ML20211K447
| ML20211K447 | |
| Person / Time | |
|---|---|
| Site: | Fort Saint Vrain  |
| Issue date: | 02/10/1986 |
| From: | Gahm J PUBLIC SERVICE CO. OF COLORADO |
| To: | Gagliardo J NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV) |
| Shared Package | |
| ML20211K444 | List: |
| References | |
| P-86097, NUDOCS 8611170184 | |
| Download: ML20211K447 (22) | |
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16805 WCR 19 1/2, Platteville, Colorado 80651 company of colorado February 10, 1986 Fort St. Vrain Unit No. 1 P-86097._ __
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i Regional Administrator FEB l 21986 Y, i
Attn: Mr. J. E. Gagliardo g'.
Region IV I
U U. S. Nuclear Regulatory Commission 611 Ryan Plaza Drive, Suite 1000 Arlington, Texas 76011 Docket No. 50-267
SUBJECT:
I&E Inspection Report 85-29
REFERENCE:
NRC Letter, Gagliardo to Lee, dated 01/10/86 (G-86020)
Dear Mr. Gagliardo:
This letter is in response to the Notice of Violation received as a result of inspections conducted at Fort St. Vrain during the period September 23-27, 1985.
The following responses to the items contained in the Notice of Violation are hereby submitted:
A.
Failure to Provide Adequate Training 10 CFR 50.47(b)(15) states that " Radiological emergency response training is provided to those who may be called on to assist in an emergency."
Contrary to the above, on September 23-27, 1985, the NRC inspectors determined that licensee emergency training was inadequate as evidenced by the following:
(1) During emergency response scenario walk-throughs, initial notifications to the State and local authorities and to NRC were made in an improper sequence, and the controlling RERP procedure checklist was incorrect, 9611170184 G61103 PDR ADOCK 05000267 0
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. (2) Public Service Company of Colorado interviewed the Health Physics Technicians examined by the Nuclear Regulatory Commission inspectors immediately following the inspection exit. From these interviews, it was apparent that the majority of the examined Technicians failed to fully understand what they were being asked to do during the examinations.
Public Service Company of Colorado acknowledges that further specialized training should be provided.
This is not, however, felt to be a failure to provide training to those personnel.
(3) Public Service Company of Colorado routinely gives semi-annual training with lesson plans specifically developed to meet the needs of personnel assigned to a specific emergency response facility.
These training sessions have been designed to ensure that all personnel assigned to a particular facility are aware of both their specific duties (which are contained in the training sessions) and the responsibilities of the facility and its entire staff. This training method is felt to be appropriate and adequate.
(4) Specific training for corporate level personnel is given on an annual basis.
This training has been adequate and appropriate for these personnel, to date.
There is however, no examination given on this material.
Technical Advisors have been given trainfng in areas where their assistance is specifically required (e.g.,
Off-site dose assessment, core physics, etc.) but no formal training specific to their radiological emergency response organizational role.
They are routinely apprised of these responsibilities through drills and exercises.
2.
The corrective steps which have been taken and results achieved.
(1) Public Service Company of Colorado has reviewed implementing procedure RERP-CR and drafted a procedure change that will make the call to offsite authorities prior to the Nuclear Regulatory Commission to avoid any possibility of calls being made outside of the required time limits.
I 9
-g-(2) During emergency response scenario walk-throughs, on-shift health physics technicians were unable to determine the habitability of the control room and to determine the radioiodine content of a radioactive
- plume, (3) Training was not given to individuals according to their specific functional role during emergencies, and (4) PSC training program failed to establish emergency preparedness training requirements for technical advisors and corporate personnel commensurate with their duties and responsibilities.
This is a Severity Level IV violation (Supplement VIII).
1.
The reason for the violations, if admitted.
(1) This is not felt to represent a failure to provide training.
Fort St.
Vrain Operations personnel are continuously reminded (both through training and administrative means) of the necessity to perform notifications in a timely manner.
The occasion to utilize this training is most frequently in association with a Non-Emergency Event (Four Hour or One Hour Report).
In these events, the instinct is to noti fy the Nuclear Regulatory Commission as soon as possible via the Emergency Notification System.
It is noted that in implementing procedure RERp-CR, Attachment 4, that the Nuclear Regulatory Commission notification call is not the last call made, but the next to last.
The Nuclear Regulatory Commission call precedes a call to the Colorado Department of Health.
It is felt that this sequence of reporting problem stated in the violation is not the result of a failure to provide training but the result of over-exposure to a specific notification sequence.
It must be noted that despite any problems observed in the reporting sequence, the auditor did note that in only one of nine simulated notifications was a notification made outside of the time requirements.
. (2) Public Service Company of Colorado has prepared a new lesson plan specific to the needs of Health Physics Technicians in the areas of habitability determinations, plume tracking, airborne sampling in a plume, and good Health Physics practices during a radiological emergency.
(3) No action required.
(4) Specific training for the Technical Advisors was given during their annual requalification training which was completed on January 23, 1986. This training focused on their specified role in the emergency organization.
This training was followed up by a written examination to evaluate the Technical Advisors' understanding of the learning objectives.
3.
The corrective steps which will be taken to avoid further violations.
(1) Operations personnel will continue to be trained in the required notifications and the time limits within which notifications must be made.
Procedure changes to RERP-CR to move the Nuclear Regulatory Commission notification call on Attachment 4 to the end of the call sequence will be finalized and a formal procedure revision made.
(2) The formal training upgrade for Health Physics Technicians will be taught at first quarter Personnel Control Center training. This training program will be part of the training program submitted for INP0 accreditation.
This training will become part of the annual training requirements. Following completion of accreditation, this will be incorporated into the Health Physics Technician Training Program, and be a formal requirement for full qualification.
(3) No further action required.
(4) An examination will be administered to corporate personnel in association with the 1986 Radiological Emergency Response training.
The results of this examination will be trended to evaluate weaknesses or needs for further training. The program presently in effect for Technical Advisors will be retained in effect.
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. 4.
The date when full compliance will be achieved.
(1) March 3, 1986.
(2) April 21, 1986.
(3) Presently in full compliance.
(4) August 1, 1986.
B.
Failure to Perform Adequate Reviews of the Emergency Preparedness Program 10 CFR 50.54(t) states that the licensee "shall provide for the... implementation and maintenance of its emergency preparedness program."
The licensee "shall provide for a I
review of its emergency preparedness program at least every 12 months
.." The review "shall include an evaluation for adequacy of interfaces with State and local governments and of licensee drills, exerci ses, capabilities and procedures."
i Contrary to the above, on September 23-27, 1985, the NRC inspectors determined that the licensee failed to perform adequate reviews of the emergency preparedness program in that:
(1) PSC performed inadequate audits for the years 1984 and 1985 by limiting their effort to the observation of annual exercises and as a consequence, focused on l
verifying procedural adherence instead of procedural adequacy.
(2) PSC performed inadequate audits of interfaces with State and local governments for the years 1984 and 1985, by limiting their effort to the observation of their emergency operations centers during annual exercises.
(3) PSC failed to resolve a deficiency identified as Action Request CAR-080, dated August 17,
- 1984, relating to PSC's ability to staff and activate Fort St. Vrain Station emergency response centers in a timely manner.
i This is a Severity Level IV violation (Supplement VIII).
l
. l (1) PSC performed inadequate audits for the years 1984 and 1985 by limiting their effort to the observation of annual exercises and as a consequence, focused on verifying procedural adherence instead of procedural adequacy.
(1) The reason for the violation if admitted:
4 a)
No reason for the violation is stipulated because PSC did perform adequate audits of the emergency preparedness program for the years 1984 and 1985. This will be shown through evidence and discussion of:
)
i) audit activities in 1984 and 1985 regarding evaluation of procedural adequacy, systematic 4
review of emergency areas and tasks, and 4
evaluation of personnel training, and
- 11) discussions of monitorings performed on related activities during the cited time period.
l Discrepancies and inadequacies noted during an audit are documented as " Findings" and/or " Observations".
An AUDIT FINDING is defined as:
An identified and documented statement i
describing an ineffective or nonconforming i
condition or item in terms of applicable specified requirements.
That is, a finding tells precisely what requirement (s) was (were)
- violated, and describes specifically how the audited activity failed to comply.
Findings are documented on Corrective Action Requests.
An AUDIT OBSERVATION is defined as:
i A documented observation, which does not qualify as a finding, but is of sufficient significance, or which may cause a
nonconformance, or merits documentation for management information.
That is, observations refer to auditor comments that do not constitute findings of noncompliance with requirements, but information about conditions that cause concern.
Observations are documented in the Audit Report.
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. Audit reports must be reviewed in conjunction with the audit checklists for complete understanding of findings and observations.
b)
The 1984 and 1985 audits of Emergency Plans, NFSC-E-84-01 and NFSC-E-85-01 respectively, performed evaluations of procedural adequacy as evidenced by the following information drawn from the findings and observations in the audit reports and checklists:
1984 - NFSC E-84-01 The procedure TPAM-Situation Response does not identify Weld County Ambulance personnel as requiring training although they may transport injured / contaminated individuals.
(audit report, page 7, page 9 paragraph 5.3)
Procedures TPAM-Situation Response and RERP-ECP require revision to update titles and duties of responsible personnel.
(audit report, page 9 paragraphs 5.1 and 5.2)
" Notification of Emergency Event" form (RERP-CR, Attachment A) revision recommended to reflect time of declaration of emergency.
(audit report, page 9 paragraph 5.4; checklist 8, comment page)
Arrangement of the Personnel Control Center as specified in procedure RERP-PCC is inadequate to prevent the spread of contamination.
(audit report, page 10 paragraph 5.6; checklist D,
comment page 2, comment #14)
Inconsistency exists between the protective action guidelines on the notification form and the supplement. (checklist B, comr'nt page)
There are inadequate guidelines for the responsibility of notifications by the company operator.
(Checklist B, comment page)
Verbal briefings alone of field survey teams do not provide sufficient means of jogging memories.
Recommendation was made to include maps.
(Checklist K, comment page, comment #5) 1
. 1985 - N:SC E-85-01 Inadequate definition of Technical Advisor's role.
(audit report, page 2 paragraph 4.1, page 9 paragraph 5.2; Checklist A, comment #3)
Lack of procedural requirements for securing the Personnel Control Center ventilation.
(audit report, page 4 paragraph 4.3, page 10 paragraph 5.8)
No procedural requirements for additional oxygen cylinders for the Scott Air Paks in the field survey team vehicles.
(audit report, page 5, paragraph 4.10, page 11 paragraph 5.11)
No procedural requirements for Scott Air Paks to be in an emergency team truck.
(audit report, page 11 paragraph 5.11)
No procedural requirements for Scott Air Paks to be checked before use.
(audit report, page 5 paragraph 4.11, page 11 paragraph 5.11)
Recommendation of change to RERP-Implementing to specify formal logging requirements use of ink, printed log sheets, annotation and dating of corrections).
(audit report, page 8 paragraph 4.16.1)
Change to procedure RERP-Implementing recommended to require legible maps of a size convenient for use in a vehicle and that correspond to those used in the Technical Support Center.
(audit report, page 9 paragraph 4.16.2)
Recommendation of change to procedure RERP-Implementing to specify knowledgeable personnel to be dedicated to manning the Emergency Operations Center and Emergency Command Post communications.
(audit report, page 9, paragraph 5.1)
Recommendation of change to procedure RERP-Implementing to specify a person in charge of the personnel accountability station located in the plant
.unchroom.
(audit report, page 11 paragraph 5.10)
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. It can be seen from the above items that, although many of them were determined during the drill period, they are concerned with the adequacy of the procedures, not just adherance.
Some of these findings / observations would not have been noted without the procedure review being closely tied to the drill as the written procedures appeared adequate and were not seen to be otherwise until they were used.
Therefore, it is concluded that procedural adequacy was addressed in the 1984 and 1985 audits, c)
The 1984 and 1985 audits performed systematic, in-depth reviews of the emergency areas and tasks associated with these areas.
A review of the 1984 and 1985 checklists showed that in each audit a separate, unique checklist was developed and completed for each emergency area. These checklists are summarized as follows:
1984 - NFSC E-84-01 Checklist Title Subject B
Control Room (CR) examined CR operations and the performance of duties such as notifications, dose assessment, communications, emergency level classifications, habitability verification, accountability verification, briefings and control of plant operations.
C Technical Support examined performance in the establishment Center (TSC) and use of communications, completion of logs / data sheets and transmittal of data, assessment of plant status and sequence of events, dose projection calculations, directing of performance of surveys and analyses of releases and contamination, dispatch and directing of teams, and briefings.
D Personnel Control examined the establishment and set-up of Center (PCC) the PCC, control of the area and personnel, equipment, distribution, notifications, communications, coordination with off-site medical facilities, selection and dispatch of rad. survey and other response teams, and maintenance of personnel accountability.
4 Checklist Title Subject E
Forward Command examined transmission of data updates, Post (FCP) manning, recommendations of actions to the CED, weather monitoring, and logging of activities.
F Executive Command examined manning, performance of briefings, Post (ECP) communications.
G State Emergency examined manning, provision of information Operations Center to the Public Information Coordination (SEOC)
Team Chief, communications, and logging of activities.
H Lunchroom examination of personnel accountability station activities. Note: since this drill was performed during backshift, normally assigned personnel reported to the shift supervisor in the Control Room.
I Health Physics examined contamination control and personnel Access Area accountability.
J Emergency Planning not performed as this team was not Zone (EPZ) Survey dispatched.
Team
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K Emergency Area examined communications, equipment i
Boundary (EAB) availability and check-out, field l
Survey Team practices, and data collection.
L Inplant/Onsite not performed as these teams were not j
Survey Team dispatched.
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{ p 1985 - NFSC E-85-01 T
Checklist Title Subject A
Control Room (CR) examined monitoring, assessment of plant conditions and releases, communications, event classification, notifications, personnel accountability, dispatch of emergency teams, briefing, plant control activities.
B Technical Support examined manning, habitability verification, Center (TSC) communications (video and radio), completion of documentation, data evaluation and transmittal, briefings, dose projection, coordination with other posts, direction of analyses performance, adequacy of reference materials and supplies, log maintenance, and dispatch of repair / survey / search and rescue teams.
C Personnel Control examined establishment of the PCC, Center (PCC) habitability maintenance, notifications, manning and personnel assignments, area i
control, equipment distribution, communications, dispatch of teams, personnel i
accountability maintenance, briefings, log maintenance, and contamination control.
D Forward Command examined manning, communications, receipt Post (FCP) and transmittal of plant status updates, release assessment, weather monitoring, 4
data calculation and posting, and damage evaluations.
E Executive Command examined staffing, communications and Post (ECP) personnel accountability.
F State Emergency examined staffing and personnel Operations Center accountability, communication, log (SE0C) maintenance, and coordination with other posts / centers.
s
. Checklist Title Subject G
Lunchroom examined habitability check of personnel l
accountability station located in lunchroom, completion of personnel accountability.
H Health Physics checklist not completed as this area Access Area was not used.
I Emergency Planning examined manning, equipment checkout, Zone (EPZ) Field equipment availability, communications, 1
Monitoring Team field practices, sampling and contamination j
control.
J Emergency Area examined manning equipment availability and i
Boundary (EAB) checkout, communications, field practices, Field Monitoring sampling practices and contamination control.
Team K
Inplant/Onsite examined manning, equipment availability, Radiological health physics briefing, field practices, Monitoring Team and communications.
L Medical Emergency examined notifications, first aid practices, transportation, contamination control and j
dosimetry, and Radiation Accident Treatment Team activities.
M Quantitative Rating This checklist was used in every Post /
of Response Center Center / Team / Area and as an overall numerical Performance rating of activities.
Each audit report also contained paragraphs devoted to the assessment of each specific area where observations were noted.
1984 - NFSC E-84-01 Report Page Number Area Assessed 3
Control Room 4
5 Personnel Control Center 6
Forward Command Post 6
Executive Command Post 6
State Emergency Operations Center 7
EA8 Survey Team i
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i 1 1985 - NFSC E-85-01 Report Paragraph Number Area Assessed 4.1 Control Room (CR) 4.2 Technical Support Center (TSC) l 4.3 Personnel Control Center (PCC) l 4.4 Forward Command Post (FCP) 4.5 Executive Command Post (ECP) 4.6 State Emergency Operations Center (SEOC) 4.7 Lunchroom 4.8 Health Physics Access Area 4.9 EPZ Field Monitoring Team 4.10 EAB Field Monitoring Team 4.11 Inplant/Onsite Radiological Monitoring Team a
4.12 Medical Emergency 1
The information presented above clearly shows that each 4
I and every emergency response area and its associated tasks were evaluated in depth in both the 1984 and 1985 i
4
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audits.
d)
Personnel training was examined in the 1984 ana 1985 i
audits of Emergency Plans. Additionally, monitoring of training activities was performed during the years of 1984 and 1985.
A description of the examinations performed is listed below.
4 1984 i
NFSC E-84-01 Audit Checklist A,
Training, was devoted entirely to examination of training records for 50 individuals
)
assigned key roles by the emergency response procedures. The checklist was appended with two pages of comments regarding deficiencies noted.
Also examined was the training provided to five i
non-PSC organizations for their roles in responding to radiological emergencies at Fort St.
- Vrain, l
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4
, Quality Assurance Monitoring Activities There.
were two Quality Assurance Monitoring Procedures on Emergency Response Plans training executed in 1984. These were:
1.
QAMP GS-1, 84-01 Radiological Emergency performed in January, 1984.
The subjects covered in this monitoring were:
Observation of PCC Activities Observation of EAB and EPZ Survey Team Field Activities Lunchroom Accountability and Habitability Shift Supervisor's Office and Control Room Accountability and Habitability Technical Support Center Accountability and Habitability Visitors Center Accountability and Habitability Roll Call - Supervisor's Code QAM Revisions to APM G-5, PPC-83-3214 Lesson Plan Accountability Drill and PCC Setup Review of Results of QAMP GS-1, 84-01 The exercise performed in conjunction with this monitoring activity was a combination drill / training session, therefore, training of personnel was evaluated,
- 11. QAMP GS-1, 84-02, Radiological Emergency, performed in July 1984. The area covered was a training exercise of the EAB Survey Team Field Activities.
N 1985 NFSC E-85-01 Audit Although there was no checklist devoted to training alone, the auditors did keep this subject very much in mind throughout the performance of the audit. This can be seen from the following quotes from the audit report.
"The personnel performing the dose calculation were obviously well-trained, producing calculations of an every 15 minute rate." (audit report, page 3)
.The availability of two highly-trained alternates who manned the communications between the FCP and the ECP and the EOC freed the CED from routine communications tasks."
(audit report, page 4, paragraph 4.4)
"As was indicated by the summated checklist M, not all response center personnel performances were rated satisfactory or better. With the premise that effective training results in effective personnel performance during a drill on an actual emergency, training should be devised to improve personnel performance to satisfactory or better."
(audit report, page 9, paragraph 4.16.4)
It must be noted that this audit was performed during a routine annual drill of the emergency response force. This drill is set-up and carried out under the aegis of the Production Training Section and is therefore considered to be a training exercise.
Deficiencies in personnel performance as cited above and in previous paragraphs are also deficiencies against personnel training.
Quality Assurance Monitoring Activities There were two QAMP's executed in 1985. They were:
1.
QAMP GS-1, 85-01, Radiological Emergency, performed February, 1985.
This monitoring covered a walk-through training session of the set-up and operation of the Personnel Control Center (PCC).
t 11. QAMP GS-1, 8E-02, Radiological Emergency, performed in May, 1985.
This monitoring covered practice drills in the following areas:
Observatten of PCC Activities.
Observation of EAB Survey Team Field Activities Initial Personnel Accountability Habitability of Personnel Accountability Stations Control Room Technical Support Center Forward Command Post Again, personnel training was evaluated through the vehicle of evaluation of personnel performance.
e)
As can be seen from the evidence drawn directly from the relevant audit reports, audit checklists and monitoring procedures, PSC has performed adequate audits
- and, in
- addition, on going monitoring activities, of the emergency preparedness program in the years 1984 and 1985.
Thorough review of the evidence presented precludes the conclusion that PSC limited its activities to only observing the annual exercises.
(2) Corrective steps which have been taken and results achieved.
See Programmatic Corrective Steps and Results Achieved, Page 18.
(3) The corrective steps which will be taken to avoid further violations.
i Since it is imperative that emergency preparedness audits are perceived as being comprehensive, a separate audit dedicated to procedure review will be performed on an annual basis.
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l (4) The date when full r.dmpliance will be achieved.
Initial performance of the emergency preparedness procedure review audit is scheduled for April 1986.
(2) PSC performed inadequate audits of interfaces with State and local governments for the years 1984 and 1985, by limiting their effort to the observation of their emergency operations centers during annual exercisis, t
1 (1) The reason for the violation if admitted.
The evaluation of interfaces with State and local governments for the years 1984 and 1985 did not provide for an in depth review of'these areas.
1 Examination gf the audit reports and checklists for the NFSC E-84-01 and NFSC E-85-01 audits, Emergency Plans, shows that evaluations were performed of the PSC activities in the State Emergency Operations Center, training of personnel for emergency medical and fire assistance, and communications between response centers, however, an in depth examination of State and local governmental interfaces was not addressed.
(2) Corrective steps which have been taken and the results achieved.
No specific corrective steps have yet been taken.
See Programmatic Corrective Steps and Results Achieved, Page 18.
t (3) Corrective steps which will be taken to avoid further violations:
Duringi the audit of emergency preparedness, a separate checklist will be prepared and performed to examine these interfaces in detail.
(4) The date when full compliance will be achieved.
The emergency preparedness audit is scheduled in conjunction with FOSAVEX-86 at which time a review of interfaces will be performed.
. Programmatic Corrective Steps and Results Achieved Public Service Company of Colorado (PSC) believes that it is imperative to both employ and demonstrate a strong, comprehensive audit program to review the operation of Fort St. Vrain and all 6
supporting activities.
This determination is reflected in the steps outlined below.
1.
An internal assessment of the overall audit program was completed on October 21, 1985.
The assessment was initiated following notification that this violation concerning emergency preparedness was to be issued and following an NRC inspection of security which identified audit weaknesses.
The methodology used in conducting the programmatic evaluation consisted of two primary steps.
a)
A review of the reference copies of all audits - Quality Assurance (QA), Nuclear Facility Safety Committee (NFSC),
and Contractor performed - on hand as of October 11, 1985, was performed. Emphasis was placed on determining the use of documented evidence to arrive at conclusions, and addressed completeness of checklists.
A total of 63 audits were reviewed which included 41 QA Audits and 22 NFSC Audits which, dependent upon the audit subject, covered time periods from 1981 to 1985 and included every activity which is evaluated in QA or NFSC audits.
Of the 63 audits, 24 contained discrepant conditions which required further review and evaluation.
Each discrepancy listed was addressed relative to:
1)
Root cause of the condition.
2)
Effect condition had on validity of audit results.
3)
Action taken to correct the condition.
4)
A timetable for completion of the corrective action.
5)
Acticn taken to preclude a similar occurrence.
6)
Whether a re-audit of the associated activity was required and the basis for the recommendation.
/
. The results of the review disclosed that:
The majority of the conditions listed as discrepant were attributed to the use of an audit format which did not facilitate listing of objective evidence. A format presently utilized in QA and NFSC audits will resolve this issue.
Several audits which utilized the newer format, contained questions which were not documented as having been completed or did not reference objective evidence.
These constituted less than one percent of the total audit questions, and it was determined that the conditions noted did not affect the validity of the audit results.
The revision to QA Auditing Procedure (QAAP-1), noted below, which addresses responsibility for review of audit checklists will resolve this issue.
In the final analysis, of the 24 audits requiring further review and evaluation, the validity of only three audits was viewed as possibly being questionable.
These were the QAA-1002-84-01 audit of Plant Scheduling and Quality
- Control, the NFSC-C-85-01 audit of Corrective Action, and the NFSC-F-85-01 audit of Security.
Based upon the scope of the audit in question, the results achieved as derived from audit checklists and reflected in the audit report, and the schedule for performance of a subsequent audit of the activity, it
+1s determined that audits of QAA-1002-84-01 and NFSC-C-85-01 during the regular 1986 scheduled time frame is justified.
Conversely, " fol low-up" of the NFSC-F-85-01 audit was warranted.
Therefore, an audit of security was performed in December, 1985, and included security system
- testing, testing of safeguard
- systems, commitments established for responses by local law enforcement agencies, and effectiveness of physical protection system.
b)
A revision was made to QA Auditing Procedure (QAAP-1) to clearly define what the signatures of the Lead Auditor, Supervisor, QA Auditing, and the QA Operations Manager signify on the review of audit reports, and to elaborate on the conduct of audit section of the procedure.
. All individuals involved in performance of audits have received copies of the revised QAAP-1.
The need for understanding and adherence to the provisions of the procedure were stressed, and special attention was directed to the two areas noted above.
2.
On October 17, 1985, a training meeting was held with the Manager, Quality Assurance, the QA Operations Manager, and QA and NFSC auditors to discuss the Notice of Violation and the conduct of audits.
The QA Operations Manager discussed the background associated with the Violation, and what is to be done administratively to preclude a recurrence. The QA Auditing Supervisor discussed some of the " mechanics" of the audit process and certain elements of QAAP-1.
Administrative issues discussed during the meeting included ctrengthening the audit program; preservation of auditor independence; the need to employ a deliberate, systematic approach during the development and performance stages of audits; and reiterated steps to be taken if auditors have concerns about the conduct of audits.
Fourteen of eighteen auditors attended the training meeting, and a special session was held with one individual.
Copies of the material which was presented were sent each of the three NFSC members who could not attend the training sessions. Each of the three acknowledged a
review of the information and an understanding of the concepts contained therein.
All individuals involved in performance of audits have received instructions on the conduct of audits.
3.
All audit reports sent to the Vice President, ETectric Production are transmitted under a cover memo which provides an " Executive Summa ry" of the audit results, and directs attention to particular strengths or weaknesses disclosed in the course of the audit.
4.
In addition, the QA Operations Department recognized the need to broaden the scopes of audits, assure all relevant elements are included, and the overall program strengthened and improved.
I i To that end, a major program was begun in early September, 1985, and involved a review of the Final Safety Analysis Report, Title 10 Code of Federal Regulations, Fort St. Vrain Technical Specifications, NUREG's, Regulatory Guides, I&E Bulletins, Circulars, and Information Notices; Generic Letters, American National Standards Institute Standards, and Fort St.
Vrain Administrative documents.
The review identified the requirements for inclusion of particular provisions into the evaluation of each activity which is audited.
In this manner, it is anticipated that the audits will reflect the letter of the rules as well as meeting the spirit and intent behind them.
The programmatic nature of the steps outlined in this response are intended to further reinforce Public Service Company of Colorado's commitment to a strong, comprehensive audit program.
(3) PSC failed to resolve a deficiency identified as Action Request CAR-080, dated August 17, 1984, relating to PSC's ability to staff and activate Fort St.
Vrain Station emergency response centers in a timely manner.
(1) The reason for the violation if admitted.
No reason for the violation is stipulated in this response because PSC did resolve a deficiency identified as Action Request CAR-080 (CAR-84-080).
The deficiency cited in Corrective Action Request 84-080 was the inability to activate the station emergency organization during FOSAVEX-84 within 90 minutes after classification of an ALERT or higher level incident. The underlying cause for 4
this deficiency was identified as the inadequacy of the initial notification system. This inadequacy was corrected by the initiation of " fan out" procedures for such notification and was demonstrated to be effective in F0SAVEX-85.
The concern raised in CAR-84-080 was therefore fully addressed and, in accordance with Fort St.
Vrain Administrative Procedure Q-16, Corrective Action System, the deficiency cited was resolved and CAR-84-080 was closed.
i t
. NRC open item 50-267/8314-06 stated that "an unannounced, full scale, shift staffing and augmentation drill should be held to confirm the accuracy of staff augmentation time estimates". This NRC open item continues to be tracked with CAR-83-128, which was issued on September 6, 1983, and will remain open until corrective action is adequately demonstrated in an off-hours augmentation drill.
(2) The corrective steps which have been taken and the results achieved:
For the reasons stated in (1) above, no corrective steps have been taken nor are any required.
(3) Corrective steps which will be taken to avoid further violations:
For the reasons stated in (1), above, no corrective steps are anticipated or required.
(4) The date when full compliance will be achieved:
For the reasons stated in (1), above, PSC has been in full compliance.
Should you have any further questions, please contact Mr. Frank J. Novachek, (303) 571-7436, ext. 201.
Sincerely, hmk n'Til J. W. Gahm Manager, Nuclear Production Fort St. Vrain Nuclear Generating Station JWG/kis