brien)

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i ATTACHMENT 1 l REGION lli'S RESPONSE TO REVIEW FINDINGS I l

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