ML20216B928

Proposed Final Rept, Integrated Matls Performance Evaluation Program Review of Region II, for April 1998

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INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM REVIEW OF REGION ll April 1998 4

PROPOSED FINAL REPORT

\\

U.S. Nuclear Regulatory Commission 9804140202 980402 PDR ORG NOMA i

PDR j

Region 11 Proposed Final Report Page1

1.0 INTRODUCTION

This report presente the results of the review of the Region 11 (Rll) nuclear materials program.

The review was conducted during the week of February 9-13,1998, by a team comprised of technical staff members from the U.S. Nuclear Regulatory Commission (NRC) and the Agreement State of Califomia. Team members are identified in Appendix A. The review was conducted in accordance with NRC Management Directive (MD) 5.6, " Integrated Materials Performance Evaluation Program (IMPEP)." Preliminary results of the review, which covered the period from April 1996 to February 1998, were discussed.with Ril management on February 13,1998.

[A paragraph on the results of the Management Review Board (MRB) meeting will be included here in the final report.]

The Ril program is administered by the Division of Nuclear Materials Safety (DNMS). An organization chart for DNMS is included as Appendix B. At the time of the review, the Ril program regulated approximately 840 specific licenses, including several major fuel cycle facilities and the master materials license for the United States Navy.

In preparation for the review, a questionnaire addressing the common and non-common indicators was sent to Ril on November 26,1997. The Region provided a response to the questionnaire on January 16,1998. During the review, discussions with the regional staff resulted in the responses being further developed. A copy of the final response is included in Appendix C of this report.

The review team's general approach for conduct of this review consisted of: (1) examination of Rll's response to the questionnaire; (2) analysis of quantitative information from the NRC License Tracking System (LTS), and Nuclear Materials Events Database (NMED); (3) technical review of selected licensing and inspection actions; (4) field accompan:ments of three Ril inspectors; and (5) interviews with staff and management to answer questions or clarify issues.

The team evaluated the information that it gathered against the IMPEP performance criteria for each common and non-common indicator and made a preliminary assessment of the program's performance.

Section 2 below discusses the actions in response to recommendations made following the previous review. Results of the current review for the IMPEP common performance indicators are presented in Section 3. Section 4 discusses results of the applicable non-common indicators, and Section 5 summarizes the review team's findings and recommendations.

Suggestions made by the review team are comments that the review team believes could enhance the Rll's program. The region is requested to consider suggestions, but no response is requested. Recommendations relate directly to program performance by the region. A response is requested from Ril to all recommendations in the final report.

Region ll Proposed Final Report.

Page 2 L

2.0 '

STATUS OF ITEMS IDENTIFIED IN PREVIOUS REVIEWS l

During the previous routine review, which concluded in April 1996,11 new recommendations were made (some directed to Ril, others to NRC Headquarters offices), with one recommendation carried over from the 1994 IMPEP review. The results were traremitted to l

Stewart D. - Ebneter, the Regional Administrator at that time, on August 26,1996. The follow-l up review resulted in the closure of all but one of these recommendations.

l The team's review of the current status of these recommendations follows:

~

(1)

Recommendation 8, frorn.1994: "Ril should reconcile its intemal written procedure (Branch Guidance Procedure 4.2) for event evaluation and its informal practices for event evaluation."

Current Status: This recommendation is closed, The_ original recommendation related to the documentation of event follow-up at the time of event reporting and during subsequent inspections.> The Office of Nuclear Material Safety and -

i Safeguards (NMSS).sent a mem_orandum to Ril dated May 9,1996, dscribing efforts to revise inspection field notes in Inspection Procedure 87100. Rll.

responded with a memorandum dated June 3,1996, with an attached Regional Office Instruction (ROI) 720, Materials Event Log. Since that time, the NMED l

has been developed. This reduces the need for region-specific guidance.

However, additional NMED training is needed, to enhance its usability throughout the Agency, and in Agreement States. NMED is diticussed in Section 3.5 and a related new recommendation.

l

.(2)

Recommendation 1, from 1996: "The review team recommends that Ril license L

. reviewers add written explanatory comments in the tie-down condition listing the applicable sections in each old reference "(i.e., references before the most recent license application)."

i Current Status: This recommendation is closed. The review team determined that Ril license reviewers added written, explanatory comments for every document dated after 1996 in the tie-dcwn condition. These comments list the applicable items in each document, and/or summarize the contents of the document. The review team did observe, however, that it may not be obvious to a person not familiar with the Ril licensing procedure if the items listed in the comments are to be included or excluded from the referenced document, or if

. the items merely constitute a summary of the document. This is discussed further in Section 3.4.

.(3)

Recommendation 2, from 1996: "The MRB recommends that Ril document the basis for complex or unusual licensing decisions, and retain these documents in the licensing file."

Current Status: This recommendation is closed. The review team determined l

Region 11 Proposed Final Report Page 3 that in every license file reviewed, including complex and/or unusual licensing cases, the file contained appropriate documentation, including deficiency letters and responses, and technical assistance requests and responses.

(4)

Recommendation 3, from 1996: "The review team recommends that Ril continue to emphasize performing and documenting performance-based materials inspections, and internally evaluate progress on this issue in about a year."

Current Status: This recommendation is closed. Attachment 25 to the regional respotise to the IMPEP questionnaire, " Principles of Performance-Based inspection" ar,d observations discussed in Section 3.4 of this report suggest the region has placed additional emphasis on this issue since the 1996 review. The region also has begun to require written inspection plans for inspections of Type A broad licenses, with an emphasis on planning review of licensee performance in the more safety-significant areas. A July 1997 Ril management audit verified j

that considerable performance-based inspections were being done, but that the documentation did not reflect this well. Rll supervisors continue to emphasize the need to plan, conduct, and document the results.

(5)

Recommendation 4, from 1996: "The review team recommends that the Office of Nuclear Material Safety and Safeguards (NMSS) officially extend Temporary Instruction (TI) 2800/24, " Remote After loading Brachytherapy inspections," in writing, if materials inspectors are still expected to follow it and complete the HDR field notes."

l Current Status: This recommendation is closed. NMSS issued a v ndum dated August 28,1996, extending Tl 2800/24. It is now working,

.,a;64 ate this guidance in its upcoming revision of Inspection Procedure 87 'It (6)

Recommendation 5, from 1996: "The review team recommends that NMSS add event follow-up as a section in the next revision to the irradiator inspection field notes."

Current Status: This recommendation remains open. The update to the irradiator inspection field notes will be completed when NMSS revises Inspection Procedure 87100 (scheduled for Spring 1998).

(7)

Recommendation 6, from 1996: "The MRB instructed NMSS to develop guidance on how often regional survey instruments should be calibrated."

Current Status: This recommendation is closed. NMSS issued this guidance in a memorandum dated September 27,1996.

(8)

Recommendation 7, from 1996: "The review team recommends that allegations received by the Region which are outcide of NRC jurisdiction be referred expeditiously to the appropriate regulatory authority, and that the Region follow MD 8.8 and guidance developed by the Office of State Programs which l

Region ll Proposed Final Report Page 4 specifically addresses referrals to Agreement States (Office of State Programs intemal Procedures for Management of Allegations).

Current Status: This recommendation is closed. Review of allegation files

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demonstrated that allegations received by the Region, which are outside NRC jurisdiction, are being referred expeditiously to the appropriate regulatory authority.

(9)

Recommendation 8, from 1996: "The review team recommends close adherence to ROI 1030, Revision 7, dated March 18,.1996, regarding advising allegers of the status of allegations every six months, particularly for allegations requiring extended time periods to resolve."

Current Status: This recommendation is closed. ROI 1030, Revision 9, was

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' issued October 17,1997. Review of allegation files demonstrated that allegers were kept informed on the status of allegations approximately every 6 months as detailed in the ROI.

. (10)

Recommendation 9, from 1996: "The MRB directed that for future IMPEP reviews of regions, the review team contact the Agency Al;egation Coordinator,'

L in preparation for the IMPEP review, to discuss the resqlh of the Agency -

Allegation Coordinator's last regional audit."

i Current Status: This recommendation is closed. One of the IMPEP team L

members made this contact before the review, and received a copy of the most l

recent Ril audit.

.l (11)

Recommendation 10, from 1996: "The review team recommends that the decommissioning Manual Chapter currently being developed by NMSS include i

. guidance regarding the following items:

o The appropriate level of documentation needed to support the staffs decisions during license termination.

p o

The records that should be included in the terminated license file to support the decision to terminate a license.

o When closeout inspections should be conducted to support

- license termination."

Current Status: This recommendation is closed. The"NMSS Handbook for Decommissioning Fuel Cycle and Materials Licensees," published in final form in March 1997, includes guidance regarding the items listed above.

(12)

Recommendation 11, from 1996 "The review team recommends that NWISS and AcOD continue to investigate and consider alternatives to the in-house classroom training courses currently required to qualify fuel facility inspectors (for example, alternatives such as commercially-available training, video tapes from previous courses, or computer-based individually-paced training)."

hegion ll Proposed Final Report Page 5 Current Status: This recommendation is closed. The Office for Analysis and Evaluation of Operational Data's (AEOD's) Technical Training Division, is implementing new self-study programs to replace the required fuel cycle courses formerly presented in a classroom format. Two courses already hav Seen submitted to NMSS for final approval; and three others have been combined into another self-study course expect'ed to become available in April 1998. Another is expected to be available in September 1998.' The self-study courses are now being provided in the form of hardcopy course manuals combined with any associated audio-visual aids (if applicable). This format is considered the most cost-effective format at the present time." As technology advances, and relative L

costs of this and other possible formats may change, other more technology-rich formats, such as computer-based training, may be considered.

3.0 COMMON PERFORMANCE INDICATORS i H

IMPEP identifies five common performance indicators to be used in reviewing both_ NRC Regional and Agreement State programs. These indicators are: (1) Status of Materials Inspection Program; (2) Technical Quality of Inspections; (3) Technical Staffing and Training-l.

(4) Technical Quality of Licensing Actions; and (5) Response to incidents and Allegations.

3.1 Status of Materials insoection Proaram The team focused pn several factors in reviewing this indicator. (1) overdue inspections, L

(2) inspection frequincy: (3) timely dispatch of inspection findings to licensees: (4) completion I

l of initial inspections for new licenseest (5) the decision process and implementation of regional decisions to extend or reduce inspection frequencies based on licensees' past performance; and (6) and the completion of reciprocity inspections. This evaluation was based on the Region's questionnaire responses relative to this indicator, data gathered independently from the LTS, and interviews with managers and staff.

Each month, NMSS generates reports licting the number of overdue inspections in each region.

The team reviewed these reports for the close of fiscal year (FY) 1996, the close of FY 1997, and for January 31,1998. Several other monthly reports were also selected ai random for review. Each report showed Ril with no more than one or two overdue inspections. Several of the reports showed no overdue inspections, including the January 1998 report. These reports are based on LTS data, tabulated in accordance with inspection Manual Chapter (IMC) 2800 t

frequencies. In its recent performance report to the Executive Director for Operations, Ril considered its performance in this area to be a regional strength. The team's analysis supports this essessment.

_ in response to the IMPEP questionnaire, Ril indicated that the only type of licensee it inspected

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more frequent!y than what was prescribed in IMC 2800, was the Strontium-90 eye applicstors.

Ril accelerated the inspection frequency for these licensees to assure propn calculation of J

doses by this group of licensees.

l

Region ll Proposed Final Report Page 6 Ril issued its' materials inspection reports in an average of 8-9 days over this review period.

This figure is the best of any of NRC's regions. It includes a number of reports issued as NRC Form 591s,'which are usually issued in the field at the time the inspection is completed..These help to reduce the average. The goal, as stated in IMC 610, is to complete the reports within 21 days, or 30 days for team inspections. IMC 610 includes a statement that ".. although this goal may not be met in all cases, the report should ba issued no later than 30 calendar days after inspection completion (45 days for integrated reports and team inspections)." Rll reported that 7 of its 63 inspections completed in FY 98 exceeded the 21-day goal, but only 3 of these 7 extended bayond 30 days, independently, the review team looked at 22 other. inspections-(taken from various points in time during the review period), and made a similar finding. The team found that 19 of these 22 inspection reports were issued within 21 days,2 were issued in 28 days, and 1 was completed in excess of 30 days. Although figures are well-within the range of acceptability for IMPEP criteria, Ril identified this as a focus area for the next quarter of FY 98.

The team reviewed all 21 new licenses ispued by Ril in tO period from January to June 1997, to deterr.cne whether the region was cond Jcting initial inspections in a timely fashion. The team found that all but three of them had been. inspected as of the date of the IMPEP review, with the others listed on the regional"due list." These three licensees had been called to determine that they did not possess material or had not begun operations. Notations of these telephone contacts were found in the regiontsl files. ' All three are now scheduled to be completed in the next few months.

The team reviewed an LTS printout comparing the nu ber of licensees in each State with the number of inspections conducted by Rll since the last IMPEP review, As shown by the following table, these numbers aligned very closely, suggesting there was no geographic bias on the part of the region in scheduling its inspections.

State /Territorv Number of insoections. % ; Sumber of Licenses. %

' Alabama 2

Florida 3

3 Georgia 2

2 Kentucky 2

2

. Mississippi

<1 1

North Carolina 2

2 Puerto Rico 16 16 South Carolina 1

2

' Tennessee 2

3

' Virginia 46 45 Virgin Islands 1

1

West Virginia.

22 22

- The team reviewed a R!! memorandum dated August 15,1995, that showed that Ril had begun to implement NMSS guidance for extending or reducing inspection frequencies, on August 1,

.1995. The team also reviewed an LTS printout that showed 182 inspection intervals were i

extended,32 were reduced, and 248 were left unchanged in the period since the last IMPEP

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l Region ll Proposed Final Report Page 7 review. These decisions were based on discussions ofinspection findings between the inspectors and their managers, in accordance with IMC 2800 criteria (that primarily take into consideration the inspection results and past enforcement history of that licensee). The team reviewed two inspection reports of licensees who had their inspection intervals extended, and found that the Region did follow the guidance properly in reaching its decision.

The team also rev'ewed the region's questionnaire response and determined that the region had completed 29 reciprocity inspections over the !MPEP review period. This matches the

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number called for based on IMC 1220 criteria at the grand total level, although it was noted that some of the subcategory goals were not attained. Ril expressed difficulty in conducting field inspections of some of the licensees working under reciprocity, because of the last-minute nature of many of the filings. In its questionnaire response, Rll indicated it intends to conduct some office inspections for those licensees located in Ril conducting licensed activities in areas of Federaljurisdiction.

in summary, the review team had no recommendations with regard to this indicator. Based on the IMPEP evaluation criteria, the review team recommends that Rll's performance with respect to the indicator, Status of the Materials inspection Program, be found satisfactory.

3.2 Technical Quality of Insoections Region 11 performed over 450 materials inspections during the review period. Of these, the review team selected 22 inspection reports to review. These reports comprised a wide spectrum of the type of licensees that are inspected by the region. Categories of licenses selected were: (1) five hospitals with nuclear medicine and brachytherapy; (2) three radiographer licenses (two operating under reciprocity): (3) two pool irradiators (one under constnetion, considered pre-licensing); (4) two medical private practice (Sr-90 eye applicators); (5) the Navy master license, and (6) three university research and development operations.

Three inspector accompaniments were conducted to support this IMPEP review (although two of the three took place a few weeks after the IMPEP review was conducted, because of scheduling conflicts). The accompaniments were performed by individuals from NMSS and Region Ill. Comments regarding inspector technique were positive. The accompaniments indicated that the inspections performed in an exemplary and professional manner. They pursued safety issues and identified violations that had safety significance. The inspections were performance-based and included observations of licensee procedures. At the exit meetings, findings were explained to licensees in a clear and logical manner and the findings were not disputed by the licensees. Because some of the inspections were conducted only :

week before the IMPEP review, and others were conducted after the review, none of these inspections,eports was available for review. The IMPEP reviewer did interview the inspector accompanied before the review, and found that she described her inspection method well.

Appendix D includes the list of files reviewed and the inspection accompaniments conducted.

Allinspection reports reviewe. 4 the team indicated that they were unannounced. During interviews with the four inspecm available for questiciong, the team confirmed that they were unannounced inspections. Several inspectors commented that they might phone licensees to

Region ll Proposed Final Report Page 8 i

ask for directions, but they would not indicate the date and time of their planned inspections.

In general, the inspection reports reviewed were of good quakity._ They covered all necessary elements of the licensees' radiation safety programs. However, in almost all of the reports, the descriptions of licensees' scope of operations were limited. The inspectors documented their observations and interviews with the staff fairly well, but it was difficult for the IMPEP reviewer to determine that most elements' were covered in detail, other than by a check in a box stating a

. practice was covered. Some reports did not include the correct check list (i.e., high-dose-rate after-loader 2800/24) but all had the appropriate quality management ruie check-list documentation. The review team suggests that Ril inspectors use the inspection field notes pilot format developed for nuclear medicine license inspections.- One inspector used this format to document her inspection; This~ provided a clear picture of the licensee's operations.

One inspector acovered a large nurnber of misadministrations by a physician using a Sr-90 eye applicator. The inspector questioned the accuracy of the device's calibration certificate, and also the doctor's decay correction of the source over time. The inspector was correct in his assessment of the calibration, and as a result, the doctor was required to notify all patients of

' the error of the treatment plan, as well as be subject to escalated enforcement by the Region.

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This inspector is to be commended for his keen observation because the Sr-90 eye applicator y

. field notes do not clearly emphasize a review of the device calibration certificate or discussion with the user to determine if the output is accurately decayed. The review team suggests that NMSS develop guidance for inspections of Sr-90 eye applicators for distribution to the Regions and Agreement States.

All files reviewed were complete, with necessary documentation. The files were reviewed by supervisors, and they were properly signed by the inspector and the supervisor. Notices of Violation (NOVs) were written in clear regulatory language, with minor violations noted on NRC Form 591. These were written correctly as well. The reports reviewed were all signed off in a timely fashion, most within 2 to 3 weeks after the inspection. Licensee responses to NOVs were reviewed by the supervisors, and the close findings letters were signed by the Branch Chiefs.

Supervisors performed accompaniments of allinspectors annually, during the review period. In some cases, some inspectors were accompanied more than once per year. There were several reports completed by an inspection team of two or more inspectors. Team inspections were made of large complex licenses, and the team approach seemed to work well to accomplish the review d significant license activities.

AI'most all inspection reports reviewed indicated that the inspectors had made independent measurements of storage and use areas. The inspectors listed the survey meters used and the meters' calibration dates. In two instances, inspectors used survey meters that were calibrated beyond the allowable intervals specified in an NMSS memorandum dated September 27,1996, which established the frequencies of survey meter calibrations based on the calibration frequencies for the licensee inspected. The instances where meters were used beyond the acceptable calibration date were both radiography inspections. In one case, a meter last calibrated in February 1996 was used to inspect a radiography licensee in December 1996.

The meter shruld have been calibrated within 3 months of the inspection, or no earlier than

o Region ll Proposed Final Report Page 9

. September 1996. In the other instance, the inspector indicated that the meter she used to make inc'erendant measurements during a radiography field site inspection was last calibrated in February 1996, although the inspection date was April 1997, or 14 monthe later.

1 The region has an ample supply of survey meters to support the inspection program, in addition, there is a fully-equipped laboratory with a liquid scintillation counter, gamma spectrometer, well counter, gas flow proportional counter, and fume hood,' to support any

-decommissioning effort needed. Survey meters are calibrated under a contract with a private firm. There is a short turnarourvi time for meters dropped off for calibration. Each meter has a

" calibration sticker placed on it with the date and meter serial number.1There is also a

' calibration certificate maintained in the file.

The inspector was not available to interview about the above instance, but tYer supervisor did confirm that the calibration for the serial number of the meter listed on the report was correct.

There is a possibility that the inspector used a meter that she did not i,ndicate on the report; however, the content of the report is presumed to be correct, and it had been reviewed by the 4

supervisor. The review team recommends that Ril inspectors adhere to the guidance issued in NMSS' September 27,1996, memorandum, regarding the frequency of inspectors' survey meter calibrations.

Based on the IMPEP evaluation criteria, the review team recommends that Ril's performance with respect to the indicator, Technical Quality of. Inspections, be found satisfactory.

3.3 Technical Staffing and Training As part of its evaluation of this indicator, the team reviewed: (1) the DNMS program staffing level; (2) staff tumover; (3) technical qualifications of the staff; and (4) the availability of training required for qualification as license reviewers and/or inspectors. The review team examined Rll's questionnaire responses relative to this indicator, interviewed program management and staff, and considered any possible programmatic impacts of vacancies. (This section of the report is limited to discussion related to the Ril materials program. See Section 4.2 for a similar discussion related to Rll's fuel cycle program.)

DNMS includes two materials branches, currently staffed with 12 direct full time equivalents (FTEs), supported by two clerical FTEs, and led by two Branch Chiefs. The FY 98 budget supports 13.1 FTEs of direct effort. Three individuals retired from the materials program since the last IMPEP review--two staff members and one Branch Chief. One of the staff positions has been filled by a former Ril employee with extensive experience, who retums after taking a consultant position outside NRC. A vacancy announcement was posted in December 1997 for another position. The second staff vacancy is not expected to be posted because of projected budget reductions in FY 99. The Branch Chief vacancy is currently filled with a member of

- Headquarters on rotation. Ril announced a permanent selection for this pc en during the IMPEP review week, but no reporting date was announced at the time of tht WIPEP team's exit.

Each of the vacancies developed in late 1997 or early 1998. All were the result of retirements.

in anticipation of these losses, Ril developed a Skills List outlining the needed staff capabilities

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Region 11 Proposed Final Report Page 10 for its liconse reviewers, its specithst ireper. tors, its master material s.. cense project manager, and its project managers for terminated / contaminated sites. Copies of two Skills Lists (one for materials, arid one for fuci cycle) are provided as Appendix E. Thw lists allow the region to identify important attributes for recruitment and can help provide beckups to assure complete program coverage. Although this is desirable for most programs, this is especially important in a smalbr program such as Rll's. For this reason, the team considers this to be a

" Good Practice."

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At the time of the IMPEP review,11 technical staff members were qualified materials inspectors, and three license reviewers had full signature authority. At least four others were --

expected to complete the licensing qualification process over the next year, with many needing only to complete one or two major licensee site visits, or a few more selected licensing actions, based on the requirements of IMC 1246. Based on the FY 98 budget, with only about 2 FTE of licensing work anticipated, three reviewers with full signature authority,'with several others j

having partial authority, should be three more than adequate. Course availability is not an impediment for materials program qualification, in summary, the review team had no recommendatioris with regard to this indicator. Based on the IMPEP evaluation criteria, the review team recommends that Ril's performance with respect to the indicator, Technical Staffing and Training, be found satisfactory.

3.4 Ischnical Quality of Licensina Actions The review team examined completed licenses and casework for 16 licensing actions in 15 license files, representing the work of nine Ril license reviewers. The license reviewers and supervisors were intervier~t, when possible, when needed to supply additional information regarding licensing decision., or file contents.

Licensing actions were evaluated for: (1) completeness; (2) consistency; (3) proper isotopes and quantities used; (4) qualifications of authorized users; (5) adequate facilities and equipment; and (6) operating and emergency procedures sufficient to establish the basis for

- licensing actions. Licenses were reviewed for: (1) accuracy; (2) appropriateness of the license and of its conditions and tie-down conditions; and (3) overall technical quality. Casework was evaluated for: (1) timeliness; (2) adherence to good health physics practices; (3) reference to appropriate regulations; (4) documentation of safety evaluation reports; (5) product certifications or other supporting documents; (6) peer or supervisory review, as indicated; and (7) proper signature authorities. The files were checked for retention of necessary documents and supporting data.

The licensing actions reviewed included the following types of licenses: (1) master materials license; (2) portable gauge; (3) fixed gauge; (4) small medical; (5) large medical; (6) beta eye i

. applicators; (7) teletherapy; (8) high-dose-rate remote after-loader; and (9) veterinary.

' Licensing actions included six new licenses, seven amendments, two notifications, and one

. termination. A list of these licenses with case-specific comments can be found in Appendix F.

The review team found that the licensing actions were generally thorough, complete, consistent, j

and of acceptable quality, with health and safety issues properly addressed. Tie-down j

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Region ll Proposed Final Report Page 11 conditions were backed by information contained in the file, and are inspectable. License reviewers had the proper signature authority for the cases they reviewed independently.

Deficiency letters clearly stated regulatory positions, were used at the proper time, and generally identified all the deficiencies in the licensees' documents. Terminated licensing actions were well-documented, showing appropriate transfer and survey records. Finally, applicable guidance documents were available to reviewers and were followed.

The 1996 IMPEP team noted that, for some renewals and new licenses, the tie-down conditions listed old documents (i.e., documents dated before the most recent license application). At times, some sections of the old documents did not apply to the current license. However, it was noted that there was nothing in the tie-down condition to indicate which sections of these old documents did not apply. Therefore, the 1996 team recommended that, for these types of licensing actions, Ril license reviewers add wntten, explanatory. omments in the tie-down condition, listing the applicable sections in each old document.

The 1998 IMPEP review team determined that Rll license reviewers add written, explanatory comments for every document dated 1996 or later, in the tie-down condition for every licensing action. These comments list the applicable items in each document, and/or summarize the contents of the document. The review team did observe, however, that it may not be obvious to a person not familiar with the Ril licensing procedure, if the items listed in the comments are to be included or aciuded from the referenced document, or if the iteins merely constitute a summary of the document. This potential confusion could easily be alleviated with the use of words such as " including" or " excluding," as in the following examples:

l A.

Letter dated June 1,1997 (inc uding Section 1, Personnel Dosimetry)

B.

Letter dated June 2,1997 (ext:luding Section 2, Daily Surveys)

The review team noted that every licensing document to leave the Region, including deficiency letters, cover letters, and licenses, is reviewed by management before the document is mailed to the licensee. However, the review team identified minor " clerical" errors on cover letters and licenses, as well as minor " content" errors on licenses, which were not identified during the management reviews. In addition, the team identified minor deficiencie,s, in licensee applications, that were not identified during the initial and/or management reviews. Therefore, to minimize these types of mistakes, the review team recommends that Ril develop and implement an effective, periodic, in-depth, peer-review type of quality assurance program for licensing actions.

I The review team noted that an obsolete standard license condition (LC), former LC 166, is still being applied to Ril licenses. This license condition was identified as obsolete in an NMSS memorandum to the Regions dated March 17,1994. Therefore, the team suggests that this license condition no longer be applied to new Ril licenses, and be removed from current Ril licenses.

j The review team determined, through interviews and record reviews, that, in many instances, j

an incorrect date for " Milestone 22" (licensing action completion date) was entered into the LTS.

l This appears to be caused by a misunderstanding about the difference between the date a license is signed and the date the action is mailed to the licensee. Therefore, the review team

1 Region ll Proposed Final Report Page 12 suggests that NMSS clarify this issue _ by memorandum to all Regions.

The review team reviewed a major amendment to the Navy's master material license. This

' review includad a comparison of this license with that of another NRC master materiallicense.

No problems were identified.

Based on the IMPEP evaluation criteria, the review team recommends that Ril's performance with respect to the indicator, Technical Quality of Licensing Actions, be found satisfactory.

4 s

3.5.

Resoonse to incidants and Allaa=+ians LThe review team evaluated Ril performance involving incident response and allegation activities since the last review. The team examined the Ril questionnaire response to this indicator and reviewed 10 files containing incident reports, as well as 11 allegation files. In addition, the team conducted interviews with DNMS Branch Chiefs, the Senior Allegations Coordinator (SAC), and I

several materials inspectors.

The team examined the regional response to 10 selected events that the region identified as

. significant events in response to the questionnaire. The events included: (1) three potential overexposures; (2) two misadministrations; (3) one radioactive material spill; (4) one receipt of a contaminated package; (5) two cases of scrap metal yards receiving contaminated metal; and -

)

(6) one incident involving a lost radiography camera. Appendix G contains a list of incident file casework and reviewer comments.

4 The review team found that Ril responses to incidents were timely, appropriately coordinated, and of acceptable quality, with health and safety issues properly addressed. Reports of special l

inspections resulting from events were well-documented, and Ril took enforcement action when j

appropriate. in cases with potential high safety significance, inspection reports or information 1

.' provided by interview indicated that an onsite inspector or team thoroughly evaluated l

circumstances surrounding events. Less significant events were followed up during the next i

. scheduled inspection.

The." materials event log" kept by Ril and discussed in the 1996 IMPEP review is no longer in service. Thus, the region. depends on the NMED for complete event information. In the response to the IMPEP questionnaire, Ril noted that it was working to make more effective use of_NMED, including better assurance that it is complete and accurate for Rll license events.

The review team noted no NMED reporting problems involvir'g events in Ril. All 10 events evaluated by the review team were on the NMED system. However, Ril materials inspectors' knowledge of and familiarity with the NMED system were very inconsistent. Some inspectors knew the system well, while others were completely unfamiliar with NMED. The review team noted that Ril appears to have problems in properly using the NMED system, and that this problem does not appear to be limited to Ril. The review team recommends that AEOD provide supplementary training to NMSS, the Office of State Programs (OSP), the Regions, and i

Agreement States, in order to make the NMED system more accessible and usable for NRC and Agreement State staff, i

i

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. Region il Proposed Final Report Page 13

. The review team made performance evaluations of allegation files in the areas of investigation procedures, implementation of these procedures, internal and external coordination, and allegation follow up procedures. Eleven allegation files were selected for review, involving a -

variety of technical and administrative issues from a list provided by, the NMSS Allegations Coordinator. In most cases, information contained in allegation files was indicative of good technical follow up activities by regional staff. Allegations received prompt attention, tracking, and assignment.

The review team did note one concern in a file regarding staff use of ROI No.1030, " Processing Allegations, Complaints, and Concerns." When handling the initial phone call from an alleger, a staff member appeared to not follow the guidance in that: (1) the phone call should have been directed to the SAC; and (2) the specific information about confidentiality should have been told -

' to the alleger, in this specific case, the call was not directed to the SAC and the alleger was not specifically informed as to the circumstances where NRC could not protect her, identity. The SAC. informed the review team that because of the sensitive nature of allegations, cases must be handled on a case-by-case basis, depending on many circumstances, including: the state of mind of the alleger, if the alleger has a problem in referring the matter to an Agreement State, if

- the SAC can be reached, etc. There appears to be no problem in handling allegations, but the

- actions taken did not match the guidance as written. The call was not handled improperly from

- a performance standpoint, and information about the alleger's identity was not given to the State as requested by the alleger. Nonetheless, the IMPEP_ team suggests that Rll alter the language to ROI 1030 to allow more flexibility in handling phone calls from allegers.-

. Based on the IMPEP evaluation criteria, the review team recommends that the Region's J

performance with respect to the common performance indicator, " Response to Incidents and Allegations," be found satisfactory.

4.0 NON-COMMON PERFORMANCE INDICATORS 1

This IMPEP review included only two non-common performance indicators: (1) Ril's Operating Plan Performance and Resource Utilization; and (2) Ril's Fuel Cycle Activities. No Site Decommiasioning Management Plan sites are found in Rll, and other NMSS program areas -

- include c.ily a modest level of activity in this region.

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4.1 Ooeratina Plan Performance / Resource Utilization 4.1.1 Ooeratina Plan Performance

= This IMPEP review included a period from April 1996 through January W98-a timeframe

- spanning parts of 3 FYs. In this period, the FY 96 and FY 97 Operating Plans were structured l

along traditional lines, with their contents coordinated with the Offices of Nuclear Reactor Regulation (NRR) and NMSS. This section of the repcrt discusses regional performance only for those areas not discussed elsewhere in this report.

1

- With respect to materials licensing timeliness, the Region reduced the number of older cases significantly over the review period. As of September 30,1996, the region had 17 new l

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'{.

' Region 11 Proposed Final Report Page 14 applications or amendments pending completion for over 180 days, and one renewal pending for over a year. As of January 31,1998, these figures were reduced to seven amendments greater than 180 days, and no renewals greater than a year old. The backlog, which correlates closely to these statistics, showed a similar reduction, from 9 to 5, over this same interval. Most of the older cases currently pending involved financial assurance reviews that require support from NMSS. The number of pending cases rose slightly over the same period, with 81 cases pending on September 30,1996, and 98 cases pending as of January 31,~ 1998.

Another key element of the region's FY 96 and FY 97 Operating Plans related to the level of -

support shown for NMSS materials program initiatives. The region performed exceptionally well in this area, with severalindividuals active on a number of projects. Some examples of Ril's strong support from FY 96 to the time of the review include:

o Business Process Reengineering activities.

Participation on several guidance consolidatiori teams, including: (1) portable gauges, o

(2) radiography; (3) self-shielded irradiators; (4) medical use licenses; (5) academic, research and development, and laboratory-use licenses of limited scope; (6) the Veterans' Administration masterlicense application, and (7) the " Decommissioning Handbook." The Region participated at the working level and on several pink and red management review teams.

- o

- A special inspection for broken radiography cable incidents.

This level of support is particularly noteworthy considering Rll's modest staffing level. The region has been able to participate in these and other ancillary ' projects while effectively executing its' ongoing program requirements.

The FY 98 Operating Plan is structured differently, using the NRC Strategic and Performance Plans as its basis. Under this new formet, output measures are linked to the Agency goals.

The Region reported its first quarter performance directly to the Executive Director for Operations (EDO) a few days before the IMPEP team began its review (by memorandum dated February 5,1998). Using a set of pilot output measures, Ril identified five areas in which it intended to increase its focus in the second quarter of FY 98. These included:

- o Conducting weekly allegation meetings. Ril missed its intemal goal of 90 percent, conducting 11 of 13 weekly meetings.

o improving the timeliness of its materials inspection reports (as stated in Section 3.1 of this report,7 of 63 were issued outside the 21 day goal).

o improving the timeliness of its fuel cycle inspection reports (see discussion in Section 4.2 of this report).

o Resuming the Ril quarterly self-assessment reports.

o.

Providing enforcement information to the Office of Enforcement at least 48 hours5.555556e-4 days <br />0.0133 hours <br />7.936508e-5 weeks <br />1.8264e-5 months <br /> in advance of the panels. ' Ril missed this goal for 2 of its 15 panels.

i The region also reported that it completed 84 percent of its new application and amendment licensing reviews within 90 days. This met the NRC performance goal of 80 percent, and beat the NRC-wide tally for the first quarter of FY 98 (82 percent on time). In addition to these pilot

- output measures developed by the Region, NMSS has placed a higher emphasis on I

t Region ll Proposed Final Report Page 15 regional / Headquarters communication in this FY. The Region's performance was strong in this

)

area. One example is the flow of information from RP to Headquarters, related to the series of inspections conducted in FY 97 and FY 98 at the Applied Radiant Energy irradiator facility in Forest, Virginia. Ril kept NMSS well-informed of the issues and progress associated with the 1

construction work at this site.

J 4.1.2 Resource Utilization The following table shows Ril program resources budgeted for FY 96 through FY 99.

Resources expenditures for FY 97, the only full year of this review period, are also provided as

)

comparison.

l t

FY 96 FY 97 FY 97 FY 98 FY 99 l

Proaram Area Budget Budget Exoend.

Budget Budget l

Materials 13.7 13.0 11.8 13.1 11.8 l

Fuel Cycle 8.2 9.2 8.1 9.5 9.5 Waste Activities 2.0 1.0 0.9 0.8 0.3 l

Spent Fuel

_.QA

_.Q&

_QA Qd

_QA TOTAL 23.9 23.2 20.8 23.8 22.0 The region expended only 90 percent of its FY 97 NMSS program allocation, but was able to meet its mission objectives with minimal licensing backlog, and virtually no overdue inspections, in addition, it provided strong support to a number of Headquarters program initiatives.

Regional materials program vacancies were anticipated, and these Radiation Specialist positions are being filled quickly with minimal program impact. The region has experienced greater difficulty in filling its fuel cycle vacancies, and will broaden its search for qualified engineers in this FY. Additional fuel cycle discussion follows in Section 4.2.

4.2 Fuel Cvele Proaram 4.2.1 Status of Fuel Cycle insoection Proaram inspections at fuel facilities are coordinated with NMSS and the Regions through an integrated Fuel Cycle Master Inspection Plan, based on considerations of risk and licensee performance.

Besides meeting the general guidelines for frequency of inspections in IMC 2600, Ril has prepared detailed written guidance targeting specific plant operations and functional areas for emphasis during inspections. This guidance translates the lessons learned from previous inspections and Licensee Performance Reviews into specific guidance to inspectors, and is considered a good practice worthy of emulation in the fuel cycle inspection programs of the other Regions and Headquarters.

With closer integration between the fuel cycle inspection programs of the regions and Headquarters, there is an increased need for Headquarters end Region-based inspectors to have ready access to each other's inspection reports. _Rll inspectors have expressed a need for more ready access to inspection reports for Headquarters inspections. NOTECHIS, the existing institutional means for providing such access, is not satisfactory, since it involves

~..

pa Region ll Proposed Final Report Page 16

~

obtaining the reports from microfiche, a time-consuming and sometimes poor-quality process.-

A new system, ADAMS, will eventually provide online access to inspection reports, but is not yet available. : It is suggested that NMSS consider ways in which information technology could be hamessed in the interim to improve the accessability of completed inspection reports to Headquarters and region-based inspectors, Some suggstions include exchanging electronic versions of completed inspection reports between the Regions and Headquarters via CD-ROM discs or other large media, or placing them on the NRC intemal intraneti Also, the executive summaries and results (e.g., violations, inspector follow-up items, unresolved items, etc.) of inspection reports could be included in the Fuel Cycle Inspection Management System (FCIMS) computer database used to manage.the Fuel Cycle Master inspection Plan.

Ril currently is using the inspection Follow up System (IFS) for tracking the results of fuel cycle

' inspections. Recent developments indicate that the IFS, currently maintained by NRR, may.

soon cease operation. The IFS is not Year-2000 compliant, and is soon to be replaced by a new NRR program, the Automated Inspection Reporting System (AIRS), which does not presently address fuel cycle inspections. Following the successful full deployment of these programs, which may occur as soon as Summer 1998, NRR plans to stop suppo ting IFS.

Therefore, the team recommends that Ril should ensure that the fuel cycle inspection program is not adversely affected when the current IFS program for tracking inspection results

' is terminated.

Ril's scheduling and performance of inspections generally optimize the use of inspection resources so that inspectors are permitted sufficient time to prepare for, and document,-

inspections. Occasionally, however, inspectors have had to perform inspections with just 1 week between inspections, or back-to-back from 1 week to another. This situation is most likely.

related to the problems Ril is experiencing in filling two inspector position vacancies. These situations arise in meeting certain exigencies in the inspection program, but tend to decrease the time available to the inspector to complete inspection reports while having to plan or

. perform the next inspection. In the most recent instance when an inspector had to perform back-to-back inspections, planning for both inspections was accomplished well in advance. The resulting limitations on the time permitted for preparation of the inspection reports has contributed to problems in meeting the timeliness goals for the reports.

' Ril fuel cycle inspections were generally timely from the point of view of the current IMPEP performance indicator, which indicates routine non-team inspection reports should be issued -

within 30 days. Instances of late inspection reports were traced to the Region's placing a higher priority on ensuring the quality of the reports over their timeliness. According to Ril's first quarter FY 98 Operating Plan report to the EDO, none of the 10 fuel cycle inspection reports for the first quarter was issued within the stated goal of 21 days; but 8 of ten were issued within 30 days. Though it is easy to measure the timeliness of inspection reports, the Ril Operating Plan currently does not include a metric for the quality of inspections. Until such a metric is established, it will be difficult to determine whether or not there will be an impact on the quality of inspections as additional emphasis is placed on meeting the 21_-day goal for inspection report timeliness. The Rtsport identifies the timeliness of inspections as a focus area where Region ll would like to improve.

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- Region ll Proposed Final Report Page 17 1

4.2.2 Technical Staffina and Trainina

. Two project inspectors, hired during the IMPEP review period, have been interim-qualified.

They were hired to conduct inspections with an area of emphasis in nuclear criticality and -

operations review, based upon skill profiles similar to those used for hiring materials inspectors and licensing personnel (which already has been recognized as a good practice in the Section 3.3). Their backgrounds and experience in chemical engineering provide strong capabilities for performing inspections of the complex chemical process operations conducted at fuel cycle i

- facilities. When hired, it was recognized that they both needed to improve their capabilities in nuclear criticality. One had already completed the required Nuclear Criticality Safety Course (F-101) at the time of this report, whereas the other is expected to challenge the course -

. examination after viewing tapes from a previous presentation of that course. It was observed that both could benefit from additional supplemental training in nuclear criticality, which previous occupants of their positions customarily have taken.! For example, one such known training experience has been considered especially valuable, because it permits personal contact with numerous expett practitioners in the criticality field,'and includes discussions and question and answer sessions regarding actual criticality incidents that have occurred at fuel cycle facilities.

Such training would be expected to promote increased sensitization of the inspectors to -

possible criticality issues they may encounter during future inspections.

In effect, Region ll has had two vacancies for fuel cycle inspectors at the Grade 13 level remain unfilled since Summer 1997. It was observed that the dearth of a few highly-skilled personnel from an authorized inspection staff level of nine has led to greater demands on the remaining.

staff, and contributed toward problems in attaining the Region's 21-day timeliness goal for fuel cycle inspection reports. Finding acceptable candidates for these positions has proven difficult, while rejections late in the hiring process have led to additional unavoidable delays in filling these vacancies.

4.2.3. Technical Quality of Fuel Cvele Insoections The reviewer observed that Rll's inspection findings were well-founded and well-documented throughout the assessment period. A cross-section of reports was evaluated against the requirements in IMC-610, " Inspection Reports," dated February 2,1996, and found to meet those requirements. In general, the reports received proper peer and management review.

The inspection program in general and the specific reports reviewed appeared to focus on the higher-risk functional areas. Ril has a program in place to track past issues at each facilityc i

These issues include past inspection findings, events, and routine activities at each site. This

" site integration matrix" is kept current for each facility and is used by the inspectors in the planning phase of the inspection, to focus on areas that may be weak. The inspection effort

. does address past findings, and programs are in place to track the status of open inspection items.

One area that Ril will have to continue to evaluate and provide management attention is the review of licensee responses to Notices of Violation and events. The fuel cycle' inspection program is continuing to raise the bar on the expectations of licensee responses to NOVs and events to assure they identify the root causes and that documented corrective actions

Region ll Proposed Final Report Page 18 specifically address these root causes and not the symptoms.

During the review period, Region ll has hired three new inspectors. Management has performed appropriate inspection observations, focusing on these new inspectors.

4.2.4. Resoone to Fuel Cycle incidents and Alleaations During the review period, eight allegations were received regarding activities at fuel cycle facilities. As of January 2,1998, all were closed. The reviewer observed the inspection reports used to close these allegations. These reports supported the timely closure of the allegations and used technically sound arguments.

Responses to events appeared to be appropriate, with the region coordinating with NMSS, as needed. During the reporting period, the Incident Response Center (IRC) was activated several times for severe weather events and once for a fire at a fuel cycle facility. All these activations appeared appropriate. Lessons learned from these actions and the drills performed during the review period were tracked and incorporated into future expectations. Ril has a program in place to ensure full staffing of the IRC, when needed, it tracks and provides training for critical l

branch personnel, to support their IRC duties. In general, the reviewer observed that the IRC is well-staffed, and appears prepared to support an event 'at a fuel cycle facility.

Based on the IMPEP evaluation criteria, the review team recommends that the region's performance with respect to the non-common performance indicator, " Fuel Cycle Program," be found satisfactory.

5.0

SUMMARY

As noted in Sections 3 and 4 above, the review team'found that Rll's performance with respect to each of the performance indicators to be satisfactory. Accordingly, the team recommends the Management Review Board find the Rll program to be adequate to protect public health and and safety.

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Below is a summary list of recommendations, suggestions and good practices, as mentioned in earlier sections of the report, for evaluation and implementation, as appropriate.

RECOMMENDATIONS FOR Ril:

1.

The team recommends that Ril assure its inspectors make use of survey instruments l

(

calibrated at proper frequencies (Section 3.2).

2.

The team recommends that Rll develop and implement an effective, periodic, in-depth, peer-review type of quality assurance program for licensing actions (Section 3.4).

3.

The team recommends that Ril should ensure that the fuel cycle inspection program is not adversely affected when the current IFS program for tracking inspection results is terminated. (Section 4.2).

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[

y.

Region ll Proposed Final Report Page 19 RECOMMENDATIONS FOR OTHERS:

1.

The review team recommends that NMSS complete its efforts to add event follow up as a section in the next revision to the irradiator inspection field notes (Section 2).

2.

The review team recommends that AEOD provide supplementary training to NMSS, OSP, the regions, and Agreement States, to make the NMED system more accessible and usable for NRC and Agreement State staff (Section 3.5).

l SUGGESTIONS:

1.

The team suggests that Ril use the inspection field notes pilot format developed for nuclear medicine license inspections for other categories of inspections, to provide l-greater description of licensee operations. (Section 3.2).

l l

2.

The review team suggests that NMSS develop guidance for inspections of Sr-90 eye applicators for distribution to the Regions and Agreement States (Section 3.2).

t l

3.

The team suggests that former standard license condition 166 no longer be applied to new Rll licenses, and be removed from current Ril licenses (Section 3.4).

)

4.

The review team suggests that NMSS clarify the " Milestone 22" issue by memorandum l.

to the Regions (Section 3.4).

5.

The team suggests that Ril consider altering the language of ROI 1030 to allow more flexibility in handling phone calls from allegers (Section 3.5).

6.

It is suggested that NMSS consider ways in which information technology could be hamessed to improve the accessability of completed fuel cycle inspection reports to Headquarters and Region-based inspectors (Section 4.2).

GOOD PRACTICES:

1 1.

The review team identified the Rll Skills Lists (one for materials and one for fuel cycle positions) as a good practice. These lists allow the region to identify important attributes for recruitment and can help provide backups to assure complete program coverage (Sections 3.3 and 4.2).

2.

The team identified the Ril detailed, written guidance targeting specific fuel cycle plant operations and functional areas for emphasis during inspections as a good practice (Section 4.2).

j i.

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l' I

LIST OF APPENDICES AND ATTACHMENTS Appendix A iMPEP Review Team Members Appendix B Region 11 Division of Nuclear Materials Safety Organization Chart (will be added to final report)

Appendix C IMPEP Questionnaire Response (will be added to final report)

Appendix D inspector Accompaniments and Inspection File Reviews Appendix E Good Practices:

(1)

Needed Skills, Capabilities (Materials and Fuel Cycle)

(2)

Guidance Targeting Specific Plant Operations &

Functional Areas for Emphasis During Fuel Cycle Inspections Appendix F License File Reviews 1

Appendix G Incident File Reviews Ril's Response to Review Findings (will be added later) i i

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l f.

l-APPENDIX A' f

IMPEP REVIEW TEAM MEMBERS Name

'. Area of Responsibility l

l George Deegan, NMSS/IMNS On-Site Team Leader l

Status of Inspections Technical Staffing and Training i

Operating Plan / Resource Utilization l

Donald Bunn, Califomia Technical Quality ofInspections Mich'ael Weber, R'il Technical Quality of Licensing Lance Rakovan, OSP Response to incidents and Allegations Lance Lessler, NMSS/FCSS Fuel Cycle-Status of Inspections Fuel Cycle-Technical Staffing and Training Garrett Smith, NMSS/FCSS Fuel Cycle-Technical Quality of Inspections l

Fuel Cycle-Response to incidents and Allegations 1:

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I i

i

APPENDIX B -

REGION ll DIVISION OF NUCLEAR MATERIALS SAFETY l

ORGANIZATION CHART (will be added to the final report) l l

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APPENDIX C i

INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM (IMPEP) QUESTIONNAIRE RESPONSE l

i

A ter UNITED STATES

/

ug'o NUCLEAR REGULATORY COMMISSION

.[

o' REGION 11 l. #3 D-ATLANTA FEDERAL CENTER 61 FORSYTH STREET. SW. SUR E 23T85 k

ATLANTA. GEORGIA 30303-3415 p/[/\\/ $

pgld January 16. 1998 M5MORANDUMT0:

Carl J. Paperiello. Director Office of Nuclear Material Safety and Safeg ar s FROM:

Luis A. Reyes Regional Administrat

SUBJECT:

INTEGRATED MATERIALS PERFORMANCE EVALUATION (IMPEP)-

OdESTIONNAIRE This is-in response to your memorandum dated November 26, 1997 requesting Region II to provide answers to the IMPEP questionnaire. The completed questionnaire is attached. We believe that our inspection and licensing staff have the proper safety focus and that our programs are identifying safety issues during licensing reviews and inspections.

You will pote that we have identified items during our self-assessments' where improvements are needed as indicated in the questionnaire answers. We have discussed several of these areas during our management retreats, and we have actions ongoing to make improvements. Areas of particular emphasis are improvement in the quality and timeliness of materials licensing actions and inspection reports, and improvement in the quality and timeliness'of fuel facility inspection report drafts provided to the Branch Chief for review.

In addition, due to the recent loss of staff due to retirements, we continue to

. emphasize recruiting quality staff and the training of backups for critical functions.

If you have any questions, please give me a call.

l

Attachment:

IMPEP Ouestionnaire l

i cc w/att.

G. Deegan. NMSS l

l 4

1

INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM OUESTIONNAIRE Region II Reporting Period: March 1996 to February 1998 A.

COMMON PERFORMANCE INDICATORS I.

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.

RESPONSE

There are currently no overdue inspections.

However, during the assessment period the following inspections were overdue:

Insp. Frequency Licensee Name (Years)

Due Date Months 0/0 Princeton Diagnostic 1

5/96 5 (Inspected Isotopes 10/96)

[Two attempts had been made to inspect prior to overdue date, but the licensee was not available]

Technical Welding 1

11/96 6 (Inspected 5/97)

[ Licensee's home office is in Texas; Region II is licensing and ins)ecting region since all work was done in the Virgin Islands.

Wit'1 a Texas prefix on the license number, it was not picked up on the inspection due list developed from LTS.

Region II identified this as a generic problem and worked with NMSS to have it corrected.]

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.

RESPONSE

Currently Region II has no overdue inspections.

The Region has a process to maintain a minimum of overdue inspections.

Under this process, the Branch Chief or his designee obtains a "Due List" printout to identify those inspections coming due.

The Branch Chief or designee develops itineraries and monthly schedules for inspections.

These itineraries are reviewed by the Branch Chiefs after the inspection trips to determine whether inspections have been comaleted.

If an inspection is not completed. the Branch Chief scledules the inspection for a subsequent trip.

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 state the reason for the i

change.

l

RESPONSE

Region II implements the criteria in MC 2800 for the inspection frequency, including extension and reduction of inspection frequency based on licensee performance (inspection findings).

The frequencies for future inspections are established, based on type of licensee and inspection findings, by the Branch Chief as 3 art of the process for review of insaection reports -(narrative or rield Notes) after each inspection.

Region II is accelerating the inspection of licensees using Sr-90 eye applicators to assure that.

licensees are properly calculating doses to be administered. This is based on findings that licensees have mah errors in determining output (rads /second) either because of improper calibration or decay of tne sources.

In January 1998. Region II began special insaections of these licensees with a goal to complete them by iarch 1998.

As a result of this special effort.

several of these licensees will be inspected before their next due date.

4.

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

RESPONSE

The Table below provides the requested information. - The table shows that Region II has not met' the goal for inspections of licensees conducting inspections under reciprocity. Our emphasis has been on conducting inspections of such licensees when actually doing work in NRC jurisdiction rather than completing inspections at the licensees permanent facilities in Agreement States.

In the past, we have been more successful in inspecting licensees in the field. but within the last year we have found that licensees have

-been giving shorter notice for reciprocity work.

As a result, we have not been able to inspect these licensees in the field.

However, we will conduct office inspections for licensees who are located in Region II and have indicated in the NRC Form 241 that they planned to conduct licensed activities in areas of exclusive Federal jurisdiction within Region II for 1997.

These inspections will be completed by March 31. 1998. We have re-emphasized the need to complete reciprocity inspections and will continue emphasis on completing field inspections.

We will conduct inspections at licensee's facilities (rather in the field) who have filed for reci)rocity in 1998 starting in September of 1998 if we have been una)le to ins)ect the licensee in the field.

This action has been added to the )NMS tracking system.

2

Number of Licensees Number of Priority Goal Granted Licensees (Percent)

Reciprocity Inspected Each Permits Each Year Year Service Licensees 1996-3 1996-3 performing 1997-2 1997-0 teletherapy and 100 1998-1 1998-0 irradiator source installations or changes 1996-11 1996-6 1

50 1997-12 1997-4 1998-1 1998-0 1996-0 1996-0 2

50 1997-0 1997-0 1998-0 1998-0 1996-5 1996-3 3

30 1997-10 1997-0 1998-4 1998-0 5/7 10 1996-29 1996-6 1997-20 1997-7 1998-5 1998-0 5.

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

RESPONSE

Region 11 attempts to perform a field inspection of each radiography licensee with temporary job site authority during each inspection.

We accomplish this by determining where the licensee is doing or planning to do field work.

We make such l

determinations by review of licensees records during inspections at their facility, by interaction with State representatives, and i

by interactions with facilities that routinely contract for l

radiography services (power authorities, refineries, etc.)

In some cases, we have made multiple attempts (in one case four l

attempts) to conduct field inspections.

If we are unable to l

observe field operations, the inspections have been closed based 3

L

on an inspection conducted at the office facilities. Listed below is the information on field inspectiens for the current and two previous fiscal years.

FY 96 - 6 (28 percent of radiography licensees)

FY 97 - 8 (30 percent)

L FY 98 (4 Percent) 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.

RESPONSE

In past fiscal years (FY) the Region II Operating Plan established two goals for inspections: number of inspections to be completed and no overdue inspections. Our )erformance in meeting these goals has been monitored during tie quarterly self-assessments.

In addition, we tracked completion of _ inspections throughout the year as part of the regional Management Information Report (MIR).

As a result we have been able to complete the planned inspections and have had a minimum number of overdue inspections.

In the I

current Region II Operating Plan, the primary goals are to do reactive inspections to review events and to perform inspections when they are due based on IMC 2800 frequencies, including I

consideration of inspection results.

This is in keeping with the 3rototype Regional Operating Plan developed by NMSS. We currently lave no overdue inspections. We are revising the MIR for FY 98'to show any overdue inspections rather than the number of i

inspections.

The number of inspection due and actual completions for the IMPEP period are:

GQAL ACTUAL COMPLETIONS l

FY 96 260 323 FY 97 250 322 FY 98 based on due list 63(thru 12/31/97) none overdue II.

Technical Quality of Insoections 7.

What, if any changes were made to your written inspection L

procedures during the reporting period?

l l

RESPONSE

The main changes in Region Il-specific processes and procedures are discussed below (program changes, e.g. IMC 2800 and 0610, changes in IPs changes in the Enforcement Manual, etc., are not discussed).

Region 11 formalized our previous processes for 4

I e

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selecting areas and ap3 roaches to inspection of fuel facilities

-(see Attachment 7. Risc Informed. Performance-based Inspections, and Attachment 7a Targeting Information. for details).

In the materials area, we began conducting inspections of Type A broad L

licensees with two or more inspectors based on written inspection j

plans and writing narrative reports for such inspections.

8.

Prepare a table showing the number and types of supervisory l

accompaniments made during the review period.

Include:

InsDector Suoerviso.t License Ca".

Qats l

RESPONSE

l Attachments 8. 8a. and 8b show DNMS management site visits for l

FY 1996, 1997, and 1998 respectively-. Attachments 8c. 8d. and 8e show dates when inspectors were accompanied by their supervisor.

Normally for materials inspectors, the accompaniments are for several licenses over a period of several days.

9.

Describe internal procedures for conducting-supervisory accompaniments of inspectors in the field.

If supervisory accompaniments were documented, please provide copies of the l

documentation for each accompaniment.

RESPONSE

The Region II Operating Plan establishes goals for inspector ~

l accompaniment by su)ervisors. The DNMS self-assessments review accomplishment of t1ese goals on a quarterly basis.

Regional Office Instruction (ROI) 2213 (Attachment 9) establishes the process for inspector accompaniments. This establishes that. on-the average. the Division Director or Deputy will visit a site each month, each Branch Chief will accompany an inspector each quarter, and each Branch Chief will accompany each ins)ector once each fiscal year. The ROI requires documentation of t7e site visits by each su]ervisor.

Copies of such documentation is provided as Attac1 ment 9a for certain of those visits conducted in the 3ast six months. We identified that such documentation was not 3eing completed, and have re-emphasized to su)ervisors and managers that this must be done in accordance wit 1 the ROI.. A check of this documentation on a quarterly basis has been added to the DNMS tracking system.

l 3

In addition, the Branch Chief observes the performance of each l

inspector during an inspection before recommending the individual be qualified as an inspector, l.

5 L

1 l

10.

Describe or provide an update on your instrumentation and methods of calibration.

Are all instruments properly calibrated at the present time?

RESPONSE

Region II established an inspector in charge of the laboratory and instruments (part time, rotating among inspectors) and a Branch Chief responsible for such activities.

In addition, procedures for such activities have been established. With regard to instrumentation, the Region has two types of instruments:

(1) fixed gamma, beta, and alpha counting systems in the screening laboratory, and (2) portable instruments (survey metarr, area monitors, alarming dosimeters, and air samplers) for use by field inspectors during routine as well as decommissioning inspections.

The fixed instruments in the screening laboratory are calibrated by the staff using current NIST '.raceable standards.

The portable instruments are calibrated by a vendor in accordance with ANSI calibration standards.

The calibration specifications applied to the vendor are provided as Attachment 10, and Attachment 10a is a list of portable instruments used in Region II.

III. Technical Staffino and Trainina l

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 and compliance, emergency response. LLW, U-mills, other.

If these regulatory responsibilities are divided between offices, the table should be l

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.

I If consultants were used to carry out the program's radioactive materials responsibilities, include their efforts.

The table heading should be:

l l

NAME POSITION AREA 0F EFFORT FTE%

l RESPONSE: 1 is a copy of the Region II DNMS organization chart.

In 1995. Region II reorganized to place NMSS programs and the Agreement State Officer in DNMS.

Coordin e on of escalaLe enforcement and allegations was placed in the Enforcement and Allegation Coordination staff reporting to the Regional Administrator.

6

The Table below lists the requested information for 'adterials staff.

In addition DNMS obtains engineering support from the Division of Reactc; Safety when necessary, such as in the case of concrete construction work at ARECO. Similar information is provided in B.I.4 and B.I.3. below for Fuel Facilities Branch staff.

There have been several recent retirements by staff in and supporting the materials area. (Earl Wright and Jerry Ennis who retired on January 3. 1998 John Potter, who retired on December 3, 1997, and Bruno Uryc who retired in December 1997, and these are included below but noted with an *.

Prior to these retirements. DNMS established a listing of skills needed in the Division and developed backups so that skills would not be lost if an individual left the agency.

As a result, when the individuals retired, there were sufficient staff with the necessary skills to continue activities.

For example. Earl Wright had been lead for Financial Assurance Reviews.

We designated John Pelchat as backup, and he now has the lead for these cases.

There is one vacancy in the materials area.

The position is posted and we are actively working to fill it.

NAME POSITION PRIMARY AREA LEVEL OF LEVEL OF OF EFFORT EFFORT-%

EFFORT-%

LICENSING INSPECTION BERMUDEZ SR RAD SPEC INSPECTION 25 75 COLLINS (DJ)

RAD SPEC LICENSING 75 25(including reciprocity)

DIAZ RAD SPEC INSPECTION 25 75 ENNIS RAD SPEC INSPECTION 9

100 FRANKLIN RAD SPEC INSPECTION 0

100 FULLER RAD SPEC INSPECTION 0

100 HEIM LIC ASST LICENSING 100 0

HENSON RAD SPEC LICENSING 75 25 JONES RAD SPEC INSPECTION 10 90 LOO RAD SPEC LICENSING 40 60 MASNYK BAILEY RAD SPEC INSPECTION 50 50 PARKER RAD SPEC INSPECTION 10 90 (inc.

term.

sites)

PELCHAT RAD SPEC LICENSING 50 50 7

l NAME POSITION PRIMARY AREA LEVEL OF LEVEL OF 0F EFFORT EFFORT-%

EFFORT-%

LICENSING INSPECTION WRIGHT

• SR LIC LICENSING 100 0

REVIEWER WATSON / SPARKS ENFORCEMENT INSPECTION 0

0.4 FTE (enforcerwnt)

COORDINATOR DEMIRANDA/

ALLEGATION INSPECTION 0

0.4 FTE IGNAT0NIS COORDINATOR (allegations)

HOSEY BRANCH CHIEF BOTH 25 75 AND DEP, DIV.

DIR.

POTTER

• BRANCH CHIEF BOTH 50 50 COLLINS (DM)

DIV. DIR.

BOTH 10 90 MALLETT FDPE R DIV.

BOTH 10 90 (THROUGH DIR.

MAY 7. 1997)

DECKER BRANCH CHIEF BOTH 25 75 BOLAND/URYC*

DIRECTOR.

INSPECTION 0

30 l

(Enf. and ENF. AND aleg.)

ALEG.

l 12.

Please )rovide a listing of all new professional personnel hired since tle last review, indicate the degree (s) they received, if applicable, and additional training and years of experience in i

health physics, or other disciplines, if appropriate.

RESPONSE

The following individuals,'added to the Division during the period, are currently qualified as inspectors (Ayres and Humphrey interim qualified pending completion of specific courses).

Michael Fuller (Materials Radiation Specialist)- BS degree (minor in HP),15 years experience in radiation protection, five years as i

l Radiation Specialist in Region II prior to returning recently.

David Ayres (Senior Fuel Facility Project Inspector) - BS in chemical Engineering,15 years of experience in fuel facility 1

operations and nuclear criticality safety, including three years experience with the NRC.

8 i

l

[

Gary Humph ey (Senior Resident Inspector) - BS in Industrial Technology, eight years experience in gaseous diffusion plant operations, five years reactor service engineering, and 11 years as reactor resident inspector.

Decorah Seymour (Senior Fuel Facility Inspector) - BS in Chemical Engineering and Materials Engineering. six years of research in high voltage electrical cables (including neutron effects), three years as an MC&A inspector, three years as a radiological effluents and chemistry inspector of reactors and fuel facilities.

i two and a half years as a reactor project inspector, and two and a half years as a reactor resident inspector.

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.

RESPONSE

Region II is in the process of qualifying materials staff as buth inspectors and license reviewers.

All technical staff in MLIB1 and 2 are qualified as inspectors.

The staff below are in the process of becoming qualified as license reviewers; all other MLIB1 and 2 technical staff are qualified license reviewers.

Hector Bermudez - qualified as a license reviewer for several categories of licenses, but not qualified for all categories. We plan to finish his full qualification by May 1998.

Jose Diaz - not qualified as a license reviewer. He is in the process of qualification with a goal of completion in September 1998.

Lee Franklin - not qualified as a license reviewer. A schedule for his qualification has not been developed.

Michael Fuller - qualified as a license reviewer for several categories of licenses, but not qualified for all categories. We plan to finish his full qualification by July 1998.

l Andrea Jones - not qualified as a license reviewer.

She is in the l

l process of qualification, with a goal for completion in January l

1999.

Wade Loo - not qualified as a license reviewer.

He is in the process of qualification, with a goal for completion in March 1998.

9 l

J

Orysia Masnyk Bailey - not qualified as a license reviewer.

She is in the process of qualification, with a goal for completion of in July 1998.

Bryan Parker - not qualified as a license reviewer.

He has begun the process of qualification, with a goal for completion in May

'i 1999.

14.

Please identify the technical staff who left the RCP/ Regional DNMS j

program during this period.

RESPONSE

Those who left the Fuel Facility Branch are discussed in B.I.5.

below.

Division level and materials staff changes were:

Bruce Mallett -

assigned to position of Acting Deputy Regional Administrator Jerry Ennis -

retired John Potter -

retired Earl Wright -

retired 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.

RESPONSE-Fuel Facility Inspector (2) - Two positions became available in the Fuel Facility Branch when one staff member (GS-14) transferred to NRR in July 1997, and another staff member (GS-14) retired in August 1997.

A GS-14 and twc GG-13s were posted in September 1997.

One of the GS-13s was filled by a transfer in October 1997.

This individual was selected for the GS-14 in November, 1997, l

leaving two GS-13 positions open again.

Region II interviewed three applicants for the GS-13s in December 1997.

The individual i

selected declined to move to Region II (from outside the agency) for personal reasons.

The GS-13 positions have been re-posted.

Radiation Specialist - In anticipation of the retirement of two staff in early 1998. Region Il selected a GS-13 Radit: tion Specialist in October 1997.

In addition we posted a GS-14 Senior Radiation S)ecialist position in November 1997 and selected the l

GS-14 from legion II materials staff in December 1997.

We posted I

a GS-13 in December 1997. Apalications are currently being received and interviews will 3e scheduled after the candidates are rated.

10 s

l l

l Branch Chief. MLIB2 - The Deputy Division Director is acting as Branch Chief for this Branch.

The Branch Chief position will be i

filled by a staff member from HQ for a five week period beginning l

late in January 1998.

We are in the process of evaluating options for filling this position.

l Secretary. NFS Resident Office (part time) - We posted and l

advertised the position, but the individual sclected declined to accept the job. We have re-advertised the position.

l IV.

Technical Quality of Licensino Actions l

16.

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

RESPONSE

Licensing cases that involved major, unusual or complex licenses included:

ARECO -

renewal of large underwater irradiator.

'B&W Services -

license for site remediation.

Major, complex license.

Baxter -

request by irradiator licensee to perform maintenance of safety related equipment.

Unusual and complex amendment still in progress.

Syncor -

complex change of ownership.

l Ashford Pharm. - radiopharmacy.

Majorlicense.

St. Luke Pharm. - radiopharmacy.

Majorlicense.

There were four cases involving bankruptcy: Maben Energy.

l Westmoreland Coal. Now Care, and Newport News General Hospital.

There were no new licenses requiring emergency plans or amendments to licenses that increased possession limits such that emergency plans would be required.

l 17.

Discuss any variances in licensing policies and arocedures or i

exemptions from the regulations granted during t1e review period.

RESPONSE

Unless Region II is authorized to issue an exemption to the regulations in an NMSS Policy and Guidance Directive or generic Technical Assistance Request (TAR) response from NMSS. Region II 11 l

l

- =

evaluates such requests and sends a TAR to NMSS'for review. As part-of self-assessment process, we performed an audit of our process for granting exemptions. Attachment 17 is a copy of a memorandum documenting this audit of exemptions granted for the period April.1996 to April 1997.

This audit concluded that exemptions granted were either approved in an NMSS Directive or l

.were reviewed by NMSS via TAR from the Region.

On June 30, 1997.

l

. Region 11 provided a listing of exemptions to licensees during the period January 1 to June 30, 1997 (Attachment 17a). Since that l-time, B&W Services was issued a remediation license that included license conditions (standard for such licenses as specified in l

Policy and Guidance Directive FC 94-02) that did not require an 3

emergency plan or financial assurance.

l In addition, we occasionally identify cases where we have deviated from licensing guidance in error.

In these instances, we review each case and take corrective action.

Cases where we have identified licensing actions not fully in accordance with policies and procedures include:

Ashford Pharmalogic - We issued a radiopharmacy license without verifying that the facility was a pharmacy licensed by the State.

We received an allegation to this effect.

In reviewing'the-l 111egation we found that the Commonwealth of Puerto Rico did not l

. require a license for Ashford to operate. We have sent to NMSS 6 l

TAR for review.

We have reminded materials staff that we are required to verify that applicants for radiopharmacy licenses must I

demonstrate that they are a pharmacy licensed by the State and that if the State does not require such a license, we are to send a TAR to NMSS for review for an exemption to our regulations.

1 Westinghouse de Puerto Rico/Wittnauer Worldwide - We amended the l

license to transfer the license to Wittnauer without first obtaining new financial assurance.

In the application for I

l transfer. Wittnauer committed to provide Financial Assurance L

information separately, but did not do so promptly. We identified this discrepancy in December 1996 during our annual review of Financial Assurance files as required by MD 8.12. We subsequently communicated with Wittnauer to obtain the Financial Assurance documentation (including a Demand for Information (DFI)).

In res)onse to the DFI, Wittnauer provided a Financial Assurance paccage, which has been reviewed by an NRC contractor who identified deficiencies in the documentation.

We are in the process of requesting additional information from Wittnauer.

Isomedix Operations Inc. - We transferred the Abbott Health Products license to Isomedix without having a satisfactory Financial Assurance package from Isomedix. The application for transfer committed to provide Financial Assurance, but it was not reviewed and found acceptable before the transfer of the license.

The Financial Assurance package was found to be deficient, and these deficiencies were sent to the licensee for resolution.

12 i

To assure that we do not again transfer licenses without adequate Financial Assurance, we have discussed with materials staff the requirement to have an acceptable Financial Assurance document-from the entity taking over a license before transferring a license.

18.

What, if any, changes were made in your written licensing procedures (new procedures. updates. policy memoranda, etc.)

during the reporting period?

RESPONSE

Generally Region II attempts to minimize the issuance of Region II-specific licensing procedures. As a result of our self-assessment findings, we issued one such procedure during the period. Licensing Procedure 1.0. Processing of Exemption Requests, which is included as Attachment 18.

19.

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

RESPONSE

l There are currently none in Region II.

Region II, as part of our l

self-assessment reviews, identified that we has several renewals T

that had been in process for some time and were not coming to closure. We began a focus'on these renewal applications. As a result, when licenses were extended by regulation. Region II had very few renewals pending.

V.

Resoonses to Incidents and Alleaations_

20.

Please provide a list of the reportable incidents (i.e., medical misadministration, overexposures, lost and abandoned sources, incidents recuiring 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 buclear Material Event Reporting in Agreement States for additional guidance.) that occurred in the Region / State during the review 3eriod. For Agreement States.-information included in previous su)mittals to NRC need not be repeated (i.e., those submitted under OMB 3150-0178).

The list should be in the following format:

LICENSEE NAME LICENSE #

DATE OF INCIDENT TYPE OF INCIDENT

RESPONSE

Events requiring 24 hour2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> notification of the NRC are captured by AEOD Event Reporting System, and frequently result in a PN or MR.

The dates listed below under " Event Date" are the date the event (s) was reported, since the report may be for several events 13

over a period of time.

In the cases of significant events. we promptly notify NMSS. OSP and the ED0's office verbally, and followup with a PN or MR.

Materials Licensees LICENSEE NAME LICENSE #

DATE OF INCIDENT TYPE OF INCIDENT Dr. Jose De Leon 52-19206-01 12/11/97 misadministrations Ryder Hospital 52-21026-01 12/11/97 misadministrations V. A. Hos) ital.

01-00643-02 12/10/97 received cont.

Birminglam AL package WV De)t. of 47-07838-01 12/02/97 damaged moisture Hig1 ways density gauge Navy. Bremerton 45-23645-01NA 11/25/97 received cont.

Naval Hospital package Virginia Beach 45-11035-01 11/25/97 misadministration Hospital. VA Army. Ft. Campbell 12-00722-06 11/20/97 broken H-3 KY collimator Air Force.

42-23539-01AF 10/31/97 lost compasses Tyndall AFB. FL (H-3) j Navy. Arlington.

45-23645-01NA 10/08/97 lost Am-241 VA sources Baxter Healthcare 52-21175-01 10/1/97 inoperable floor PR mat Mayaguez Medical 52-13598-03 9/17/97 I-131 spill i

Center. PR Ames. Inc.,

Scrap Yard 9/3/97 found cont steel Parkersburg, WV Marshall Miller &

45-17195-01 8/29/97 overexposures Assoc., VA Army. Ft. Bragg.

12-00722-13 8/28/97 lost Am-241 NC sources Law Engineering 45-21498-01 8/28/97 lost moisture Chantilly VA density gauge Weavexx. Wake 32-18405-02 8/26/97 lost moisture Forest. NC density gauge Potomac Hospital.

45-15367-01 8/1/97 found 1-125 Reston, VA sources in Jatient Northern Virginia 45-25221-01MD 7/29/97 ligh film badge Isotopes. VA reading (445 Rem)

Bluefield Medical 47-19142-01 7/14/97 potential Center.../

misadministration Steel of WV.

Scrap Yard 6/4/97 found cont. steel Huntington, WV Hos) ital San Pablo 52-21325-01 5/14/97 lost Cs-137.

PR Co-60, and Co-57 cal. sources Luis Vasquez OutSt.

52-16660-03 3/7/97 misadministrations Svc. Clinic. P1 14

National Hospital 45-17123-01 '

2/27/97 received cont.

Med. Ctr.

VA package Navy Arlington. VA 45-23645-01NA 1/27/97 lost ka-241 source Jaca & Sierra Test.

52-19064-01 12/31/96 lost moisture Labs. PR density gauge Army. Ft. Bragg. NC 12-00722-07 12/9/96 missing cont. dirt (Pm-147)

Pinkerton Chevrolet.

Gen. License 11/14/96 lost Po-210 VA sources Baxter Healthcare PR 52-21175-01 11/13/96 inoperable floor mat Army. Ft. Bragg NC 12-00722-06 11/8/96 area cont. with H-3. 2 exposures PSI. Bristol. VA 45-25088-01 11/8/96 overexposure Portsmouth General 45-09102-02 10/31/96 lost Cs-137 Hospital. VA cal source Herman Strauss Scrap Yard 10/4/96 found cont. steel Industries. Wheeling.

WV Navy. National Naval 45-23645-01NA 10/1/96 lost Pd-103 source Medical Center. MD VA Hospital. Memphis 41-00119-08 9/23/96 misadministration TN Navy Arlington VA 45-23645-01NA 9/4/96 lost Am-241 l

sources Dr. Fernandez PR 52-25114-01 8/7/96 misadministrations Centro de Card. Y 52-25075-01 5/16/96 misadministrations Med., PR l

Longview Insp.,

45-25279-01 4/10/96 lost radiography Richmond. VA camera Centro De Med. Nuc.,

52-25127-01 3/29/96 stolen spent Mo-99 PR generators VA Hospital. Tampa.

09-15294-01 3/1/96 cont. area with l

FL P-32 i

PR Opth. Inst.. PR 52-25114-01 3/1/96 misadministrations Fuel Facilities BWXT/NNFD SNM-42 6/10/96 Alert-Tornedo.

SRI Response BWXT/NNFD SNM-42 12/19/96 91-01-Mass 1 4it exceeded in m it.

SRI response.

BWXT/NNFD SNM-42 03/04/97 Alert-Spill causing evacuation.

SRI response.

15

BWXT/NNFD SNM-42 07/28/97 91-01-Transport cart exceeded mass limit. SRI response. Special RII/HQ inspection (97-08).

BWXT/NNFD SNM-42 09/96 Although not reportable, a special RII inspection was conducted in response to a series of zirconium fires.

FCF SNM-1168 11/13/96 50.72(b)-Loss of Fuel Assembly.

Special RII/HQ inspection (IR 96-205).

Westinghouse SNM-1107 3/11/97 70.50(b)(3)-

Medical Treatment involving contamination.

l l

Westinghouse SNM-1107 4/17/97 74.11(a)-Missing Fuel Rods. Special HQ/RII inspection.

Westinghouse SNM-1107 6/23/97 91-01-Loss of Contingency in pellet line.

Special HQ/RII inspection.

Westinghouse SNM-1107 10/16/97 91-01-Deficient analysis on ventilation system.

GE SNM-1097 3/28/96 24 hour2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> report-small fire in incinerator.

GE SNM-1097 3/29/96 91-01-Loss of Geometry control (powder spill).

16

GE SNM-1097 7/12/96 60.72(b)(2)(I).

Alert. Hurricane force winds.

GE SNM-1097 8/8/96 91-01-Loss of criticality control. Bulging tank.

GE SNM-1097 10/30/96 91-01-Mass control loss.

Scrubber failure.

GE SNM-1097 12/3/96 91-01-Failed calciner tube.

Special HQ/RII inspection (IR 96-12).

GE SNM-1097 2/3/97 91-01-Buildup of material in filter housing.

GE SNM-1097 9/5/97 70.50(b)(2)(ii)-

Release through recovery stack.

NFS SNM-124 3/25/96 70.50(b)(2)(I)-

l Failure of criticality alarm.

NFS SNM-124 4/2/96 Site Area Emergency-t l

Incinerator fire.

l AIT (IR 96-05).

NFS SNM-124 8/8/96 70.50(b)(2)(I)-

Criticality alarm system failure.

NFS SNM-124 10/22/96 UPS for security system inop, NFS SNM-124 9/4/97 29.73-FFD-Positive I

drug test, I

17

21.

During this review period, did 'any incidents occur that involved equipment or source failure or ap3 roved operating procedures that-were deficient? If so, how and w1en were other State /NRC licensees who might be affected notified? For States, was timely notification made to NRC? For Regions, was an appropriate and timely PN generated?

RESPONSE

Materials Licensees PSI (11/8/96)- initially it appeared that there might have been a malfunction of the >ortable gauge, but evaluation of the gauge by the manufacturer, o) served by a member of the NRC AIT. showed no indication of gauge malfunction. A PN was issued.

Baxter Healthcare (10/1/97 and 11/13/96)- failure of the floor mat that activates source drop when an individual steps on the mat.

The failures resulted from product carrier impact on the mat and these failures did not appear to be of generic applicability. A

'MR was issued after the 1996 event. The 1997 event was discussed with NMSS in the morning telephone' call.

Baxter Healthcare - failure of roof plug interlock switch.

Based on NRC and irradiator vendor review of the failure, it did not appear to have generic applicability. This was identified during a routine inspection. An MR was issued.

Region II did contribute to the development of Information Notice 96-66. Recent Misadministrations Caused by Incorrect Calibrations of Strontium-90 Eye Applicators. PNs were issued if the above events met PN criteria.

Fuel Facilities Many of the events above did involve failures of equipment or L

inadequate procedures.

In each instance. Region II (frequently in 6'

conjunction with NMSS) reviewed the failures to determine if there might be applicability to other licensees.

Because of the l

uniqueness of. equipment and procedures at these facilities, there were no failures identified that had generic applicability 22.

For incidents involving failure of equipment or sources, was information on the incident provided to the agency responsible for i

evaluation of the device for an assessment of possible generic l

design deficiency? Please provide details for each case.

RESPONSE

Region II did not identify any failures that warranted such a referral.

18 i

23.

In the period covered by this review, were there any cases involving possible wrongdoing that were reviewed or are presently undergoing review?

If so, please describe the circumstances for each case.

RESPONSE

Region II follows MD 8.8 and holds an Allegation Review Board (ARB) meeting for each wrongdoing case with DNMS and 01 representatives as part of the ARB.

The Deputy Regional Administrator reviews the status of each OI case with 01 monthly.

After each 01 report is issued. DNMS and EICS review the report for appropriate action.

During the period, the Office of Investigation (01) opened

'10 cases in the NMSS program areas. These cases are listed the agency Allegation Management System (AMS).

In one of these cases.

Baxter Healthcare Corporation. 01 substantiated that the RSO deliberately authorized operation of the irradiator in an altered condition that was prohibited by Condition 14 of the license.

This finding was provided to the licensee and the individual, and a pre-decisional enforcement conference was held on January 12.

1998.

The final resolution of the case is in progress.

I During the IMPEP period. Region II completed enforcement action related to an 01 investigation of activities at NDT Services.

In this case OI found that the Radiation Safety Officer and former President of the Company deliberately failed M use qualified radiographers. The licensee was issued Severity Level I and Severity Level III violations. The two individuals were issued Orders prohibiting their involvement in licensed activities for five years.

I 24.

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

a.

For Agreement States, please identify any allegations referred to your program by the.NRC that have not been closed.

RESPONSE: 4 is a copy of ROI 1030. Revision 9. Processing Allegations. Complaints.'and Concerns. This ROI provides details i

on the implementation of Management Directive (MD) 8.8. Manegement of Allegations.

Region II has updated this ROI each time MD 8.8 has been updated. We review the status of allegations each week with the Deputy Regional AdPinistrator.

1 19

/

VI.

General

.25; Please pre)are'a summary'of the status of the State's or Region's actions tacen in response to the comments and recommendations following the last review.

RESPONSE

- The IMPEP/MRB recommendations for Region II action (numbers listed below are the number for the recommendation in the IMPEP report) and actions.in response were:

(1)

License-reviewers add written explanatory comments in the tie-down~ condition listing the a>

old reference (i.e.

references )plicable sections in each efore the most recent license application) (Section 3.3).

Action:

Licensing staff were informed to include such clarification in tie-down conditions, and Branch Chiefs have been verifying that such clarification' are in the tie-down conditions as part of their review of ecch licensing action prior to their concurrence on the action.

-(2)

Region II document the basis for complex or unusual licensing decisions, and retain these documents in the licensing file (Section 3.3).

Actioni Staff were informed of.the need to improve documentation, particularly when the written documentation might not be clear as to why certain actions were taken.

l' Since the last IMPEP. staff have been encouraged-to document l

discussions with supervisors. managers, or program office staff. that contributed to their decisionmaking.

Each licensing action is reviewed by the license reviewer's Branch Chief.

(3)

Region II continue to emphasize performing and documenting performance-based materials inspections, and internally evaluate progress on this issue in about a year.

l (Section 3.4)

Action:

Region II supervisors and managers have continued to emphasize performance-based inspection, including 3roviding information to staff in the Division Operating

)lan in FY 97 to assist in such inspection (Attachment 25).

In addition, this is emphasized in )lanning and in discussion of results with staff.

legion II has begun to require written ins)ection alans for inspections of Type A broad licenses, wit 1 an emplasis on planning review of licensee performance.in the more safety-significant areas.

In July 1997. the Acting Division Director audited a

' sampling of inspection reports (narrative and Field Notes) 20

and discussed the reports, inspections, and findings with select staff in an effort to determine the degree of performance-based inspection being conducted and documented.

This review found that there was considerable performance-based inspection being conducted, but that the documentation of inspections did not reflect this well.

Supervisors and managers in the Division continue to emphasize performance-based inspection in planning, conduct and documentation of results. The revision of the materials inspection procedures and method of documentation that has been recently developed by NMSS should contribute to improved performance-based inspections and documentation.

(7)

Allegations received by the Region which are outside of NRC jurisdiction be referred eneditiously to the appropriate regulatory authority, and tlat the Region follow MD 8.8 and guidance developed by the Office of State Programs which specifically addresses referrals to Agreement States

(" Office of State Programs Internal Procedures for Management of Allegations") (Section 3.5).

Action: All allegations are reviewed by the Region II ARB.

q The ARB normally designates DNMS/the Agreement State Program l

Officer as responsible for referral of allegations to Agreement States.

Referrals to licensees are normally assigned to the Branch responsible for inspecting the licensee. Those issues that are not within the NRC's jurisdiction which an ARB suggests be referred to a party outside the NRC are normally assigned to the Branch responsible for inspecting the licensee or to the Government Liaison Officer for referrals to other government agencies

-(other than Agreement State Programs). The status of referrals and licensee or Agreement State responses to l

allegations (when required) is monitored weekly through an AMS printout of open allegations, and the status is discussed weekly with the Deputy Regional Administrator. 5a is a copy of a recent summary of allegation timeliness for DNMS.

(Note that the four cases over 180 days involve two 01 cases, a referral to an Agreement State and on case awaiting a TAR response.) If an allegation indicates improper actions by an Agreement State, the allegation is discussed with representatives of the Office of State Programs (OSP). and referred to OSP for review by an OSP ARB.

In instances where there are allegations that contain both technical issues and issues related to the Agreement State performance, a joint ARB has been held that includes OSP and Region II representation.

Since the last IMPEP. Region II was audited by the agency Senior Allegation Advisor, and found to have generally effectively implemented MD 8.8.

i 21 i

(8)

Region II closely adhere to ROI 1030. Rev. 7. dated March 18. 1996. regarding advising allegers of the status of allegations every six months, particularly for allegations requiring extended time periods to resolve (Section 3.5).

Action:

The status of allegations including six month notifications, is reviewed every week with the Deputy Regional Administrator.

Each Monday, a Senior Allegation Coordinator obtains a printout that shows the time period since last written contact with eacn alleger.

For those that are approaching six months. a status letter is developed and sent.

This has been effective in assuring that status letters are sent, with rare exception. When the new AMS went into operation there were some cases that did not receive timely letters because of problems in using the new system. There also have been instances when six month letters have not been sent when the closure letter to the alleger was in concurrence at the time.

Now the system in place is assuring the status letters are sent in a timely manner.

From 1994 IMPEP:

1 (8)

Region 11 should reconcile its written internal procedure j

(Branch Guidance Memoranda 4.2) for event evaluation and its

(

informal practices for event evaluation.

J Action: With the initiation of the Nuclear Material Event Database (NMED), Region II began using NMED as the database for events rather than using the Region II-specific method.

j Region II inspection staff have been informed that, as Jart of the preparation for inspections, they are to review 1MED for events at facilities to be inspected.

We are in the process of revising the Field Notes to add this as a specific item to be reviewed prior to an inspection.

26.

Provide a brief description of your )rogram's strengths and weaknesses. These strengths and wea(nesses should be supported by examples of successes, problems or difficulties which occurred during this review period.

RESPONSE

Each Branch performs self-assessments of their program areas quarterly.

The assessment criteria for FY 97 are provided in 6. The assessment criteria for FY 98 are the elements in the Region II Operating Plan (Attachment 26a).

These.self-assessments identify areas where performance is good and where Jerformance needs improvements. Where improvement is needed the 3 ranch develops actions to implement improvements. The current strengths and areas needing improvement are listed below.

22

Materials Program The strengths in the materials program area are:

1; Safety focus' of inspections and identification of safety issues.

2.

Response to events - understanding of event evaluation of safct.y significance of events (with NMSS).

3.

Timeliness of inspections.

The areas we are working to improve in the materials area are:

1.

Quality and timeliness of materials licensing' actions.

2.

Quality and timeliness of materials inspection re> orts.

3.

More effective use of NMED. including assurance tlat it is complete and accurate for Region-II licensee events.

4.

Development of a more efficient method or accumulation and monitoring information needed for program management.

5.

More effective and efficient completion of licensing actions.

6.

Timeliness, completeness and accuracy of filing in docket files.

Fuel Facilities The strengths'in the fuel facility inspection program include:

1.

Safety focus of inspections and identification of safety issues.

2.

Overall planning of inspections (Master Inspection Plan) for each facility with emphasis on risk specific to each facility.

3.

Response to events - understanding of event evaluation of safety significance of events (with NMSS). followup. to monitor licensee corrective action integration of event-into future planning.

l The' areas we are working to improve in the fuel facility area are:

1.

Technical quality clarity, and content of draft inspection reports (prior to review by the Branch Chief) including improving the flow of inspection findings from report observations and findings, to conclusions to enforcement, i

to executive summaries to site integration matrices. to Licensee Performance Reviews (LPRs).

l 2.

Inspection planning for specific inspections (not overall plan for a facility and not for special inspections) with emphasis on performance measures (implementing the overall facility plan into specific inspections).

j 3.

Cross-training of staff in technical areas to increase versatility and scheduling flexibility.

4.

Timeliness of enforcement actions.

5.

Timeliness of team inspection reports.

23

B.

NON COMMON PERFORMANCE INDICATORS I.

Fuel Cycle Inspections Status of Inspection Procram 1.

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

)rocedure number (e.g.

IP 88020). A sample format is shown 3elow.

RESPONSE

The following is a list Gf the inspections performed by Region II since the last IMPEP.

Inspections led by NMSS that included Region II participation are not included below.

These inspections were conducted in accordance with the criteria of IMC 2600 and 2681 as implemented 'y the Master Inspection Plan (MIP). The o

development and change of the MIP are coordinated with NMSS.

Inspections at fuel facilities are unannounced except for rare instances such as in responding to an event or in inspecting the readiness of a facility or portion of a facility for operation (GE Dry Conversion facility and NFS startup of certain operations).

Decommissioning inspections are listed separately under Section B.V.12

.he inspections specified in the IMC were completed except for IP 88050. Emergency Preparedness (EP), at Framatome in FY 97 because they do not have an emergency plan and the MIP planned not to do an EP inspection and IP 83822.

Radiation Protection, was done only once at Framatome in FY 97, as i

planned in the MIP based on the work at the facility.

Licensee Dates / Procedures Tyge l

BWXT 96-04 4/29/96 81912.88020.88015 81915.88010.88025 83822.88005.88035 BWXT 96-05 5/2/96 81933.81601.81820 81930.81932.81501 81931, 93880 I

l BWXT 96-06 5/11/96 88015.88020,83822, 92901 BWXT 96-07 6/22/96 88020.88005.88015 88025.92701.

1 24 I

2

BWXT 96-09 7/12/96 81038.81915.81917, 81919,81920,81921 81924.81927.81916 81925,81911.81918, 81928 BWXT 96-10 8/3/96 92702.88020.88005, 88050.88015 BWXT 96-11 8/23/96 88050 BWXT 96-12 9/14/96 (M050.88015.88020.

E5822,88035,86740, 92701.92702.88045.

84850.88025.88010 BWXT 96-13 8/23/96 81934.81922.81935.

81930.31022.81912, 81914.81926.81034, 81020.81929 l

BWXT 96-14 10/4/96 88055 Reactive BWXT 96-15 10/26/96 83822.88005.88020.

88055.88010 BWXT 96-16 10/24/96 81911.81935.81020.

l 81022,81920.81914.

81917.81925.81930, 81928,81038,81916.

81919 l

BWXT 96-17 12/7/96 88020 BWXT 96-18 12/13/96 88045.88035.83822 BWXT 96-19 1/18/97 88020 BWXT 97-01 1/10/97 81022.81910.81918.

81923.81020.81335, 81034,81038.81926 81913 BWXT 97-02 3/1/97 88020.88025.88055 BWXT 97-03 2/28/97 81931.81914.81921.

4 81927.81934.81929, 81922.81924.81932.

81933 BWXT 97-04 4/12/97 88020.88025 25 i

BWXT 97-05 5/24/97 88020,88005.88010, 92702.88050 BWXT 97-07 7/5/97 88020,81925.81928, 81601,81911,81916, I

81919,81920,81917, 81915,81501,81930 BWXT 97-08 9/15/97 88020,88005,88010 Reactive BWXT 97-10 9/27/97 81916,81919,81920 8.917,81915,81501, 81930,88020 BWXT 97-11 11/1/97 88020,81022,81911, 81914,81923.81930, 81501,81601,81935, 81924.81922.81913, 81910,81020,92702, 88020 BWXT 97-12 12/6/97 88020,88005 BWXT 97-13 1/10/98 88020 j

l i

FCF 96-02 3/29/96 88005,88015,88025, 36100,88020,88010 FCF 96-03 7/26/96 88020,83822,88055, 1

92701,88050 FCF 96-04 9/23/96 88045,88035,84850 FCF 97-01 1/17/97 83822,92701.84850, 88045,92702, 88035 FCF 97-02 3/4/97 92701,92702 FCF 97-03 4/4/97 88020 FCF 97-04 5/16/97 88055,92702 FCF 97-05 6/20/97 88025,88010,88005, 88020 FCF 97-06 11/7/97 88010,88005.88045, 86740,84850,88035 88020,84900 GE 96-02 3/1/96 88005.88020,88015 26

i GE 96-05 4/19/96 88050 GE 96-06 5/24/96 88025.92701.88020.

88015 GE 96-07 8/9/96 84850.83822.86740 GE 96-08 8/2/96 88025.88005.92701.

88020.88055.92702 GE 96-09 7/26/96 88020 GE 96-11 10/18/96 88025.88020.88005 GE 96-12 12/8/96 88020 Reactive GE 97-01 1/31/97 88020.88010.88005.

88010.88025.92701 GE 97-02 3/21/97 88020.88010.88025 GE 97-03 3/28/97 83822.88045.88035 GE 97-04 5/9/97 88020.88005.88025, 88010.92701 4

GE 97-05 4/18/97 88055.83822.88050 GE 97-06 6/27/97 88020.88005.88010.

88025.92701.

GE 97-07 7/18/97 84900,88020.86740, 88050.84850.

GE 97-08 12/12/97 88025.88020 NFS 96-02 3/8/96 81502 NFS 96-03 3/22/96 81924.81927.81931, 81911,81913.81919.

81921.81926.81928, 81920.81918.81923.

1 81910 NFS 96-04 4/18/96 81501.81932.81934.

)

81917.81925.81914, 81916.81929.81912, 81930.81601.81933.

1 81915.81922 NFS 96-05 4/6/96 93800 Reactive 27

NFS 96-06 5/12/96 81915.81022.81038, 81501.81917.81916.

81601,81911.81020, 81034.81030.81820 NFS 96-07 5/17/96 88055.88010.88020, 88025.88015.88005 NFS 96-08 5/24/96 83822.92703.88045, 92701.88035 NFS 96-09 6/5/96 81925.81920.81038.

81915,81917,81919, 81911.81020.81928, 81916 NFS 96-10 7/12/96 84850.88045.88050, 83822.86740 NFS 96-11 8/30/96 88010.88025.88020, 88025.92703.83822, 81929.88055.92701 NFS 96-12 9/12/96 81918,81924.81820.

81601.81935.81022, 81038.81911.81913.

81915.81917.81921, 81922.81923.81927.

81929.81931.81933, 81925.81934.81034, 81920.81501.81910, 81932.81926.81916.

81928.81030.81020, 81912.81919.81914 NFS 96-13 9/27/96 88020.88010.88025, 88005 NFS 96-14 12/18/96 88035.88045.83822 NFS 96-15 11/15/96 88025.92701.88010 92701.88020 NFS 96-16 11/22/96 81919.81930.81501.

l 81038.81918.81923.

81924.81911.81601, 81920.81928,81935 NFS 97-01 1/28/97 88055.88025.88020 NFS 97-02 3/7/97 86740.83822.84850 92701 28

_--._-__,._______m-,

NFS 97-03 3/21/97 88020.81335.88055 NFS 97-04 4/25/97 88025.92701.88020 NFS 97-05 5/16/97 92701,88045,88035.

NFS 97-06 8/15/97 88020,81922,81929, 81933,88055.88025, 81914.83822.88005, 88010.81501.81934, 81912.88015 NFS 97-07 6/13/97 88050 NFS 97-08 6/27/97 81917,81925.81918, 81034.81915.81916, 81923,81926.81924.

81038 NFS 97-09 9/29/97 81917.81919.81921.

81925.81920.81601.

81930.81927.81928, 81931.81815,81020, 81022.81911.81932, 81935.81930.81810.

81913.81915,81910.

81916,81820,81915.

81912.81910. 81920, 81935 NFS 97-10 9/27/97 88020.88015.88025, 81930.88055 NFS 97-11 11/8/97 88020,88025.88015, 83822 NFS 97-12 12/20/97 88025.83822.88015, i

88020.81911.81916, 81919,81923.81926.

81502,81917,81915, 81920,81038.81928.

81925,81921,83822, 81601.81935,88055.

}

88060,88058,88035.

81930.88010,88025.

81501.88057.88061.

88056,88059 NFS 97-13 1/31/98 83822.88025.88020, 88015 29

West 96-02 7/12/96 88055.88010.88025, 88005 West 96-03 10/4/96 88050.88045.83822.

88035.84850 West 96-04 9/27/96 88015.88020 West 96-05 11/1/96 88025 West 97-01 2/6/97 83822.84850.86740 West 97-02 2/28/97 88020 West 97-03 5/30/97 88020.88005 West 97-04 6/27/97 88045.88035 West 97-05 9/26/97 88050.88055.88020, 88010.80005 2.

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

RESPONSE

All inspections are generally based on MC 2600 required frequencies.

Specific adjustments are based on LPR results for a particular facility.

The actual MIP for each facility was developed in conjunction with NMSS for FY 97 and FY 98. Any changes to the MIP have been coordinated with NMSS.

Attachments FF2 and FF2a contain general details of planned inspections for the branch. As noted in B.I.1. above. in FY 97 there were two inspections listed in IMC 2600 that were not conducted at Framatome. Attachment 7a discusses particular areas of emphasis for each facility.

Technical Ouality of Insoections 3.

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.

RESPONSE

The Region II Operating Plan establishes goals for inspector accompaniment by su)ervisors. The DNMS self-assessments review accomplishment of t1ese goals on a quarterly basis.

Regional Office Instruction (ROI) 2213 (Attachment 9) establishes the L

30

process for inspector accompaniments.

This establishes that, on the average. the Division Director or Deputy will visit a site each month, each Branch Chief will accompany an inspector each quarter, and each Branch Chief will accompany each inspector once each fiscal year.

The Branch Chief selects the accompaniment based on the schedule and the significance of any issues to be reviewed during the inspection.

The accompaniment includes a review of the inspection plan, direct observations of the i

inspector, debriefing of issues attendance of exit meetings, and feedback to the inspector.

The ROI requires documentation of the

{

site visits by each supervisor.

Copies of such documentation is provided as Attachment 9 for those visits conducted in the 3ast six months.

We identified that such documentation was not 3eing completed and have re-emphasized to supervisors and managers that this must be done in accordance with the ROI.

A check of this documentation on a quarterly basis has been added to the DNMS tracking system.

In addition, the Branch Chief observes the performance of each i

inspector during an inspection before recommending the individual be qualified as an inspector.

See Attachments 8. 8a. 8b. 8c. 8d and 8e for accompaniments.

Technical Staffino and Trainina 4.

Please list the professional (technical) personnel assigned to perform inspections in the fuel cycle facilities inspection I

program, and the fractional amount of Jerson-years of effort to I

which they are normally committed in t1e program. Also, include the general inspection areas of responsibility (e.g.. E =

l environmental protection. N = nuclear criticality. 0 - operations.

l P = physical security. R = radiation protection. T = other).

For j

those who joined the program since the last review, and any others who have not yet met the qualification requirements of fuel cycle l

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.

Name Position Level of Effort Insoection Areas

RESPONSE

All individuals listed below are qualified inspectors per IMC 1246. The Senior Resident Inspectors were qualified under a Region II develo)ed program reviewed and concurred in by NMSS.

In addition. DNMS o)tains support from the Division of Reactor Safety staff for certain engineering reviews when needed.

31

NAME LEVEL OF INSPECTION BACKGROUND EFFORT AREAS l

AYRES*

1.0 N0 Chemical Engineering GLDERSEN*

1.0 ER g Radiological Protection l

GOODEN 1.0 R T(EP)

Biology HUGHEY 1.0 EN0R Chemistry HUMPHREY 1.0 EN0R Industrial Engineering l

SEYMOUR*

1.0 N0 Chemical Engineering TOBIN 1.0 P

Physical Security MCALPINE 1.0 Branch Chief Chemical Engineering

" Also have Project Inspector responsibilities.

Seymour, Humphrey and Ayres have not completed all courses in the current MC 1246. but are in4 erim qualified until these courses are completed.

(See the response to item A.I.12 above for their degrees and experiences.)

5.

Please identify any professional

' technical staff who left the fuel facility inspection program during the review period, and if possible, describe the reasons for their departures.

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 gNis have been achieved, and the reasons for any differences between the goals and the actual implementation of your program as the result of such personnel issues.

RESPONSE

The staff who left the Fuel Facility Branch during the period were Craig Bassett (transferred to NRR). Dennis Kasnicki (resigned),

i and Gerry Troup (retired).

Prior to these staff leaving. DNMS i

established a listing of skills needed in the Division, and j

developed backups so that skills would not be lost if an individual left the agency.

As a result, when the individuals retired. there were sufficient staff with the necessary skills to continue activities.

For example, in anticipation of Gerry Troup's retirement, we were developing David Ayres as a fuel l

facility operations inspector.

In planning for the inspections for FY 98, the required inspections were planned using the current staff. Attachments 2, 2a, and 2b show the planned inspections by facility and staff member.

This plan does not include reactive 32 L

i i

inspection that might be needed, and if there is substantial reactive inspection. the schedule for inspections will be revisited.

As noted in I.A.15 above, two Fuel Facility Inspector positions are currently being re-posted.

II.

SDMP Prnaram 6.

What is the status of meeting the milestones in SECY-96-207 for i

the SDMP listed sites? Were any significant delays identified and

)

corrective actions put in place in a timely manner? Are policy i

issues being resolved in a timely manner?

RESPONSE

Region II has no SDMP sites.

There are sites where we are following up on licensee's actions for cleanu) in a manner similar to SDMP remediations, e.g. NFS urtions of t1e GE site, and part c

of the Fram3 tome site.

III.

Uranium Recovery Proaram 7.

Please include information on the following questions in Section A. as they apply to the Uranium Recovery Program:

Status of Materials Inspection Program-AI.

1-3. A.I.6 Technical Staffing and Training-A.III 12-15 Technical Quality of Licensing Actions-A.IV. 19 Responses to Incidents and Allegations-A.V. 20-23.

RESPONSE

Region II has no Uranium Recovery sites.

IV.

General 8.

Provide a summary of actual expenditures and accomplishments as compared to operating plan / budgeted expenditures and accomplishments for FY 98 to date.

Discuss reprogramming changes or diversions of resources for items unbudgeted.

RESPONSE

l The information below for resource expenditure is from the RWAT printout, but does not include resources in the EICS staff for support in coordination of escalated enforcement and allegations.

PROGRAM FY98 BUDGET EXPENDITURES THRU (12/20/97)

Materials Licensing 2.3 1.09 Materials Inspection 4.0 1.22 Event Evaluation 2.2 0.43 33

Program Initiatives

• 4.6 0.47 Fuel Cycle Inspection 9.5 1.90 LLW ins)ection 0

0 Matls.

)ecomm. Insp.

0.8 0.11 Uranium Rec. Insp.

0 0

React Decomm. Insp.

0 0

Spent Fuel Stor. Insp.

0.4 0.04 TOTAL 23.8 5.26

• Includes regional initiatives. IMPEP. GLA registration program.

Part 35. Regulatory Product Development activities, risk assessment, and regulatory guidance activities.

Our initial analysis of the data for the first quarter of the FY shows that the Region is under-spending resources at a rate of approximately 2.0 FTE/yr, but again this does not include EICS support for escalated enforcement and allegations. The under-expenditure in the Fuel Cycle Inspection area results from the two o)enings that the region is recruiting for.

The underspending in t1e Spent Fuel Storage Inspection Area, which is also in the Fuel Facility branch. is a result of the schedule for the North Anna ISFSI facility, which has only recently started active construction and as a result of planning ISFSI inspections later in the FY.

Resources will be spent in this area as part of the inspection of this new ISFSI construction and in completing the routine inspection program for the other ISFSIs in Region II. The rate of resource use for Program Inititiative is low because of the number of staff assigned to Guidance Consolidation Projects early in the FY. We currently have four staff assigned to Projects and thus the resource use should increase for the remainder of the FY. The rate of resource use for " Materials Licensing Casework" is higher than the budget, and this results from our emphasis on competing old casework actions and the training of inspectors to become qualified license reviewers. We expect our rate of use of resources for decommissioning to increase since we recently began an emphasis on terminated sites resolution.

9.

Provide any comments and recommendations regarding the effectiveness of Headquarters support to regional activities and the Region / Headquarters interface.

Identify any regional interaction with Headquarters and licensees to improve the quality of your licensing / inspection program.

RESPONSE

In general. Region 11 views the interface between NMSS and OSP to be very effective. When issues or potential interface problems appear, we believe that Region II and NMSS and OSP have worked effectively to resolve them.

For example, one area we have emphasized this past year was to clarify. in response to an event at a fuel facility, whether NMSS or Region II had the lead for 34

followup.

We have worked to make this clear after receiving initial information, and we believe this has worked effectively.

In addition, the Agreement States Officer has worked effectively with OSP in the application of the IMPEP program at Agreement States.

10.

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

RESPONSE

Region II's most pressing needs are in the areas of Fuel Cycle Facility Courses listed in IMC 1246.

We recognize that the Fuel Cycle Courses are being converted to self-study in an effort to provide cost-effective training to the limited number of staff who need the courses.

Region II will schedule staff into these self-study courses as they are developed for staff still needing the training.

In addition it would be helpful, as course are offered less frequently, if courses could be video taped and the tapes made available for new staff to review. We recognize that this is not as effective as personal attendance at the course, but this could be useful in training staff in the period until the course is presented.

V.

Decommissionina 11.

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).

RESPONSE

Licensee License No.

Inspector Date Initiated

• Dept of Army Ft. McClellan 01-02861-05

0. Masnyk Bailey 6/96

1. • EPA-Montgomery 01-07317-01 J. Henson/0. Masnyk Bailey 8/96

1. • Dept of Interior USGS 45-15923-01 A. Jones 12/96

1. • Roanoke College 45-10085-04 J. Pelchat 12/96

1. • HHS-NIEHS 32-12358-01 J. Henson/B. Parker 1/97

1. • EPA-Athens 10-10146-01

0. Masnyk Bailey /B. Parker 3/97

• Phillip Morris 45-00385-06 J. Ennis 4/97 35

' College of William l

and Mary-45-03499-09 J. Pelchat/B. Parker 5/97 U.S. Navy 45-23645-01NA

• NAMRL B. Parker 7/97

1. • White Oak J. Henson 9/97

1. • NOW CARE 47-25152-01 A. Jones 9/97 Radiology Services l

of Hampton 45-25349-01MD B. Parker 11/97 i

Charleston Area Med. Ctr.

47-15473-01 W. Loo /B. Parker 12/97

1. • Pharmaco 45-25314-01

0. Masnyk Bailey /J. Pelchat 1/98-1 12.

List the decommissioning inspections that were carried out during the review period.

Please indicate if the inspection schedules recuired by MC 2602 were prepared for licensed facilities l

uncergoing decommissioning 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.

RESPONSE

M SJJE REPORT NO.

E Gloersen BWXT-96-12 8/4-9/96 96-18 12/9-13/96 97-10 8/17-9/27/97 Gloersen Framatome 96-04 9/10.13.23/96-Gloersen GE 96-07 8/5-9/96 97-03 3/24-27/97 97-07 7/14-18/97 Gloersen NFS 96-10 7/8-12/96 96-14 11/4-7/96 97-05 5/12-16/97 All entries in Item No. 11 marked by an asterisk (*) were inspected during and/or after the licensee's decommissioning, activities.

Schedules per MC 2602 were not generally required or i

prepared in these instances.

36 i

i

There were no inspections that were overdue by more than e

.25%.

No issues were identified.where licensee's were not conducting their-decommissioning activities in accordance with decommissioning plans where such plans were required.

13.

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.

RESPONSE

All entries in Item No.11 marked by a pound sign (#) were inspected and included a review of licensee's final surveys and/or confirmatory surveys were conducted.

In addition to the above, the following licenses were-terminated after decommissioning inspections were completed:

Arc Professional 45-25126-01 A. Jones 4 & 10/96-Dept. of Army Ft. Knox 16-05033-01 W. Loo 6/96 SUB-417 Provalid Corp.

.45-25060-01 A. Jones 12/96 45-25060-02G Dept. of Interior Fish & Wildlife 01-10058-01

0. Bailey 3/97 In all of the above decommissioning inspections, inspection activities included review of licensee's decontamination / decommissioning methods and procedures; instrumentation (calibration. MDA. counting, appropriateness and capability): review of records (inventory. use surveys.

leak tests.-incidents spills, etc.): and independent / confirmatory surveys per inspection plans developed for the inspection.

14.

List all appropriate staff. who have not yet met the qualification requirements of Decommissioning Inspector as identified in MC 1246.

List the courses or equivalent training / experience they need to attend and a tentative schedule for completing these requirements.

37

RESPONSE

l Region II has designated B. Parker as the Decommissioning Project l

Manager for all materials cases.

In addition, we have designated J. Henson, and O. Masnyk Bailey (materials) and W.

Gloersen (fuel l

facilities) as decommissioning inspectors. These staff were l

qualified as inspectors under the previous IMCs 1245 and 1246.

Our plan is that these staff complete the currently required courses for Decommissioning Project Manager and Inspector.

Remaining IMC 1246 (6/7/96) rourses are:

i l

Environmental Monitoring for Radioactivity - Masnyk Bailey, l

to be scheduled Finance for Non-Financial Professionals - Henson. Gloersen.

l Masnyk Bailey. and Parker (self-study course to be obtained)

Environmental Transport - Henson. Gloersen. Masnyk Bailey, i

and Parker (to be scheduled)

Root Cause/ Incident Investigation - Gloersen (scheduled for course 3/98) 15.

Identify by name, license number and type all licensees with l

outstanding decommissioning financial assurance reviews.

Describe the outstanding issue'and the plans to resolve the issue.

RESPONSE

Isomedix. 52-24884 See A.I.21 above.

The licensee has j

submitted additional information and that information is under l

review by Headquarters.

l Wittnauer. 52-19336 See A.I. 21 above. The licensee was issued a Demand for Information to send in Financial' Assurance information.

In response, the licensee ~provided Financial Assurance instruments. but these were found to be deficient by contractor review.

The Region is sending the results of this review to the licensee.

Belair Quartz. 55-23732 The licensee was issued a letter that j

stated that their failure to provide Financial Assurance information was being considered for enforcement.

In response, the licensee sent Financial Assurance information and has been communicating frequently with the NRC in its efforts to obtain an l

adequate instrument.

The licensee has encountered significant L

difficulties in obtaining. from financial institutions, an instrument that satisfies our criteria. The licensee has even offered to sent the NRC the actual' money for the NRC to hold, which is also not acceptable.

We continue to work with Headquarters and the licensee to resolve issues.

Communications Inst.. 45-06589 The licensee underwent a name change and the' Financial Assurance information is under review by j'

Headquarters.

38

PLEASE NOTE THAT ATTACliMENTS BEAR THE QUESTIONNAIRE NUMBER THEY ARE RELATED TO.

)

ATTACHMENTS Memorandum to Fuel Facilities Branch dated 7/14/97 a Targeting Information 1996 Site Visits a 1997 Site Visits Attachment'8b 1998 Site Visits c Accompaniment of Inspectors FY 96 d Accompaniment of Inspectors FY 97 e Accompaniment of Inspectors FY 98 ROI 2213. Rev. 7 a Trip Reports 0 Specifications 0a Instrument Inventory 1 DNMS Organization Chart 7 Memorandum to B. Mallett dated 4/16/97 7a Memorandum to D. Cool dated 6/30/97 8 Licensing Procedure 1.0 4 ROI 1030. Rev. 9 5 Principles of Performance-Based Inspection 5a DNMS Allegation Timeliness Report 6 DNMS FY 97 Self-Assessment Plan 6a RII Operating Plan Attachment FF2 RII FFB Inspection Targeting for FY 98 1

Attachment FF2a RII FFB Inspection Schedule for FY 98 l

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M y 16,1997..

y

' F

' Babcock and Wiicox Company ATTN: Mr. J. A.Qnner Vice Prey.':, & General Manager Naval Nucia i.a Division P. O. Box 785 Lynchburg, VA 24505-0785

SUBJECT:

NRC PERFORMANCE REVIEW OF LICENSED ACTIVITidS

Dear Mr. Conner:

On February 6 and 10,1997, managers and staff in Region ll and the Office of Nuclear Material

' Safety and Safeguards (NMSS) reviewed your program for conducting NRC licensed activities. The review eval: sted your performance for the period July 1,1994, through September 30,1996, with a focus on performance during the last six monthr. of the period.- The review also provides you with feedback on how NRC senior managemeret assesses your performance. The review wil he used to form a basis for establishing the NRC inspection program for your conduct of licensed activiibs during the next year.

Your performance was evaluated in the four major areas of safety operations, safeguards,-

radiological controls, and facility support. The results of the review will be discussed with you at the Babcock and Wilcox Facility during a meeting to be arranged in the near future. During that meeting, we expect you to discuss your view of your performance in the same major areas. An outline of the results of the review in the form of strengths and challenges is enclosed.

The review indicates that your performance was focused on safety in all areas. Performance in the greas of radiological controls and security was excellent.- Performance in other areas was good.

You significantly improved in implementing followup action to correct deficiencies identified during your self-assessments and audits. Your greatest challenges appear to be in maintenance of cquipment and operational upsets in the uranium recovery area.

j Based upon the review, the NRC has decided to reduce the routine inspection effort in the area of rtdiological controls at your facility during the next period. We will perform special focus inspections in criticality safety operations, and maintenance in the uranium recovery area and increase our efforts in evaluating your material control and accountability program.

In accordance with Section 2.790 of the NRC's " Rules of Practice," a copy of this letter and its enclosure will be placed in the NRC Public Document Room.

Should you have any questions or comments, I would be pleased to discuss them with you.

Sincerely, 1

Luis A. Reyes Regional Administrator Docket No. 70-27

.i License No. SNM-42 1

Enclosure:

Licensee Performance Review - Summary Outline a

B&W NNFD - LICENSEE PERFORMANCE REVIEtN -

SUMMARY

OUTLINE PERFORMANCE PERIOD: JULY 1,1994 - SEPTEMBER 30,1996 The following is a summary of the program strengths and challenges for the performance of Babcock cnd Wilcox Naval Nuclear Fuel Division in the conduct of NRC licensed activities.

PERFORMANCE AREA: SAFETY OPERATIONS This area is comprised of plant operations, criticality safety, chemical safety, fire safety and management controls.

PROGRAM STRENGTHS Competent criticality safety staff o

i Management and staff support for safety programs o

immediate response to events o

o Self-identification of deficiencies AREAS NEEDING IMPROVEMEN,I Operator adherence to nuclear criticality safety controls (postings and procedures) in uranium o

recovery and storage areas Review or walk down of procedures and equipment in uranium recovery to reduce number of %

o spills of hazardous materials CHALLENGES TO PERFORMANCE 1

i Continued management oversight of the conduct of operations in the uranium recovery area o

o Control of changes to assure they are conservative in providing the same or better margin of safety than the original design PERFORMANCE AREA: SAFEGUARDS This area is comprised of material control and accountability and physical security.

i PROGRAM STRENGTHS Response to events, including timeliness, analysis of root causes and recognition of generic o

issues within the facility Training of security force and conduct of daily operations by the security managers and staff o

Enclosure to Attachment i

2 AREAS NEEDING IMPRCVEMENT No significant areas needing improvement were identified.

CHALLENGES TO PERFORMANCE o'

Continued management attention on item monitoring program, and self-identification and correction of deficiencies.

PERFORMANCE AREA: RADIOLOGICAL CONTROLS This area is comprised of radiation protection, environmental protection, waste management and transportation.

PROGRAM STRENGTHS Early identification of problems in radiation safety via use of the Radiation Safety incident o

Notice (RSIN) program ALARA program effective in minimizing radiation exposures o

Control of radioactivity in effluents o

AREAS NEEDING IMPROVEMENT Completeness of audits performed in radioactive waste and packaging areas o

Number of releases of airborne radioactivity into uranium recovery area o

CHALLENGES TO PERFORMANCE No significant challenges to performance were identified other than the issues specified under Areas Nnding improvement.

PERFORMANCE AREA: FACILITY SUPPORT This area is comprised of maintenance and surveillance, training in safety and emergency pr:paredness.

PROGRAM S1ftENGTHS Effective safety training with emphasis on job function and requirements o

l 0

Strong management and staff involvement in emergency preparedness and training Good internal audits and critiques in emergency preparedness resulted in performance o

enhancements.

i Enclosure to Attachment 1

3

)

AREAS NEEDING IMPROVEMENT No significant areas needing improvement were identified.

CHALLENGES TO PERFORMANCE Maintenance for equipment important to safety as equipment continues to age to prevent or mitigate consequences of process upsets in uranium recovery area implementation of periodidrefresher training in nuclear criticality safety for managers and o

supervisors and lessons learned for managers and supervisors and lessons learned for operators involved in high risk operations i

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Enclosure to Attachment 1

FUEL FACILITIES BRANCH INSPECTION PLAN R:vilion D:t;: 06/12/97 Inspection of:

on Inspection Report Number.

Licensee Dates (From -- To)

On Site Hours Anticipated:

Back-shift Hours Anticipated:

TYPE oF INSPECTION TIMING oF IN$PECTioN INsPECTloN NOTIFICATION ALLEGATloN Followup INTEGRATED REPORT Routine Back Shift Announced Yes-Plan Attached Yes Special Normal Snift Unannounced No No Team Both Shifts I

L:ad Inspector:

Accompanying inspector (s):

1 Licensee Contact Name Telephone Number Motel:

Name and Lncation Telephone Number

~

Print, review, and attach a copy of the Site Integration Matrix (See G:tSIM\\*.S!M)

Inspectors initials Attach a list of all open items for the facility (See G:\\0PENITEM) and mark with a hich fiahter the issues that will be reviewed for closure. If there are items that have been closed but are not reflected as such on the list, mark th::m appropriately.

Inspectors initials On the reverse side of this form (Region 11 Fuel Facilities Brar c

'9ection Areas), mark with a high lighter th] areas (e.g. F1.05, S2.07, etc.) to be inspected and cross out tho;, areas previously inspected during the Fiscal Year.

Inspectors Initials In en attachment, list the performance measures to be inspected for each area to be inspected and specify the indicators that will be used to measure the acceptability of that performance. Also, indicate how the performance measures relate to pcrformance characteristics for this licensee that you discovered during your review of the SIM. Note that this part of the plan is the most important because here is where the real focus of the inspection is developed.

inspectors initials in:pection instructions from the Project inspector (Ayres for Framatome, Westinghouse; Bassett for R: search Reactors; Gloersen for NFS & ISFSts, and Troup for B&W NNFD & GE):

Pr: Ject inspmtor Certification that 1) the inspection focus is appropriate,2) the planned inspection is based on acceptaF s performance measures,3) performance trends from an up-to-date SIM have been appropriately considert, and 4) the inspection is specified on the Master Inspection Schedule Signature Date AdditionalInspection Instructions from Branch Chief:

cepes Win Anacnments To e,. wis t-r hap.ctort )

Protecs bspector Brwon Cheef Br:nch Chief Approval:

Signature Date a

Heoion il Fuel Facilities Branch Inspection Areas I. SAFETY OPERATIONS 03 Plant Operations (88020) 03.01 Conduct of Operations 03.02 Facility Modifications and Configuration Controls R2 Environmental Protection (88045) 03.03 Implementation of Process Safety Controls R2.01 Monitoring Program implementstion 03.04 implementation of Storage Safety Controls R2.02 Monitoring Program Results 03.05 Implernentation of Safety Controls for Material Handling R2.03 Management Audits, inspections and Controls and Movement R2.04 Ovality Control of Analytical Measurements 03.06 Housekeeping R2.05 Independent Measurement Verification (Sample 03.07 Review of Previous Events Splitting) 03.08 Folicwup on Previously identified issues R2.06 Monitoring Program Reports R2.07 Decommissioning Activities 04 Fire Safety (88055)

R2.08 Fotlowup on Previously identined issues 04.01 Review of Fire Protection Program Documentation 04.02 Review of Documentation Related to the Fire Protection R3 Waste Management (84850 and 88035)

Program R3.01 Liquid Effluent Program Controls. Procedures and 04.03 Building Design, Construction, and Venti!ation System Instrumentation 04.04 Fire Safety of Processes, Equipment, and Storage R3.02 Liquid Effluent Monitoring Results Areas R3.03 Airt ome Emuent Controls. Procedures and 04.05 Fire Protection Systems Instrumentation 04.06 Fire Hazards Analysis R3.04 Airbome Emuent Monitoring Results 04.07 Pre-Fire Plan R3.05 On site Waste Storage 04.08 Fire Brigade Training R3.06 Waste Classification 04.09 Fire Ernergency Drins R3.07 Waste Form and Characterization 04.10 Off Site Support R3.08 Waste Shipping (Manifests, Labeling, and buWeys) 04.11 Followup on Previously identified issues R3.09 Tracking of Waste Shipments R3.10 Management Control of Liquid & Airbome Efflue its and 05 Management Organization and Controls (88005)

Solid Waste 0 5.01 Organizational Structure R3.11 Quality Assurance Programs 05.02 Procedure Controls R3.12 Followup on Previous y identined issues 05.03 Intemal Reviews and Audits i

I 0 5.04 Safety Committees R4 Transportation (86740) 05.05 Quality Assurance Programs R4.01 Preparation of Packages for Shipment 0 5.06 Followup on Previousty identified isst.es R4.02 Delivery of Cornpleted Packages to Carriers R4.03 Receipt of Packages

11. S AFEGUARDS R4.04 Certi5 cates of Compliance R4.05 Management Controls

$2 Physical Protection (81000 series)

R4.06 Records and Reports S3.01 Adequacy of Physical Security Plan R4.07 Followup on Previously identined issues i

S2.02 Implementing Procedures and Guard Orders S2.03 Management Reviews, Audits and Controls IV. FACIUTY SUPPORT S2.04 Ovality of Physical Barriers S3.05 Personnel Management. Training, Quali5 cation, and F1 Maintenance / Surveillance (88025)

Fitness for Duty F1.01 Conduct of Maintenance S3.06 Assessment Aids and Lighting F1.02 Work Control Procedures S3.07 Detection Aids and Ingress & Egress Controls F1.03 Work Control Authorizations S3.08 Equipment Testing.nd Maintenance F1.04 Ovalifications of Maintenance Personnel S2.0g Locks Keys, and Combinations F1.05 Management Audit of Maintenance 52.10 Supply of Electrical Power to Security Systems F1.06 Surveillance Testing S2.11 Compensatory Measures F1.07 Calibrations of Equipment S2.12 Alarm Stations and Communications F1.08 Followup on Previously identined issues S2.13 Records, Reports, and Event Reporting S2.14 Protection of Shipments F2 Training (88010)

S2.15 Information Protection F2.01 10 CFR 19.12 Training S2.16 Review of Events and Exercises F2.02 General Nuclear Criticality Safety Training S2.17 Followup on Previously identified issues F2.03 General Radiological Safety Training F2.04 General Emergency Training lit. RADtOLOGICAL CONTROLS F2.05 Operating Procedure Training F2.06 On-the-job Training R1 Radiation Protection (83822)

F2.07 Followup on Previousy identified issues R1.01 Radiation Protection Program implementation Rt.02 Radiation Protection Program Procedures F3 Emergency Preparedness (88050)

R1.03 Radiation Protedion Program Equipment F3.01 Review cf Program Changes R1.04 Extemal Exposure Control F3.02 Implementing Procedures Rt.05 intemal Exposure Control F3.03 Training and Staf5ng of Emergency Organization R1.06 Respiratory Protection F3.04 Off site Support Rt.07 Postings, Labeling. Control F3.05 Drills and Exercises t

Q1.08 Surveys F3.06 Ernergency Equipment and Facilities Rt.09 Notifications and Reports F3.07 Followup on Previously identified issues R1.10 implementation of ALARA Program Rt.11 Management Oversight of Program R t.92 Fottowup on Previously identified issues I

l l

U.S. NUCLEAR REGULATORY COMMISSION REGION ll Docket No.:

70-xx License No.:

SNM-xxx Report No.:

Docket Number / Year-Sequential Number Licensee:

Licensee's Name Facility Name:

Specific Facility Name Location:

Town, State and Zip Code l

- Date:

Dates of the inspection inspector:

Name and Title i

Approved by:

E. J. McAlpine, Chief Fuel Facilities Branch Division of Nuclear Materials safety Note: There is no page number and the word " ENCLOSURE"is rightjustified at the bottom.

ENCLOSURE

1 EXECUTIVE

SUMMARY

Facility Name NRC Inspection Report 70-xxxx/97-xx Note that this is an Executive Summary and should contain the most important findings i

from the inspection (both positive and negative). Note also that the title is centered and it is on a separate page from the cover page. Also centered below the title is the facility name and the report number. There is a summary for each functional area inspected, and the summaries are bulletized. If r, tore than one functional area was inspected, they should be presented in the order specified below. No page number on this page. If this l

Is a multiple page summary, the second page will be numbered 2 at the top.

{

This is a very important part of the report and should be afforded sufficient time for development. Also, it should be developed in the final phase of the report writing process. It must be consistent with the conclusion sections wit %) the report. It should not, however, be a sum of a cut and paste job from those sections. Significant editing will probably be needed to make the final product a good one. Remember that the contents of the Executive Summary will end up in the Site Integration Matrix and ultimately in Licensee Performance Reviews (LPRs). Care and effort expended during development of the Executive Summary will pay oriwith less effort being required during LPRs.

MFETY OPERATIONS For enmple:

Strong implementation of active engineered controlin DCP due in part to the l

cooperative working relationship between the maintenance and operations functions during functional testing (Section X.Y 3).

Marginalimplementation of administrative nuclear criticality safety controls at the C87 distillation unit due to the difficulty in observing flow through downcomers between plates 11 and 23 (Section X.Y.3).

SAFEGUARDS RADIOLOGICAL CONTROLS FACILITY SUPPORT

Attachment:

Partial List of Persons Contacted Inspection Procedures Used List ofitems Opened, Closed, and Discussed List of Acronyms 3

{

1 Report Details No page number on this page. The next page in the report details is page 2.

1.

Summary of Plant Status This section contains a brief status of the facility during the inspectio1, For an Integrated resident report, the status will, of course, be more detailed than for a l

region based inspector's report because it covers a longer period of time, typically six weeks. The inspector should specify in non-proprietary terms what

- parts of the facility were operating, and whether any special activities are underway - such as physical inventory, emergency exercises, physical security drills, extensive maintenance on a particular area, and the like. Think of this as similar to what we provide in One-Liners each Friday. It provides a backdrop describing the environment under which the inspection was conducted.

Areas of Insoection The major subdivisions within the report following the Summary of Plant Status are the individual areas of inspection, and there will often be more than one. These areas of inspection include: Chemical Safety (8804x series) (S1), Criticality Safety (88015) (S2),

Plant Operations (88020) (03), Fire Safety (88055) (04), Management Organization and Controls (88005) (05), Material Control and Accounting (85000 series) (S1), Physical Protection (81000 series) (S2), Radiation Protection (83822) (R1), Environmental

- Protection (88045) (R2), Waste Management (84850 & 88035) (R3), Transportation (86740)

(R4), Maintenance / Surveillance (88025) (F1), Training (88010) (F2), and Emergency Preparedness (88050)(F3). Inspections in the areas of chemical safety, criticality safety, and material control and accounting will typically be performed by headquarters inspector and are included here so that the proper sequence will be maintained if an integrated report is prepared. As the above areas of inspection are added to the report, the paragraphs will be numbered beginning with the number 2. There will be no gaps in the numbering sequence. For example, if two areas of inspection (Radiation Protection and Training) were covered, the paragraphs in the report details would be as follows:

1.

Summary of Plant Status 2.

Radiation Protection (83822) (R1) 3.

Training (88010)(F2) 4.

Exit Interview Inspection Reauirements The subdivision of each area of inspection is by inspection requirements. These are outilned on the Fuel Facilities Branch inspection Plan (See attached), and are typically covered in the specific inspection Procedures. The inspection requirements are designated with a lower case letter beginning with the letter "a". Again there are no gaps in the substructure sequence within an Inspection Requirement. For example, if three inspection requirements (Detection Aids and Ingress & Egress Controls; Records,

I 2

Reports, and Event Reporting; and Review of Events and Exercises) weto inspected within the Area of Inspection - Physical Protection, the format would be:

2.

Physical Protection (applicable inspection procedures) (S2)

Detection Aids and Ingress & Egress Controls (S2.07) a.

b.

Records, Reports, and Event Reporting (S2.13)

)

Review of Events and Exercises (S2.16) c.

Substructure

-Within each inspection requirement there are three numbered subdivisions. These are:

Inspection Scope, Observations and Findings, and Conclusions. There can be multiple paragraphs within these numbered subdivisions. The subdivisions are designated with numbers in parentheses. See Enclosure insoection Scope This section describes the performance measures the inspector evaluated, why the inspector evaluated it, and the performance standard was used. This is where the contract between the inspector (s) and the branch chief that was approved in the Inspection Plan comes into play. As stated in the inspection Plan, the performance measures are the most important part of the inspection Plan. In the Inspection Rsport, the performance measure is again the key element. An example is:

The inspector observed the licensee's emergency exercise conducted on January 19, 1994 to determine if: (a) the objectives outlined in the erarcise scenario dated October 3, 1993 were met, and (b) the exercise was conducted in accordance with requirements specified in the licensee approved Radiological Contingency Plan, dated November 4, 1993, and implementing procedures. Particular inspection emphasis was placed on the j

timeliness of event classification and subsequent offsite agency notification since these had been identified as weakness during the previous emergency exercise, in addition to

- commitments in the licensee's approved Radiological Contingency Plan, the inspector used selected aspects of NUREG-0645 that were equally applicable to fuel facilities to judge the licensee's performance.

This will probable be the shortest of the three subdivisions within the inspection

- requirement area of the report and the easiest to write. Actually, most of it is written before the inspection and included in the inspection Plan.

Observations and Findirms This section should describe what the inspector observed and found, and how the inspector went about performing the inspection. This is where the real meat of the inspection is documented. These are facts, observations, and findings by the inspector.

The emphasis during the inspection which must carry through into this section of the t

1

3 report is on verification and analysis of licensee performance. That is, what did the inspector verify through independent methods, and what does it all mean relative to safety? It could also include data that the inspector obtained from a review of the licensee's records.

For eenple, if the inspector determines that the licensee has 65 open maintenance work ordee, this finding needs to be placed in safety perspective. Is the number of open work oroces increasing or decreasing? Is there a specific class of equipment that is proving to be pardcularly unreliable? Is that class of equipment of safety significance and why? What does it mean with respect of the maintenance of safety margin?

If violations, unresolved items, or inspector followup items are identified, they must be clearly specified in this section. In particular, if an item is unresolved, what aspect of the issue is unresolved? Whose court is the ballin to resolve the issue, who will resolution be obtained, and within what time period will it be resolved?

This should be the longest of the three sub-parts.

Conclusions This section has typically been the hardest part for inspectors to write, in part because the previous section did not contain sufficient analysis. This section should contain conclusion drawn by the inspector about the licensee's performance. I am looking for good strong conclusions in this section. No violations or deviations were identified is not n adequate conclusion. The type of conclusions should be like the following two conclusions:

Through the evaluation of written procedures, review of records for previous shipments, observation of packaging operations underway during the inspection, and discussions with personnel responsible for the function, the inspector concluded that the licensee had implemented an adequate program for preparation of radioactive material packages for shipment in accordance with NRC and DOT requirements. In particular, the inspector found the radiation monitoring of packages to be noteworthy based on the diligence of the responsible individual. The area of labeling, however, was a candidate for additional management attention due to upcoming changes in both NRC and DOT requirements.

On the basis of: (1) tours of the area, (2) detailed review of the design of the nuclear criticality safety controls, (3) a review of the operating procedures and observation of l

licensee personnel complying with the approved procedures, (4) the results of functional testing of active engineered safety controls, the inspector concluded that the licensee had implemented strong safety controls in Dry Conversion Process. This was due in part to the cooperative manner in which the maintenance and operations functions worked in during functional testing of equipment. The implementation of the Cdministrative nuclear criticality safety controls at the C87 distillation unit, however, was marginal due to the difficulty that licensee personnel had in observing flow through

t i

4 downcomers between plates 11 and 23.' The observation _al difficulty.wlit be further evaluated by the licensee with emphasis on redesign of observation ports.

This sub-part should be the second longest of the three.

The report continues with additional inspection requisements followed by additional inspection areas, as appropriate.

Exit Interview (30703)-

This section contains a brief summary of the exit interview, including the date it was l

1 held. If the licensse disagrees with a position taken by the inspector during the inspection, a clear shtement of the licensee's position should bo included. A stanment

- of whether proprietary information is included in the report should be made. Remember

' the significant issues discussed and items opened and closed are specified in the

' attachment. Also, sometimes it is necessary to perform a second exit interview by telephone following review of inspection findings with management. When that occurs, t

it should be documented in this section.

l-1 I

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ATTACHMENT Note; No page number on this page. if the attachment is more than one page, the next page is number 2.

PARTIAL LIST OF PERSONS CONTACTED Note: This list is a partial list and need not be exhaustive, but the important contacts should be listed. Format is as follows:

Licensee Personnel Licensee employees contacted should be listed. This typically includes managers, engineers, technicians, production staff, and security personnel.

j Other Personnel Other personnel contacted should be listed. This typically includes off-site personnel such as emergency responders, and support groups such as police, hospital personnel, and personnel from State and local agencies, personnel.

L i

NRC Personnel i

NRC personnel contacted should be listed. This might include individuals in headquarters contacted on a specific issue or accompanying management from the regional office.

Mark each person contacted with an "*" to denote those present at the exit interview.

I INSPECTION PROCEDURES USED l

Format for this section is as follows:

l lP 88005 Management Organization and Controls LIST OF ITEMS OPENED, CLOSED, AND DISCUSSED Format for this section is as follows:

Qnened 70-xxxx/96 xx-xx VIO Failure to meet some specific requirement (Paragraph X.Y.2).

. Closed 70-xxxx/96 xx-xx VIO Failure to meet some specific requirement (Paragraph X.Y.2).

1

1 6

Fuel Facility Report Structure Coverletter Safety significant issues are highlighted in the coverletter, but only if they are contained in the Executive Summary and the Exit Interview Section.

Notice of Violation and/or Deviation Cover Pane Executive Summatv Items discussed in the Executive Summary should be significant findings from the inspection. Minor aspects should not be included here. Allitems in the Executive Summary would have been discussed in the Exit Interview with the licensee.

Renort Details

1..

Summary of Plant Status 2.

Area of Inspection #1 a.

Inspection Requirement #1 (1)

Inspection Scope (2)

Observations and Findings (3)

Conclusions b.

Inspection Requirement #2 (1)

Inspection Scope (2)

Observations and Findings (3)

Conclusions c.

Inspection Requirement #3 (1)

Inspection Scope (2)

Observations and Findings (3)

Conclusions 3.

Area ofInspection #2 a.

Inspection Requirement #1 (1)

Inspection Scope

]

(2)

Observations and Findings (3)

Conclus'ons l

b.

Inspection Requirement #2 (1)

Inspection Scope (2)

Observations and Findings

{

(3)

Conclusions i

4.

Exit Interview i

Attachment C

'2 Discussed 70-xxxx/96-xx-xx URI Additional review needed to determine if a specific requirement was met (Paragraph X.Y.2).

LIST OF ACRONYMS This section should contain a hist of acron'yms used !is the report. Note that even if an acronym is used, it should be spelled out the first time it is used in the report. Format is as follows:

NCS Nuclear Criticality Safety SOP - Standard Operating Procedure I

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July 14,1997 MEMORAf 'DUM TO: Fuel Facilities Branch FROM:

E. J. McAlpine, Q#

, IW Fuel Facility Brar e

SUBJECT:

RISK-INFORMED, PERFORMANCE-BASED INSPECTION CYCLE The purpose of this memorandum is to discuss my views on the risk-informed, performance-based inspection cycle and to provide guidance on the implementation of its elements in the Region ll Fuel Facilities Branch. The inspection cycle has six distinct phases that are repeated on a predetermined frequency - annually for high-enriched uranium facilities and biennially for low-enriched uranium facilities. The steps are as follows:

1.

Performance Review - review of licensee performance by functional area based on inspection findings documented in inspection reports and the Site Integration Matrix.

2.

Inspection Targeting - specification of inspection frcquency and/or level of inspection effort by functional area. This includes identification of specific areas within each functional area where inspections will be focused due to identified deficiencies in the licensee programs, specific plant areas where the risk in highest, and inspections to be conducted conjointly with NMSS. Note that a portion of this is conducted as part of the -

performance review process, but the specific decision on actuallevel of effort is completed independent of that process. Note also that this phase forlow-enriched uranium facilities will be conducted without the benefit of a recent formal review of licensee performance every second year.

3.

Inspection Scheduling - establishment and periodic modification of the annual inspection schedule.

4 Inspection Planning - preparation ofinspection plans for the conduct ofindividual inspections.

5.

Inspection Performance and Documentation - performance of the inspection and documentation of results in an inspection report.

6.

Performance Tracking - tracking of licensee performance in the Site Integration Matrix l

to permit identification of trends on a more frequent basis than the formal performance reviews. Note that the Site Integration Matrix for the entire period covered by a Licensee Performance Review should provide the necessary and sufficient information l

to perform the review - thus reinitiating the cycle.

i Performance Review This aspect of the process is specified in Manual Chapter 2604. The letter to B&W NNFD dated May 16,1997 with a subject of"NRC Performance Review of Licensed Activities" presents the most rbcerit example of what the finished product should look like. It is presented cs Attacnment 1 to this memorandum. Also, we should expect a high level of performance in creas where the risk is high.

2 Insoection Taraetina inspection targeting should be set forth in writing before the beginning of the fiscal year. This document should specify areas to be emphasized during the coming fiscal year and the level of inspection effort to be expended. Such guidance would be based on areas of risk within the individual facilities and the levels of performance observed during and subsequent to the last performance review. The basis for performance since the last performance review should be based on information included in the Site integration Matrices. This particular area is one where branch performance (at both the Branch Chief and inspector levels) needs improvement. For Fiscal Year 1998, such a document will be prepared in draft and circulated within the Branch prior to the development of the annualinspection schedule. Guidance was not specifically created for Fiscal Year 1997, but Fiscal Year 1996 guidance which was also applicable to Fiscal Year 1997 is available in two files - G:\\ PLANS \\ EMPHASIS.NCS and G:\\ PLANS \\LOOKFOR.EJM.

Insoection Schedulina Once the inspection targeting document has been created, the project inspectors (in concert with other inspectors) can prepare the inspection schedule for the fiscal year. This will take into consideration such issues as targeted level of effort by inspection area, inspector training and leave schedules, holidays, plant shutdown periods, licensee performance review schedules, specific inspections to be conduc'ed in conjunction with the program office, etc. The Region 11

. Inspection schedule is then integrated into the national master inspection schedule. The inspection scheduling process is dynamic in that factors such as reactive inspections due to events, changes to training schedules, and time needed to complete specifically assigned action items will necessitate periodic schedu!e modification. Notwithstanding that, each time the schedule is established or modified our best effort to prepare a schedule that most efficiently utilizes our time is needed.

It is important to recognize that by virtue of integrating the Region !! inspection schedule into the national master inspection schedule, we have established a contract with the program office relative to the type and timing of our inspections. This is tracked and briefed at the office director level during periodic operating plan reviews.

Insoection Plannina The inspection planning process is where the elements of inspection targeting and scheduling come together to produce the plan that will be implemented during the on-site inspection. The Fuel Facilities Branch inspection Plan form (Attachment 2) provides a road map to this planning process. During this phase, the inspector reviews the Site Integration Matrix for performance trends, reviews the Open items List for issues needing closure, and prepares the list of performance measures to be inspected. The planning of the inspection occurs with an eye on the level of effort, areas to be emphasized, and the performance as specified in the Licensee Performance Review and the Site Integration Matrix. Planning of the inspection is the key to assuring that time on site is spent in those areas where the risk is highest and/or the licensee's performance is lowest. The approval of the inspection plan by the project inspector and the branch chief is a contract with the inspector.

3 Insoection Performance and Documentation Inspections must be performance based. Allinspectors are required to attend training on

" Inspecting for Performance

• and the techniques learned in that course are carried out during the performance of on-site inspections. During performance-based inspections, the inspectors should continually remind themselves of the " Trust, but Verify" motto. The use of the performance measures developed during the inspection planning phase will keep the inspection focused on performance and risk.

No inspection is complete until the report documenting the inspection findings is issued. presents the format forinspection reports prepared within the Region ll Fuel Facilities Branch. Note that the format has been modified slightly based on comments received from Bruce Mallett when he was the Division Director and is consistent with Manual Chapter 0610. The two most important aspects of the inspection report is the assessment oflicensee performance that is documented in conclusions and the timely issuance to the licensee.

Reports should be prepared promptly so that we can forward them to the program office for review and comment. The target is to provide the program office with two days to perform their review.

Performance Trackina The performance of licensees as documented in inspection reports is tracked on the Site integration Matrices. These are maintained by the Project inspectors and provide the mechanism by which performance can be judged during perforrnance reviews and at intervening times. It is important a keep a close eye on the performance of our licensees because it is far easier to correct a minor degradation of performance than a major performance decline. Toward that end, the types of entries into the Site integration Matrix are important. The must be clear, concise, and based on performance.

This brings us full cycle. The types of performance that should be documented in the Site Integration matrix can be seen in Attachment 1 - the results of the Licensee Performance Review. The successfulimplementation of this cycle will make a major contribution to improved performance as reflected in our quarterly Branch Self-Assessment.

If you have any questions about this memorandum, I will be pleased to discuss them with you.

Distribution:

Branch Members D. Collins T. Decker C. Hosey B. Mallett J. Potter Reading File P. Ting PAWP51\\RIPBINSP.CYC

+ -.

3 TARGETING INFORMATION l

A. -

Management Controls (88005) i B&W NNFD No particular emphasis was identified.

Framatome Cogema Fuels No particular emphasis was identified.

General Electric -

No particular emphasis was identified.

Nuclear Fuel Services l

No particular emphasis was identified.

j Westinghouse l

No particular emphasis was identified.

B.

Operations Review (88020)

B&W NNFD The program should emphasize the Uranium Recovery and Compact Reactor Fuels portions of the facility since these are the areas where the highest risk exists because of the presence of solutions. Other portions of the facility should not be ignored. Target should be 70% high risk and 30% balance of plant. At least 16 hours1.851852e-4 days <br />0.00444 hours <br />2.645503e-5 weeks <br />6.088e-6 months <br /> of effort should be devoted to the Lynchburg Technology Center.

Major reviews should be conducted of any preparations to continue process of uranium-beryllium scrap with recognition that such processing is covered by a Confirmation of Action Letter.

Framatome Cogema Fuels Program emphasis should be a balance between normal plant operations and operations associated with new work. The new work emphasis should be based on the lessons leamed by the licensee from the inadvertent shipment of two fuel assemblies to Germany which resulted from failure to conduct new, short-term projects in a manner similar to the normal routine work. a

4 General Electric The program emphasis should be divided about equally between the dry conversion facility, uranium recovery, and the balance of plant. Particular emphasis should be placed on any phase out of the ADU process. We don't want to see problems developing in ADU as the facility's attention becomes more focused on DCF.

Nuclear Fuel Services The program emphasis should be on new programs coming on line. These will be in the order in which they occur uranium-aluminum scrap recovery, down-blending of high enriched uranyl nitrate to low-enriched uranyl nitrate, and the design, construction, and testing of facilities for the new naval fuel manufacturing process.

Westinghouse The program emphasis should be on the implementation of safety controls on a plant-wide basis. Particular attention should be given to the robustness of controlimplementation. We have seen indications that administrative controls are not always included in approved operating procedures and operators are not always trained on the implementation of those controls. In addition, attention should be directed to areas where geometry controls are used. There have been indications that the development of the Criticality Safety Evaluations have not always involved a review of source evaluations resulting in the belief that geometries were favorable when they were not.

C.

Fire Protection (88055)

Overall, particular emphasis should be placed at each facility on the controls over and use of moderating materials in fighting fires. Also, the existence of significant fire loads in areas where a fire could result in the compromise of nuclear criticality safety controls is of extremely high significance. Fire protection inspection should be focused based on input from operations inspectors.

B&W NNFD Emphasis should be on portions of the plant where fires could involve uranium.

The licensee may be pursuing an analysis to demonstrate that zirconium fires in machining area could not result in the involvement of uranium. If so, this should be factored into the program emphasis by de-emphasizing this area after a technical review of such demonstration information or data by NRC. Given that the uranium recovery area (including Compact Reactor Fuels) appears to contain the major fire load, this area should receive particular emphasis.

l l

l

n i

.~

i 5

Framatome Cogema Fuels No particular area of emphasis other than to assure that the SERF facilities i

receive significant attention. The presence of byproduct material with its' significance as a source term causes those areas to be ofimportance.

General Electric'-

l-l

. No particular area of emphasis has been identified. ' Entire program area should be addressed. Of note is that the fire loading in solvent extraction is lower than l~

at other facilities because of the organic used, d

l Nuclear Fuel Services -

Emphasis should be on the control of fire loading and on the conversion of the sprinkler system in the High Enriched Uranium Recovery Facility from a manual l

to an automatic system. Emphasis should also be on issues developed during l

the UF. readiness inspection. The entire program should be covered.

Westinghouse The entire program should be covered. Only specific area of emphasis is on the Fitzmills. These have been the source of fires in the past when UO, powder burned back to U 0, due to the presence of oxygen in the collection system.

3 I

D.

HEU Access Controls (81912,81914,81915,81916,81917,81922,81925,81929,.

81932,81933, and 81934)

B&W NNFD No particular area of emphasis has been identified.

Nuclear Fuel Services l

Emphasis should be on changes to controls for the 300 complex as the new naval fuel process becomes ready for operation.

E.

HEU Alarms and Barriers (81910,81911,81913,81918,81919,81920,81921,81923, 81924, 81926, 81927, 81928, 81931, 81401, and 81402) -

B&W NNFD '

No particular area of emphasis has been identified.

Nuclear Fuel Services Emphasis should be on changes to controls for the 300 complex as the new

~

b 6

naval fuel process becomes ready for operation.

F.

. HEU Other Security Areas (81930, 81935, 81020, 81022, 81034, 81038, 81501, 81502, and 81601)

B&W NNFD Emphasis should be on the management of the program. Changes in the management structure have occurred and we need to assure that the program continues to be managed in an effective manner.

Nuclear Fuel Services No particular area of emphasis has been identified.

G.

LEU Security (81431)

Framatome Cogema Fuels No particular area of emphasis has been identified.

General Electric No particular area of emphasis has been identified.

Westinghouse l

No particular area of emphasis has been identified.

H.

Transportation Security (81310, 81335, 81340, 81360, 81365, and 81370)

B&W NNFD No particular area of emphasis has been identified.

Nuclear Fuel Services No particular area of emphasis has been identified.

I lr Spent Fuel Shipments No particular area of emphasis has been identified.

'd i:

7' l.

Radiation Protection (83822)

B&W NNFD Emphasis should be on the control of dose to workers. Particular attention should be focused on Uranium Recovery and Waste Treatment and the development and enhancement of engineered controls to minimized airborne radioactivity.

Framatome Cogema Fuels l-Emphasis should be on control of dose to the following classes of workers -

pellet loading, fuel rod downloading, and workers in the SERF facilities.

General Electric Particular emphasis should be placed on the Dry Conversion Facility (DCF) relative to the assessment of worker dose. With the startup of the DCF, the size and shape of any airbome radioactivity is expected to change. The particles should be smaller and be of a shape that does not readily clear from the lower lung. As a result, the biological half life may be increase.

Nuclear Fuel Services e

Emphasis should be on controls over worker dose. With respect to HEURF, a review should be conducted to assure concentrations'of radioactivity in air to which the workers are exposed is being properly measured. There may be a move to use fixed air samplers in the HEURF. If so, we should review the data demonstrating that fix air samplers provide meaningful data. NFS has had problems in the past when attempting to demonstrate the adequacy of fixed air samplers.

Westinghouse Continued sensitivity to the occurrence of unauthorized activities such as eat in controlled areas.

J.

Waste Generator Requirements (84850)

B&W NNFD Emphasis on proper waste characterization and program assessment.

Framatome Cogema Fuels Emphasis on proper waste characterization and program assessment.

j l

1

8 General Electric Emphasis on proper waste characterization and program assessment.

Nuclear Fuel Services t

l Emphasis on proper waste characterization and program assessment.

l Westinghouse Emphasis on proper waste characterization and program assessment.

K.

Low-Level Waste Storage (84900)

B&W NNFD i

No particular area of emphasis was identified.

Framatome Cogema Fuels No particular area of emphasis was identified.

General Electric No particular area of emphasis was identified.

Nuclear Fuel Services No particular area of emphasis was identified.

Westinghouse No particular area cf emphasis was identified.

L.

Transportation (86740) i B&W NNFC Shipment to Envirocare. Compliance with CoC requirements.

Framatome Cogema Fuels l

Compliance with CoC requirements.

General Electric Compliance with CoC requirements.

l l

9 Nuclear Fuel Services Shipment to Envirocare. Compliance with CoC requirements.

Westinghouse Compliance with CoC requirements.

M.'

Rad. Waste Management (88035)

B&W NNFD No particular area of emphasis was identified.

Fram: tome Cogema Fuels No particular area of emphasis was identified.-

General Electric No particular area of emphasis was identified.

Nuclear Fuel Services No particular area of emphasis was identified.

i Westinghouse No particular area of emphasis was identified.

N.

Etvironmental Protection (88045)

B&W NNFD i

l No particular area of emphasis was identified.

I Framatome Cogema Fuels No particular area of emphasis was identified.

General Electric No particular area of emphasis was identified.

Nuclear Fuel Services i

No particular area of emphasis was identified.

i

l' i

l 10 Westinghouse i

No particular area of emphasis was identified.

l l

O.

Decommissioning (88104)

Nuclear Fuel Services.

Work associated with North Site and Pond 4.

P.

Operator Tmining (88010)

B&W NNFD Emphasis on adherence to procedures and controls associated with calculations of H/X ratios.

Framatome Cogema Fuels Emphasis on training associated with new or non-routine work.

General Electric Emphasis on training associated with new or non-routine work, l

Nuclear Fuel Services L

l Emphasis on training associated with new or non-routine work.

Westinghouse i

Emphasis on training associated with new or non-routine work.

Q.

Maintenance / Surveillance (88025)

B&W NNFD Emphasis on maintenance of equipment and controls in Uranium Recovery which is performed by operators.

Framatome Cogema Fuels Emphasis on maintenance of safety related controls.

General Electric Emphasis on maintenance of new controls established for the DCF.

11 1

Nuclear Fuel Services Emphasis on maintenance of safety related controls associated with HEURF.

~ Westinghouse Emphasis on maintenance of safety related controls.

- R.

Emergency Preparedness (88050)-

B&W NNFD No particular emphasis was identified.

Framatome Cogema Fuels' J

No particular emphasis was identified.

General Electric l

l No particular emphasis was identified.

iL Nuclear Fuel Services No particular emphasis was identified.

Westinghouse No particular emphasis was identified.

S.

ISFSt inspection North Anna Emphasis on dry run of case loading.

T. '

NNFD Resident Emphasis in accordance with LPR U.

NFS Resident 5mphasis in accordance with LPR G:\\ SCHEDULE \\98 TARGET.

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ACCOMPANIMENT OF INSPECTORS BY DNMS MANAGERS IN FY-96

_,NAME DATE OF ACCOMPANIMENT Materials Licensing / Inspection Branch 1 J. Ennis 7/96 A. Jones 8/96 W. Loo B. Parker 11/95,5/96 J. Pelchat BPR, licensing Materials Licensing / Inspection Branch 2 H. Bermudez 2/96 D. Collins licensing, reciprocity J. Diaz 10/96 L. ' Franklin 2/96,6/96 J. Henson 5/96 O. Masnyk Bailey 12/95,9/96 Fuel Facilities Branch D. Ayres started 9/1/96 C. Bassett 3/96,9/96 W. Gloorsen 10/95,9/96 A. Gooden 3/96,9/96 D. Kasnicki 9/96 W. Tobin 3/96 C. Hughey 9/96 G. Troup 9/96 c

ACCOMPANIMENT OF INSPECTORS BY DNMS MANAGERS IN FY-97 NAME DATE OF ACCOMPANIMENT Materials Licensing / Inspection Branch 1 J. Ennis 9/97 A. Jones 4/97 W. Loo 3/97 B. Parker 5/97 J. Pelchat 5/97,7/97 l

Materials Licensing / inspection Branch 2 H. Bermudez 9/97 D. Collins licensing, reciprocity i

J. Diaz 10/96 L. Franklin 3/97 J. Henson O. Masnyk Bailey 4/97,7/97,8/97 Fuel Facilities Branch l

D. Ayres 10/S6,12/96,6/97,9/97 C. Bassett 11/96,1/97,7/97 W. Gloersen 9/97 A. Gooden 9/97 W. Tobin 7/97,9/97 G. Humphrey 7/97 C. Hughey 10/96,7/97,9/97 G. Troup 11/96,1/97,6/97,7/97 l

l d J

ACCOMPANIMENT OF INSPECTORS BY DNMS MANAGERS IN FY-98 NAME DATE OF ACCOMPANIMENT Materials Licensing / inspection Branch 1 J. Ennis l

A. Jones W. Loo O. Masynk Bailey B. Parker 12/97 J. Pelchat Materials Licensing / Inspection Branch 2 H. Bermudez D. Collins J. Diaz L. Franklin 12/97 J.Henson Fuel Facilities Branch D. Ayres C. Bassett W. Gloersen 12/97 A. Gooden W. Tobin 12/97 G. Hurnphrey 12/97 i

C. Hughey G. Troup

_ e

)

An at%

UNITED STATES NUCLEAR REGULATORY COMMISSION 8

REGION 11 101 MARIETTA STREET, N.W., SUITE 2B00

{

j ATLANTA, GEORGIA 30323419B k *... p#

August 7, 1996 l Reaional Office Instruction No. 2213. Rev. 7 MANAGEMENT OVERSIGHT OF INSPECTION AND LICENSEE ACTIVITIES

~

A.

Puroose:

To establish goals for overview of the implementation of the inspection program to ensure adequate management perspective on licensee activities; overview of NRC activities in the field including the effectiveness.of inspection; NRC staff performance and communication effectiveness; communication between Regional managers and their licensee counterparts; Regional management visibility at licensee facilities, and inspector objectivity.

This Instruction applies to all Regional managers and supervisors responsible for inspection program activities at nuclear power plants, l

non-power reactors and fuel facilities.

This revision incorporates the guidance of MC 0102, dated March 15, 1996.

This Instruction incorporates the Regulatory Impact Reporting Form (Attachment C).

This form, to be filled out by Division Directors, the Regional Administrator, and their Deputies will be used to document

feedback, both favorable and unfavorable, obtained frcm licensee counterparts during routine visits to sites.

B.

Discussion:

It is the responsibility of managers and supervisors to be knowledgeable of facilities, licensee organizations, and management control systems for which they have inspection program cognizance.

It is also the responsibility of managers and supervisors to be knowledgeable of the quality of inspection activities, capab.ilities of inspection personnel, and the general status of the program at assigned facilities.

Additionally, it is the responsibility of managers and supervisors to keep their immediate supervisors informed of significant personnel or safety issues which arise durino the course of implementing the inspection program.

Judgment should be used to achieve the desired goals for NRC mar.agement overview of licensee and inspection program activities by conducting onsite visits efficiently, such as, during periods where other-NRC inspections or meetings can be observed.

These visits should be supplemented by frequent one-on-one communications, such as periodic conference calls in the case of resident inspectors, l

The requirements and guidance provided in this ROI shall be used by NRC l

managers to verify inspector and examiner performance and objectivity by j

direct observation of on-site activities at power reactor facilities, non-power reactors and fuel facilities and through other available indirect methods as appropriate.

On-site activities include individual or team

. Attachment 9

Regional Office Instruction 2

No. 2213, Rev. 7 inspections, examinations, audits, visits, and reviews.

NRC inspectors and examiners should use the applicable guidance and requirements of this section in the performance of their inspection and examination activit,ies.

Line management is responsible for overseeing inspectors, examiners, and other staff that conduct on-site activities at reactor and fuel facilities

'by. clearly ' establishing and communicating performance expectations,

. providing appropriate staff development, evaluating feedback from reactor l

licensees, and ensuring that on-site activities are performed as intended, l

l C.

Action:

Each regional manager and supervisor is responsible for implementing the attached procedure.

D.

Contact:

Suggestions or comments should be directed to the Deputy. Regional Administrator at extension 15610.-

E.

Effective Date:

This Instruction is effective on issuance and supersedes Regional Office l

Instruction No. 2213, Rev. 6, dated June 23, 1995.

tf

&?

Stewart D. Ebneter Regional Administrator

Attachment:

Management Oversight Responsibilities w/ Appendices Distribution List D 1

e

MANAGEMENT OVERSIGHT RESPON'IBILITIES S

Procedures 1.

Division of Reactor Pro.iects (DRP) a.

Division management and supervisors will visit reactor sitds in accordance with the schedule in Appendix A.

{

\\

b.

Managers and supervisors should meet with licensee counterparts to discuss licensee performance and problems and elicit ' licensee -

comments regarding NRC programs and activities. They should observe the implementation of NRC programs in the field and the effectiveness of NRC staff communication with the licensee.

l At the conclusion of each trip, prepare a brief trip report (Appendix B) for the Deputy Regional Administrator identifying the licensee, person (s) contacted, inspection staff observed, and any identifying problem (s) or concern (s).

(See Appendix B for

<!istribution.) At the conclusion of each trip taken 'by a Regional Division' Director or Deputy Director, a Regulatory Impact Form (Appendix C) identifying the

licensee, person (s) contacted, favorable

feedback, unfavorable

feedback, comments and recommendations / solutions is to be prepared.

I j

The Division Director or Deputy is responsible for making quarterly

{

j telephone calls to SRIs to discuss key inspection issues and the l

position the SRI is taking with regard to those issues.

c.

Division Directors or their deputies shall conduct self-assessments to evaluate management's performance in oversight activities.

'3 d.

For all team inspections, a regional manager at the Branch Chief level or higher will attend the team exit.

The manager attending the exit will prepare for the exit.by at least meeting with the team that day or evening before the exit, j

l e.

Branch Chiefs shall perform the following: make at least a monthly visit, at one of the assigned sites (see Table in Appendix A), and

.should attend. exit interviews with licensee if significant inspection or examination findings especially if possible escalated enforcement or unsatisfactory requalification evaluation will be discussed.

Communicate with the resident' staff at each of their sites several times per week.

Inspection or examination plans are discussed before on-site activities are initiated to ensure the employee's activities are l

properly scheduled, coordinated and focused.

i ATTACHMENT

i 2

Discuss the findings and concerns with the! inspectors assigned to the activity. before the facility's exit n.eeting is held.

Discussions should focus-on potential safety and regulatory approaches _to issues to ensure mixed messages are not sent to the licensee.

,Get involved in enforcement decisions involving facilities or, j

activities for which they are responsible.

l j

Attend the exit briefing for their subordinate resident and i

specialist inspections if significant inspection or examination i

findings (e.g., possible escalated enforcement or unsatisfactory l

requalification examination ) will be discussed. A cognizant line manager shall attend significant team inspection exit meetings as directed by their Division Directors and should supplement the discussion, as necessary.

Line managers responsible for an inspection activity should promptly u

L and thoroughly debrief the assigned inspectors after the inspectors l

leave the site.

Line managers must promptly intervene and

. communicate any changes in findings or conclusions to DRP management and shall promptly contact the licensee to. discuss the changes if l

necessary.

i j

.f.

Branch Chiefs should accompany, at least once per year, each inspector and examiner over whom they-have direct supervisory authority during conduct of onsite activities, including preparation i

for and presentation of an exit interview. The Branch Chief should n

l focus on the following performance and objectivity attributes:

1 l'

safety perspective and the application of safety principles l

during conduct of onsite activities the adequacy of technical training and preparation for ' he t

onsite activity being conducted knowledge of applicable regulatory requirements, procedures j

and guidelines (e.g., NRC Inspection Manual procedures, UFSAR, j

Examiner Standards, NUREGs and Regulatory Guides) the ability to apply performance based-inspection / examination techniques to enhance safe and reliable facility / operation adherence to agency-wide' regulatory positions and policies and avoidance of personal interpretations and opinions objectivity, demeanor, professionalism, interpersonal skills l.

t i

.c 3

.\\

-l InkpectorObjectivityFocus:-

l-Does the inspector independently verify licensee provided (1)'

information?

I I

(2),

Does' the inspector adhere to NRC regulatory positions and policies when. discussing issues. with. licensee management or,

. NRC management?

,i l

(3)

Does the inspector maintain a professional relationship with l'

the licensee using good interpersonal-relationship skills?

I'j-(4)

_ Has the inspector provided an accurate and balanced account of licensee performance, and plant conditions, in communication with. NRC regional management via inspection ' reports, telephone, or other means?-

(5)

How do licensee staff and management respond to the

-inspector's questions or concerns?

(6)

-Is the inspector focused on safety significant concerns, applying the enforcement guidance when. required?

(7),

Does the inspector appropriately respond to issues or events duririg normal and off normal working hours?

l (8)'

Does the inspector develop ' issues fairly and objectively 4

without biased interpretation of facts?

(9).

Are findings adequately supported by the facts and are j

assessments of licensee performance adequately supported-by l

-the findings?

g.

Ihe Br.anch Chief.shall ensure the following:

-l j

(1)

NRR manager is informed of all significant issues I

l (2)

Inspectors, team leaders, chief examiners, and other staff who lead NRC on site activities (including headquarters based

' staff) use an appropriate inspection plan, brief and receive approval from the line supervisor responsible for the activity on their planned activities and provide a copy of the inspection, examination, or audit plan to the responsible regional office Division of Reactor Projects (DRP) supervisor before the on-site activities begin.

(3)

All NRC staff (including headquarters staff) who lead NRC on-site activities conduct an entrance meeting with the a'ppropriate facility personnel before beginning on-site l-activities.

The senior resident inspector (SRI) should be j

invited to all entrance briefings.

{

4 l

(4)

All NRC staff'(including headquarters staff) who lead NRC on-site activities should brief the immediate line supervisors l

responsible for the activity and the SRI regarding their findings before any exit meeting with the facility licensee

. takes place.

l-(5)

SRIs ' routinely brief their.immediate line manager on resident

.. inspection issues and findings.and keeps their supervisor

' informed of scheduled exit meetings.

(6)

SRIs keep abreast - of all NRC on-site activities at the facility to which they are assigned.

l (7)

SRIs attend entrance and exit meetings.

If the SRI is

. unavailable, other resident inspectors should attend in their i

place. For economy of time, meetings for multiple inspections should be combined whenever possible.

(8)

SRIs and RIs spend a minimum of one week per year performing inspection activities at another site.

'This may be l

accomplished by participating in a team inspection at another site, or during backup site familiarization visits.

.(9)

The resident inspec'd on staff maintains access to and familiarity with theie N ckup sites.

2.

Division of Reactor Safety (DRS) a.

Division managers and supervisors ' will participate in division inspections and operator licensing activities in accordance with the schedule in Appendix A.

b.

Managers and supervisors should meet with. licensee counterparts.to-

' discuss licensee performance and problems - and elicit licensee

.j comments reg'arding NRC activities and programs. They should observe j

the implementation of. NRC programs in the field and the l

effectiveness of NRC staff communication with the licensee.

At the conclusion of each trip, prepare a brief trip report (Appendix B) for the Deputy Regional Administrator identifying the

licensee, person (s)identifiedcontacted, ' inspection or licensing staff observeo',

and any problem (s) or concern (s).

(See Appendix B for distribution.) At the conclusion of each trip taken by a Regional Division Director or Deputy Director, a Regulatory Impact Form (Appendix C) identifying the licensee, person (s) contacted, favorable feedback, unfavorable feedback, comments, and.

recommendations / solutions is to be prepared.

c.

Division Directors or their deputies shall conduct self-assessments to' evaluate management's performance in oversight activities.

~

5

' d.

For all team inspections, a Regional Manager at the Branch Chief level or higher will attend the team exit. The manager will prepare for_the exit by at least meeting with the team that day or evening before the exit.

Branch Chi' fs should ensure that their. Division Director' and the e.

e Division Director of DRP are. informed of significant issues

' identified by insp'ec' tors and examiners whom they supervise.,

\\

f.

Branch Chiefs should attend exit ~ interviews with licensees if significant inspection or examination findings (e.g.,

possible escalated enforcement or unsatisfactory requalification evaluation) will be discussed.

g.

Branch Chiefs should accompany each inspector and examiner over whom they have - direct supervisory authority during conduct of onsite activities, including. preparation for and presentation of an exit interview.

The Branch Chief should focus on the following l

performance and objectivity attributes:

safety-perspective. and the application of safety principles during conduct of onsite activities the adequacy of technical training and preparation -for the onsite activity being conducted knowledge of applicable regulatory requirements the ability to apply performance based-inspection / examination techniques to enhance safe and reliable facility operation adherence to agency-wide regulatory positions and policies and avoidance of personal interpretations _ and opinions objectivity, demeanor, professionalism, interpersonal skills Inspector Objectivity Focus:

(1)

Does the inspector independently verify 1,1censee provided information?

j (2)~

Does the inspector adhere to NRC regulatory positions and l

policies when discussing issues with licensee management or NRC management?

(3)

~Does the inspector maintain a professional relationship with the licensee using good interpersonal relationship skills?

(4)

Has the inspector provided an accurate and balanced account of licensee performance, and plant conditions, in communication

6 with NRC regional management via inspection

reports, telephone, or other means?

(5)

How do licensee staff and management respond to the i

inspector's questions or concerns?

(6)

Is the inspector focused on safety significant concerns, applying the enforcement guidance when required?

(7)

Does the inspector appropriately respond to issues or events during normal and off normal working hours?

(8)

Does the inspector develop issues fairly and objectively

)

without biased interpretation of facts?

(g)

Are findings adequately supported by the facts and are assessments of licensee performance adequately supported by j

the findings?

l h.

DRS Branch Chiefs should brief the DRP Branch Chiefs (for Power l

Reactor Facilities) of significant inspection or examination findings.

3.

Division of Nuclear Materials Safety (DNMS1 a.

Division managers and supervisors will participate in inspection activities at non-power reactor and fuel facilities sites in l

accordance with the schedule in Appendix A.

Materials supervisors l

shall oversee each technical person supervised by inspection j

accomp'animent at least one time per year.

b.

For non-power reactors and fuel _ facilities, managers and supervisors should meet with licensee. counterparts to discuss licensee performance and problems,and elicit licensee comments regarding NRC activities and programs. They'should observe the implementation of l

NRC activities and programs in the fjeld and the effectiveness of NRC staff communications with ',he licensee.

l At the conclusion of each trip, prepare a brief trip report (Appendix B) for the Deputy Regional Administrator identifying the

licensee, person (s) contacted, inspectors

observed, and any identified problem (s) or concern (s).

(See Appendix B for distribution.) At the conclusion of each trip taken by a Regional Division Director or Deputy Director, at non-power reactor facilities, a Regulatory Impact Form (Appendix C) identifying the licensee,- person (s) contacted, favorable feedback, unfavorable feedback, comments, and recommendations / solutions is to be prepared.

c.

For materials licensees, a manager or supervisor should observe the inspection activity and attend the exit. Depending on the scope of the licensee's activities, it may be necessary to observe more than

one inspectio'n to evaluate the adequacy of the inspector's effective implementation of the program.

The manager or supervisor should meet with licensee counterparts to discuss licensee performance and problems and elicit licensee comments regarding NRC activities and programs. At the conclusion of each trip, 'they will. prepare a Nigf trip report (Appendix B) for the Deputy Regional Administrator

. identifying.the licensee (s), person (s) contacted, inspector (s) observ'ed, and any identified problems or concerns 5 (See Appendix B for distribution.)

d.

Division Directors or their deputies shall conduct self-assessments to evaluate management's performance in oversight activities.

e.

For all team inspections, a Regional Manager at the Branch Chief level or higher will attend the team exit. The manager will. prepare for the exit by at least meeting with the team that day or evening before the exit. (This does not include routine emergency exercise observations.)

f.

Branch Chiefs should ensure that their Division Director and the Division Director of Reactor Projects (for Power Reactor facilities) are informed of significant issues identified by inspectors whom l

they supervise.

l g.

Branch Chiefs should. attend exit : interviews-with licensees if significant inspections findings (e.g.,

possible escalated enforcement) will be. discussed..

h.

Branch Chiefs should accompany each inspector and examiner over whom they have. direct ~ supervisory authority during conduct of onsite activities, including preparation for and presentation of an exit interview.

.The.' Branch Chief should focus.on the following

~l performance and objectivity' attributes:

safety. perspective and the application of safety principles during conduct of onsite activ.ities the adequacy of technical training and preparation for the onsite activity being conducted (See Appendix B for distribution) knowledge of applicable regulatory requirements the ability to apply performance-based inspection / examination techniques to er. nance' safe and reliable facility / operation adherence to agency-wide regulatory positions and policies and avoidance of personal' interpretations and opinion 1

objectivity, demeanor, professionalism, interpersonal skills

~

8 l

Inspector Objectivity Focus:

(1)

Does the inspector independently verify licensee provided information?

(2)

Does the inspector adhere to NRC reguiatory positions and

. policies.when discussing issues with licensee management or NRC management?

j (3)

Does the inspector maintain a professional relationship with the licensee using good interpersonal relationship skills?

8 l

(4)

Has the inspector provided an accurate and balanced account of licensee performance, and plant conditions,.in communication with NRC regional management. via inspection

reports, telephone, or other means?

(5)

How do licensee staff and management respond to the 8

inspector's questions or concerns?

(6)

Is the inspector focused on safety significant concerns, 1

applying the enforcement guidance when required?

(7)

Does the inspector appropriately respond to issues or events during normal and off normal working hours?

l (8)

Does the inspector develop issues fairly and objectively l

without biased interpretation of facts?

I l

(9)

Are findings adequately supported by the facts and are l

assessments of licensee performance adequately supported by l

the findings?

.l i.

DNMS-Brar.ch Chiefs should brief the DRP Branch Chiefs (for Power l

j' Reactor Facilities) of signific. ant inspection or examination i

findings.

l l

4.

Inspector insoection Focus While prepring and conducting an inspection, the inspector should consider the following:

W Is the inspector focused on safety significant issues?

l I

Has the inspector prepared to conduct the inspection, and does the l

j inspector have the necessary training and tools to condut.t the l

inspection?

Does the inspector display a working level knowledge of applicable l

l regulatory requirements, procedures and guidelines?

9 Does the inspector use a performance-based approach to conduct l

inspection activities that stresses safe and reliable facility e

operation?

Does the to agency-wide positions and policy avoiding pe, inspector adhere rsonal interpretations and opinions?

~

~

~

Does the inspector use the l'icensing and design bases information

=.

l for the facility including the Updated FSAR in preparation for and 8

during conduct of inspections?

Does the inspector conduct exit interviews in accordance with NRC policies and practices?

l S.

Recional Administrator's Office a.

The Regional Administrator and Deputy Regional Administrator will visit reactor sites in accordance with the schedule in Appendix A.

b.

The Regional Administrator or the Deputy Regional Administrator will monitor Regional management activities and site visits. to ensure that all onsite activities receive adequate oversight. The RA shall ensure that the appropriate NRR manager is informed of all signi ficant, issues.

c.

The Regional Administrator or the Deputy Regional Administrator should contact each Senior Resident Inspector (SRI) periodically to discuss key inspection issues and the position of the SRI regarding those issues.

d.

ras must ensure that facility adverse comments are validated and l

appropriate corrective actions are initiated. The feedback obtained from the licensee shall be forwarded using Appendix C to the NRR j

Division of Inspection and Support Programs (DISP), Inspection l

Program Branch (PIPB). This feedback will be used in the continuing l

assessment of the regulatory impact of NRC activities on reactor j

plant operations.

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TON l\\,

APPENDIX B TRIP REPORT MEMORANDUM T0:

Deputy Regional Administrator FROM:

SUBJECT:

,REPDRT ON TRIP TO

.DATE(S) 0F VISIT:

PURPOSE OF VISIT:

INSPECTOR (S) OBSERVED:

SENIOR LICENSEE PERSON CONTACTED:

STRENGTHS OR WEAKNESSES NOTED WITH PLANT:

OTHER COMMENTS:

i I

Signature

/Date cc:

Regional Administrator Technical Division Directors Cognizant. Senior Resident. Inspector Cognizant DRP Branch Chief Cognizant NRR Project Manager

.o APPENDIX C REGULATORY IMPACT REPORTING FORM DATE:

b ORIGINATOR (NAME/0RG)

~

LICENSEE (NAME/ TITLE)

FAVORABLE FEEDBACK UNFAVORABLE FEEDBACK (ISSUE OR PROBLEM)

COMMENTS RECOMMENDATIONS / RESOLUTION cc:

Cognizant Senior Resident Inspector l

Cognizant DRP Branch Chief l

Technical Division Directors Deputy Regional Administrator Regional Administrator Cognizant NRR Project Manager j

-, NRR/ DISP /PIPB

!s l.

January 9. 1998 TRIP REPORT l

MEMORANDUM T0:

Bruce S. Mallett. Deputy Regional Administrator FROM:

Charles H. Hosey. Acting Deputy Director Division of Nuclear Materials Safety

SUBJECT:

REPORT ON TRIP T0: Puerto Rico DATE(S) 0F VISIT:

October 21-22. 1997 PURPOSE OF VISIT:

Accompany Inspector INSPECTOR (S) OBSERVED:

L. Franklin SENIOR LICENSEE PERSON CONTACTED:

i Hospital Metropolitano -Racheline A. Gonzalez Administrator San Juan Cement Co. - Rolando Melendez Administrator Bernardo A. Puebla. MD - Dr. Puebla. Owner Universidad Central del Caribe - Dr. Richard Hann, Chairman. Department l

of Biochemistry l

STRENGTHS OR WEAKNESSES NOTED WITH PLANT:

l-Hosoital Metrooolitano l

Hospital exercising little control over Oncology Department

{

San Juan Cement Co.

RSO involved in radiation safety on a daily basis, well maintained 3rogram 3ernardo A. Puebla. MD

.t l

Little use of source. Good records and user very knowledgeable of requirements.

Universidad Central del Caribe L

Small amount of research. Users very Knowledgeable of requirements. Well l

managed program OTHER COMMENTS:

i L

None cc:

Regional Administrator DNMS Division Director l a l

I i

APPENDIX 8 l

TRIP REPORT MEMORANDUM TO:

Deputy Regional Adniinistrator l

FROM:

PM b/!//7f

SUBJECT:

REPORT ON TRIP TO [n me-[ifvtf -

l2 10 f0 '1

/

DATE(S) 0F VISIT:

PURPOSE OF VISIT:

L4 f n/My, l.ff.

INSPECTOR (S) OBSERVED: Alom

,n s he m [yE, A -/n41

/

U U

hl) 0 C,aw.sv6ir>n,LosHI/h

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SENIOR LICENSEE PERSON CONTACTED:

khSve STRENGTHS OR WEAKNESSES NOTED WITH PLANT:

bW h

hJ]Qf.] h

• Sivia.U f I(t.h.M' N l 07t i

mangnud tppaa + b ee y m n Ia.

m o]1eub M s OTHER COMMENTS:

l Ifl(of$

Signature I/Date cc:

Regional Administrator Technical Division Directors l

Cognizant Senior Resident Inspector f

Cognizant DRP Branch Chief l_

Cognizant NRR Project Manager

APPENDIX B TRIP REPORT MEMORANDUM TO:

Deputy Regional Administrator FROM:

f) 41 O

11C

SUBJECT:

REPORT ON. TRIP TO NF('

DATE(S) 0F VISIT:

0l 4,7 PURPOSE OF VISIT:

1. )/)f u v [ $ r// M /

rlal) I/2 E INSPECTOR (S) OBSERVED:

[r, /d4tf.thtAf/

/

(/

SENIOR LICENSEE PERSON CONTACTED: [), / h u ( m A STRENGTHS OR WEAKNESSES NOTED WITH PLANT:

Nht/k[cQ1 ih Y) /10f)11 Y Y 0 M d' l O'lh L l

L h

JQ

/190lb)k 1 [?Yll&

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hf]?%Cy1f LVIYW s}r\\C SrfrYI hYut\\c JI~ Jfl1LT7 A15'~

OTHERCOMMENTS:hnt (I A[/K5 -M[

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tf,t //Illt' 3/1 p

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$1(?Vf7

((bij NJh IIkt/

I 0% (U l 1 $A9il N/'^-

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Signature VData cc:

Regional Administrator L/E Technical Division Directors

/

Cognizant Senior Resident Inspector Cognizant ORP Branch Chief Cognizant NRR Project Manager

1 I

APPENDIX B TRIP REPORT MEMORANDUM TO:

Deputy Regional Administrator FROM:

3 kl

($,/J)nf

SUBJECT:

, REPORT ON TRIP TO [T DATE(S) 0F VISIT:

/d ['Aff97 PURPOSE OF VISIT:

f7td hat, ]_gggag,,./q-fyg INSPECTOR (S) OBSERVED:

A/d A7a<,

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SENIOR LICENSEE PERSON CONTACTED:

[. [f g p STRENGTHS OR WEAKNESSES NOTED WITH PLANT:

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l OTHER COMMENTS:

M71Stfj:u ubuler Signature ~

'/Date l

cc:

Regional Administrator

[/gg 1

Technical Division Directors

{

Cognizant Senior Resident Inspector Cognizant ORP Branch Chief 4

Cognizant NRR Project Manager

f 1

i SPECIFICATIONS 1.

Calibration facilities for radiation detection / measuring instruments shall hold accreditation from the National Institute of Standards and Technology as a Secondary Standards Facility.

2.

All instruments shall be calibrated by methods and standards traceable to NIST. All calibration techniques used must meet or exceed the American National Standard Radiation Protection Instrumentation Test and Calibration procedures described in ANSI W323-1978, with the following exceptions or clarifications:

The instrument will not necessarily be labeled with all of the calibration information specified in section 4.5 of the standard.

' but appropriate calibration data shall be provided NRC via a calibration certificate.

Instruments shall be labeled with the date of calibration. date of expiration, and the identity of the 1

3erson performing the calibration. Beta correction factors shall Je indicated on the instrument where applicable.

3.

The facility selected for this contract may be subject to a quality assurance audit by NRC personnel prior to and at any time following the awarding of the contract.

4.

Instruments shall be shipped or delivered to personnel / locations i

specified by NRC.

5.

The facility must be capable of calibrating and returning instruments within 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> of receipt by the calibration facility. Approximately 6 such emergency calibrations may be required per year.

6.

Instruments received for routine calibration shall be calibrated and returned to NRC within 14 days of receipt by the calibration facility.

7.

Probes / detectors listed with instruments on the attached list reflect the current status of the inventory and is submitted for planning purposes only.

Probes may be switched among instruments as dictated by operational requirements. thereby requiring recalibration of the instrument-probe pair. Approximately 10% of the inventory may require recalibration in this manner during the period of the contract.

Further. approximately 25% of the inventory may require some repair during the year.

8.

The attached list of instruments is for planning purposes only and reflects the majority but not necessarily the total inventory of instruments.

Additionally, the instrument inventory may change due to the purchase of new. replacement, instruments of similar types during the year.

l l

. 0

?

,l INSTRUMENT INVENTORY l

Manufacturer /Model Otv Comment RATEMETERS (count rate)

Bicron 2000 1

w/ pancake GM Eberline E-120 9

w/HP-260 Eberline PRM-5 3 3

w/HP-260 Eberline PRM-6 2

w/HP-260 l

Eberline -

PRM-6 2

w/HP-270 3

l Eberline RM 14 4

w/HP-260 L

Eberline RM-19 1

w/HP-270 t

Eberline RM-21-1 2

w/HP-270 i

l Ludlum 3

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1. 84g,'c UNITED STATES NUCLEAR REGULATORY COMMISSION

,A REGION 11 o

101 MARIETTA STREET, N.W.. SUITE 2900 i

5 j

ATLANTA. GEORGIA 303D0199

'f April 16.1997 -

MEMORANDUM T0:

Bruce S. Mallett. Director Division of Nuclear Materials Safety FROM:

Charles M. Hosey. Acting Deputy Director Division of Nuclear Materials Safety

SUBJECT:

AUDIT OF EXEMPTIONS TO REGULATIONS GRANTED IN MATERIALS LICENSES On April 14. 1997. I conducted an audit of selected new material licenses issued by Region II between July 1.1996 and April 1.1997 to determine if exemptions granted had been previously a] proved in a NMSS Policy and Guidance l

Directive (PG&D) or in response to a Tec1nical Assistanca Request (TAR).

In all cases reviewed. if exemptions were granted, they were either approved l

by a PG&D or in a response to a TAR. A list of the files reviewed and the l

exemptions contained in each is attached.

l

Attachment:

List of Fil n i

I 7

MATERIAL LICENSE FILES REVIEWED l

LICENSE LICENSEE EXEMPTION BASIS NUMBER

)

10-25362-01 OHM Remediation

1. Leak Test Requirement

1. PG&D

2. Decom Fin Assurance

2. NMSS ltr 16-25373-01 Appalachian Reg None 39-25372-01 USGS None 41-25370-01 TVA Hold Waste for Decay-in-PG&D storage 45-25228-01 Earth Tech Leak Test Requirement PG&D 45-25366-01 Cardiology Assoc None 45-25364-01 Commonwealth Bio None 45:25381-01 Engineering Cons None 45-25382-01 Eng & Materials None 47-25363-01 Elk Run Coal None 47-25369-01 DENEX Corp None 47-25375-01 Pharmalogic

1. Leak Test Requirement

1. PG&D

2. Dispose of waste without

2. TAR removal of labels 47-25376-01 William Noble None 52-25361-01 Pharmalogic

1. Leak Test Requirement

1. PG&D

2. Hold Waste for Decay-in-

2. PG&D Storage 52-25379-01 San Jorge Hosp None

)

?

d e

[pm secoq UNITED STATES jo, NUCLEAR REGULATORY COMMISSION 8

7

,o REGION il

/ j ATLANTA FEDERAL CENTER e

61 FORsYTH STREET. Sw. SulTE 23T85

['

ATLANTA. GEORGIA 30303 June 30, 1997 MEMORANDUM TO:

Donald A. Cool, Director Division of Industrial and Medical Nuclear Safety, NMSS Douglas M. Collins, Acting Director hSY FROM:

Division of Nuclear Materials Safety

SUBJECT:

LISTING OF LICENSEE EXEMPTION REQUESTS RECEIVED AND DENIED (Your Memo, June 27,1997)

In response to your request, we have records of Region ll licensee exemptions to 10 CFR requested, granted or denied from January 1,1997 through June 30,1997, as listed below:

1.

University of Virginia, No. 45-00034-30, was granted a standard 30.35, 30 day exemption from Financial Assurance requirements for source loading of a teletherapy device.

)

2.

University of Virginia, No. 45-00034-09, was granted a standard 30.35, 30 day exemption from Financial Assurance requirements for a teletherapy source change.

3.

Department of Navy, No. 45-23645-01NA was granted a TAR exemption from certain l

provisions cf Part 36 for use of a teletherapy device for blood irradiation.

4.

Bluefield Regional Medical Center, No. 47-19142-02 was granted a standard 30.35, 30 day exemption from Financial Assurance requirements for a teletherapy source change.

5.

Hospital Oncologic, No. 52-11832-01, was granted a standard 35.647 exemption to allow five year teletherapy maintenance to be extended for up to two months, since the vendor was unavailable earlier. They were also granted a standard 30.35, 30 day exemption from Financial Assurance requirements for a teletherapy source change.

cc.

A. 9!noch R!

R. Caniano, Rlli R. Scarano. RIV 7 a

June 30, 1997 MEMORANDUM TO:

Donald A. Cool, Director Division of Industrial and Medical Nuclear Safety, NMSS FROM:

Douglas M. Collins, Acting Director (original signed by Division of Nyclear Materials Safety D. M. Collins)

SUBJECT:

LISTING OF LICENSEE EXEMPTION REQUESTS RECEIVED AND DENIED (Your Memo, June 27,1997)

In response to your request, we have records of Region 11 licensee exemptions to 10 CFR requested, granted or denied from January 1,1997 through June 30,1997, as listed below:

1.

University of Virginia, No. 45-00034-30, was granted a standard 30.35, 30 day exemption from Financial Assurance requirements for source loading of a teletherapy device.

2.

University of Virginia, No. 45-00034-09, was granted a standard 30.35,30 day exemption from Financial Assurance requirements for a teletherapy source change.

3.

Department of Navy, No. 45-23645-01NA was granted a TAR exemption from certain provisions of Part 36 for use of a teletherapy device for blood irradiation.

4.

Bluefield Regional Medical Center, No. 47-19142-02 was granted a standard 30.35, j

30 day exemption from Financial Assurance requirements for a teletherapy source change.

5.

Hospital Oncologic, No. 52-11832-01, was granted a standard 35.647 exemption to allow five year teletherapy maintenance to be extended for up to two months, since the

]

vendor was unavailable earlier. They were also granted a standard 30.35, 30 day exemption from Financial Assurance requirements for a teletherapy source change.

cc:

A. Blough, RI R. Caniano, Rlli R. Scarano, RIV l

OFFICE RIZ RII RII f,p SIGNATUEE qgp NAME DHeim JPotter TDecker DATE 6/

/S7 6/

/97 6/g {97 6/

/97 6/

/97 6/

/97 6/

/97 CO *'V't YES NO YES NO YES (NCy YES NO YES NO YES NO YES NO OFFICIAL RECORD COPY DOCUMENT NAME: C:\\DNMS\\LICXEMP.MEM

)

1. g" "I%'o UNITE'o STATES NUCLEAR REGULATORY COMMISSION 101 MARIETTA STRE 4.W.. SUITE 2900

• I Jj ATLANTA. GEoRGtA 3032M190 4

% g/

February 29, 1996 LICENSING PROCEDURE 1.0

SUBJECT:

PROCESSING OF EXEMPTION REQUESTS Backaround Some exemptions to NRC regulations are incorporated in the regulations and require no further action by the NRC for the licensee to use the exemption. In

{

addition, the Region may grant exemptions to the regulations by inclusion of a

)

l license condition in the license based on a general exemption granted by the Office of Nuclear Materials Safety and Safeguards (NMSS) or inclusion of a license condition in the license based on authorization granted by NMSS in response to a Technical Assistance Request (TAR).

The purpose of this procedure is to provide specific guidance to the license j

reviewers in Materials Licensing / Inspection Branches 1 and 2. on granting l

exemptions to NRC regulations.

s l

- Action Upon receipt of a request for an exemption, the license reviewer assigned the case will review the request and determine if an exemption is required.

If the exemption requested is granted in the regulations or if an exemption is not required, the reviewer will inform the licensee in writing.

If the exemption requested is one that NMSS has authorized the region to issue without consultation with NMSS in Policy and Guidance Directive (P&GD) 84-12 or other P&GD, add the condition specified by NMSS to the license and issue the amendment.

If the exemption requested is not covered by the paragraphs above, the reviewer will prepare a TAR for submission to NMSS in accordance with P&GD 93-02. The request will be signed by the Branch Chief.

APPROVED BY:

?/

• M D6Mn P. Pot 'er, Chief, MLIB2 Charles M. Hosey, Chief, MLIBl

' 8

G 4

,i

/ga are fo NUCLEAR REGULATORY COMMISSION UNITED STAYES l

8 fa REGION tl

/ y ATLANTA FEDERAL CENTER t

61 FoRSYTH STREET. SW. SUITE 23T85 ATLANTA. GEORGIA 30303 3415 October 17, 1997 Reaional Office Instruction No.1030. Revision 9 PROCESSING ALLEGATIONS, COMPLAINTS, AND CONCERNS A.

Puroose:

To establish Regional Office procedures for the proper processing, control, and disposition of allegations, complaints, and concerns received by any. Region II staff member involving Nuclear Regulatory Commission (NRC) licensed facilities or activities.

This revision implements the requirements of Management Directive (MD) 8.8, " Management of Allegations," and includes the following substantive changes: Section 1.5.3, scheduling and arranging the Allegation Review Board (ARB) agenda: Section 1.5.4, preparing for the ARB:

Section 1.6.5.7, setting time requirements for licensee responses: Section 1.5.4.5, completeness of ARB minutes: Section 1.8.4, review and approval l

of allegation closure documentation: Section 1.9. allegation correspondence: Section 2, standard letters: and Section 3, warning cover sheets for allegation material.

B.

Discussion:

Allegations, complaints, and concerns (hereinafter referred to as allegations) pertaining to NRC licensed facilities and activities rr.ay be received in a wide variety of forms and under varying circumstances.

It is imperative that allegations be recognized as such by Region II staff members and that this information be processed in a professional, prompt, and consistent manner. Region II staff members are required to maintain a high level of scasitivity to allegations paying particular attention to any public health and safety aspects of allegations.

An allegation is a declaration, statement, or assertion of impropriety l-or inadequacy asscciated with NRC regulated cctivities, the validity of i

which has not been established. This term includes all concerns l

identified by sources such as individuals or organizations, and technical audit efforts from Federal, State, or local government offices regarding activities at a licensee's site. Excluded from this definition are inadequacies provided to NRC staff by licensee managers acting in their official capacity, matters being handled by more formal processes such as 10 CFR 2.206 petitions, misconduct by NRC employees or l

NRC contractors; non radiological occupational health and safety issues; i

and matters involving law enforcement and other Government agencies.

Region II staff members who receive an allegation must understand that it is absolutely essential to protect the identity of the individual providing the information in an allegation and that every effort must be made to preclude the inadvertent or premature disclosure of the 4

[

.V n

i Regional' Office Instruction 2_

/

No. 1030. Revision 9 individual's identity'outside NRC. To this end. in the event an individual's identity must'be released or revealed under any circumstances, coordination must be effected with the Director.

Enforcement.and Investigation Coordination Staff (EICS) who will initiate the necessary coordination for obtaining the proper authorization to disclose the identity of an individual who provides information to the NRC. This provision for protecting the identity of an individual is not to be confused with the principle of

'" confidentiality," a matter which is discussed in detail in Enclosure 2

-to this Instructicn.

Identity protection does not include withholding an individual's identity when anonymity has been requested and the NRC representative knows the individual's identity.

It'is important to note that no information provided to the NRC can be-considered as being "off-tha record," and any potential allegation information is required to oe officially documented and acted upon appropriately.

C.

-Action:

1.

All Region II staff members generally should be familiar with the procedures for processing allegations as outlined in this Instruction and HD 8.8, "Hanagement of Allegations."

2.

Those individual staff members who can expect to receive allegations in the field shall be fully familiar with the policies and procedures contained in this Instruction.

In addition, Region II supervisors and managers-shall be fully familiar with the policies and procedures relative to processing allegations.

'D.

Resoonsibility:

1.

The Director, EICS, has the primary responsibility for. ensuring that all allegations are properly documented, controlled, and processed.

2.

The Region II Division Director having project technical o

responsibility in the area of concern identified in an allegation t

is responsible for conducting an ARB. This Division Director will act as Chairman of the ARB for those allegations 'under the purview of his technical responsibility.

3..

Each Region II Division Director and Branch Chief is responsible for assuring that allegations assigned to them for action by the ARB-are inspected and resolved in a timely manner. The performance measure expected to be met is that allegations will be closed in less than 180 days.

4.

It is the. responsibility of Region II staff members who receive allegations to document the information promptly and forward such

s Regional Office Instruction 3

No. 1030. Revision 9 l

documentation within five workina days of receipt of the l

information through their supervisor to the' Region II Senior Allegation Coordinator (SAC) so that appropriate allegation processing action can be initiated.

E.

Contact:

Questions or comments regarding this Instruction should be directed to l

the Director. EICS, at extension 24421.

F.

References:

1.

Regional Office Instruction (ROI) 1004. " Notification to the Office of Investigations of Pctential Wrongdoing"

{

2.

HD 8.8. "Hanagement of Allegations" 3.

HD 9.2. " Office of the Inspector General" 4.

ROI 1801. Revision ?.. " Handling of Allegations of Improper Actions by NRC Employees or Contractors" 5.

ROI 1040 " Assistance'to the Office of Investigations" 6.

Field Policy Manual (NUREG/BR 0075). No.1

" Coordination with FBI." and No.13

" Witnessing Unsafe Situations" 7.

Allegation Guidance Memorandum (AGM) 96 01. Revision 1.

" Additional Measures to Protect the Identity of Allegers and Confidential Sources" 8.

AGH 96 02. " Assuring the Technical Adequacy of the Basis for Closing an Allegation" 9.

NRC Policy and Guidance Procedure 002. Revision 1. August 1997.

"NRC/ FEMA Staff Procedure for Res Raised by Members of the Public" ponding to Offsite EP Issues G.

Effective Date:

l This Instruction supersedes ROI 1030. Revision 8. dated August 5. 1996, and is effective upon issuance.

!,f d)l t.

Luis A. Rey Regional A mi strator

Enclosures:

(See Page 4) 1

1 s,

e

!l Regional Office Instruction 4

No. 1030. Revision 9-

Enclosures:

1.

Receiving and Processing Allegations 2.

Protecting Identity 3.

Confidentiality Agreement 4.

Guidance for Receipt and Documentation of Allegations 5.

Allegation Report 6.

Allegation Action ~ Plan 7.

Standard Letters 8.

Warning Cover Sheets Distribution List A

f. '

s Regional Office Instruction No. 1030 Revision 9 RECEIVING AND PROCESSING ALLEGATIONS 1.1 Incomina Alleaations 1.1.1 Teleobone Calls or Visits by Allecers to the Reaional Office Any Region II staff member within the Regional Office who receives a telephone call from a concerned individual (hereinafter referred to as an alleger who wishes to make an allegation, express a concern, or re)gister a complaint shall transfer the caller to the Senior Allegation Coordinator (SAC). Likewise, if an alleger comes to the Regional Office to personally discuss an allegation, the alleger is to be referred to the SAC who will conduct an interview with the alleger. Technical staff members within the Regional Office who are unable to contact the SAC, the Director, Enforcement and Investigation Coordination Staff (EICS), or a member of EICS to meet the alleger or take a telephone call shall handle the matter themselves and obtain as much information as possible regarding the allegation.

Administrative staff members who cannot locate the SAC or a member of EICS, shall locate a technical staff supervisor or manager, and refer the alleger to that person.

1.1.2 A11ecations Received in the Reaion II Hail Allegations received in the mail normally are handwritten or typed on plain paper (no letterhead), while official correspondence is usually on letterhead stationary.

Therefore, unless it is otherwise obvious, administrative personnel who open and screen mail will forward all incoming correspondence which ap> ears to contain an allegation to the j

Director, EICS. Both t1e letter and envelope will be delivered and no copies of such documents / correspondence will be made. Any Regional staff member who receives I

documents or correspondence, including internal NRC l

memoranda, which contain allegations, shall forward the l

documents to the Director, EICS.

1.1.3 Alleaations Received Durino the Course of an Insoection If an allegation is received by an inspector in the field, the inspector should document the allegation and transmit all acquired information and documentation to the SAC for processing. The inspector should also encourage the alleger to contact the SAC directly for status of their concern and provide the alleger with the Region II "800" telephone i

I

s Regional Office Instruction 2

No. 1030. Revision 9 number (800 577-8510) or the Allegation Hotline "800" telephone number (800 695 7403) to make that contact. The inspector should also be aware that meeting with an alleger on site may compromise the alleger's identity.

If meeting off site is more ap3ropriate. the inspector should immediately inform lis or her management for concurrence.

In such circumstances, consideration shall be given to having another NRC employee present during the interview to ensure personal safety and security during the meeting.

1.1.4 Referrals from Other Acencies or NRC Offices Any member of the Regional staff who receives written or telephonic notification that other agencies or NRC offices have received allegations regarding facilities or licensees within Region II shall promptly forward such information to l

the Director. EICS.

1.2 Contact with Concerned Individuals 1.2.1 The SAC is res)onsible for ensuring that communications are maintained wit 1 an alleger. Although not always possible, the SAC should normally be the initial point of contact for the alleger when he or she communicates with the NRC. This enables more efficient control of such communications and aids in 3rotecting the identity of the alleger.

Branch

. Chiefs w1o receive direct communication from an alleger as a result of a status or closure letter should coordinate the contact with the SAC and document the contact with a memorandum to file that will be placed in the appropriate allegation case file.

l 1.2.2 All contacts with the allecer shall be conducted in a professional manner. The safety significance of the allegation, or lack thereof, should not affect the treatment of the alleger, although it may affect the timing of the NRC follow up action.

1.2.3 Any member of the Regional staff having initial contact with an alleger shall attempt to obtain as much information as l

possible, including:

Full name of the alleger and employer:

Complete mailing address:

Home and work telephone numbers:

Position in or relationship to the facility or activity involved:

l

i Regional Office Instruction 3

j No. 1030. Revision 9 Nature and details of allegation, and Alleger's preference for method and time of contact.

Additional guidance regarding the acquisition of allegation

. information is provided -in Enclosure 4 to this Instruction.

l l

1.2.4 If the alleger persists in not providing personal identification, fully document the allegation and advise the alleger that he or she may contact the SAC in 30 working days for information on the status of any actions being taken related to the information provided.

1.2.5 If the alleger does not object to being contacted again, the alleger should be informed that the SAC will be contacting them to acknowledge receipt of the allegation within 30 days. The alleger also should be advised of the NRC policy on identity protection and that they will be notified of the NRC findings at the completinn of the appropriate review.

1.2.6 Region II staff members shall, as soon as possible after contact with an alleger or receiving an allegation, notify their supervisor that they have made contact with an alleger i

and that they have received an allegation. The supervisor shall ensure that the SAC is promptly notified of the allegation.

l l

1.3 Documentino Allecations i

l 1.3.1 It is important to obtain as much information as possible from the alleger ccrcerning the allegation.

In addition to the basic information (e.g., who, what, when, where, why, and how), attempts should be made to develop and clarify the information so that the issue is relatively well defined.

Every allegation received, regardless of the source, method of communication involved, or apparent substance, must be documented and evaluated.

i 1.3.2 A standardized Allegation Report form (included as ) should be utilized to document all allegations where practicable. A memorandum format may also be used.

i 1.3.3 The importance of obtaining all possible details concerning i

an allegation cannot be overemphasized. Evaluation of the allegation as well as the proposed course of action that j

will be initiated to resolve the allegation will be based on r

this initial information.

In some instances, the i

information may be so substantial, technically complex. or

s.

Regional Office Instruction 4

No. 1030, Revision 9 indicative of possible wrongdoing. that a parsonal interview

'with the alleger is warranted.

In these cases, the Director EICS,.and the SAC will' brief the Regional Administrator (RA) and discuss the w>st appropriate means of

arranging for and conducting an interview of the alleger to obtain the details required. Depending on the nature of the allegation and time constraints..the RA may request assistance from the Office of Investigations (01) or utilize other Region II resources, as required, to promptly address the issue.

If the RA determines that 01 assistance is aporopriate, the Director. 01 Field Office. Region II, will re briefed by the SAC.

1.4-A)leoationReport The Region II staff member who receives'an allegation shall pre>are an Allegation Report (see Enclosure 5) and forward it through his/1er supervisor to the SAC. The Allegation Report shall be placed.in an envelope. marked "To Be Opened By Addressee Only" and addressed to the supervisor.

Pre)aration of the Allegation Report shall be accomplished within three worcino days following receip+ of the information and forwarded to the appropriate supervisor. The following guidelines shall be' adhered to in pre)aring the Allegation Report or memorandum and transmitting it to t1e SAC.

1.4.1 The Allegation Report shall be typed (or handwritten legibly) and no copies of the Allegation Report shall be made or distributed. This requirement prohibits the originator from retaining a copy for their oersonal file and is intended to provide an extra measure of protection for both the alleger and the staff member receiving the allegation.

If an allegation is being mailed to the Regional Office, the sender shall retain a copy until it is verified that the Regional Office has received the Allegation Report. The retained copy shall then be destroyed.

1.4.2 If placed in the U.S. Postal Service mail, the Allegation Report shall be mailed to the SAC at the following address:

RII/ SAC. Post Office Box 845, Atlanta. GA 30301. The SAC will inform the appropriate supervisor of the receipt of the allegation as well as the individual who sent the Allegation Report.

1.4.3 Prepare the Allegation Report in accordance with the guidance provided in Enclosure 4.

If a memorandum format is used, the opening paragraph shall identify the alleger, the

+

i 9

Regional Office Instruction 5

No. 1030. Revision 9 date, time, location, and circumstances surrounding the contact with the alleger including identification of other persons present during the contact.- Each succeeding paragraph shall document all information associated with a particular allegation. The NRC staff member documenting the allegation should take care to document the allegation precisely as stated by the alleger. The purpose of this is to clearly record exactly what the allegation was so as to ensure appropriate follow up.

If information is received from more than one alleger, consideration should be given to reporting the information from each alleger in separate Allegation Re memoranda to ensure clarity and separation. ports or If separate memoranda are not used, then the details should be separated so that the specific facts of the alle attributed to each individual alleger.gation can be readily If the individual receiving and documenting the allegation adds any personal views, comments, analysis or evaluation to clarify the information received. those comments should be clearly identified as such in a separate paragraph at the end of the Allegation Report. Judgement should be used in the documentation of any personal comments or observations as the Allegation Report is subject to release under the provisions of the Freedom of Information Act.

1.4.4 The SAC is responsible for reviewing all information received in conjunction with an allegation and ensuring that appropriate Region II staff are promptly and fully briefed.

If the information contained in the Allegation Report is determined to be insufficient to permit follow up, the SAC may recontact the alleger to obtain additional information, or advise the receiving staff member, after appropriate coordination with the staff member's supervision, that additional information is required and request the staff member to obtain the information from the alleger.

When an allegation involves issues outside of the SAC's area of technical expertise, arrangements shall be made to have an appropriate technical staff member present during the conversaticn or interview with the alleger to assist in fully developing the technical issues of the allegation.

1.4.5 The SAC will provide an information copy of all Allegation Reports to the Director. 01 Field Office, Region II.

i 1.4.6 Normally, the receipt of allegations shall not be addressed in Preliminar If, however, y Notifications (PN) or Daily Reports (DR).

l.

1 such entries are deemed appropriate, the l

1

~.

Regional Office Instruction 6

No. 1030 Revision 9 a) proval of the RA shall be obtained prior to issuance of t1e PN or DR, following coordination with the Director, EICS.

1.5 Processina Alleaations 1.5.1 Within 30 days of receipt of an allegation, the SAC will assign a unique file number to the allegation and enter the allegation into the Allegation Hanagement System (AMS). The following unique numbering sequence is used for allegation numbers: RII 1997 A 0001, where "RII" indicates Region II, "1997" is the calendar year the allegation was received in Region II, "A" indicates an allegation, and the four digit number represents the secuential order in which the allegation was received curing th ulendar year indicated.

1.5.1.1 A single allegation case file may include any number of concerns. Each specific concern shall be individually identified and tracked within the allegation case file utilizing documents prepared from the Allegation Management System (AMS). A single allegation case file shall be prepared for one alleger. If multiple allegers report an allegation as a group, consideration may be given to including all the allegers in one allegation case file to facilitate administrative control of the allegation.

l 1.5.1.2 Entries made in the AMS shall not contain personal, sensitive or privacy information related to the alleger, safeguards information, or information related to a civil or criminal wrongdoing case.

1.5.1.3 The following types of allegations received in the Region will not be entered into the AMS:

however, associated case files or records can be maintained as appropriate by EICS on an "as needed" basis:

Allegations related to 10 CFR 2.206 petitions; Allegations referred to the Department of Justice (D0J), state or local law i

enforcement agencies, and military agencies unless the referral is to the i

Regional Office Instruction 7

No. 1030. Revision 9 organization in the capacity of an NRC licensee; Allegations refer ~ red to the Office of the Inspector General (0IG): and Allegations referred to the Occupational

%fety and Health Administration (OSHA).

1.5.1.4 All Department of Labor (DOL) cases and Office of Investigations (01) cases opened in Region II will be assigned an allegation number and entered into the AMS for tracking purposes.

1.5.1.5 Hultiple allegations of em31oyee discrimination (as defined in the Energy leorganization Act) may be maintained under the same allegation number if the allegations are less than 90 days apart and they involve the same supervisor or manager or the alleger is claiming a continuing pattern of discrimination by management in general.

i However, for technical allegations, a new case file should be opened. This is to preclude revision of the " receipt date" of previously opened allegations in the AMS.

If an allegation has already been reviewed by an ARB, a new allegation number will be assigned to any subsequent allegations received from the same alleger. Allegations are required to be reviewed by an ARB within 30 days of receipt of the allegation.

If an alleger provides additional new concerns within 29 days of receipt of the original concerns they are to be included with the original concerns and reviewed by an ARB at the same time if possible.

l 1.5.2 The SAC will maintain a Region II allegation case file, retrievable by the allegation number, for each allegation received. The file will include all correspondence.

- memoranda to file, documentation of interviews, and summaries of telephone conversations, discussions, and meetings. The SAC-is responsible for maintaining a case chronology in the allegation case file which identifies all documents received and filed in the case file as well as all actions associated with the allegation case file.

i

Regional Office Instruction 8

No. 1030. Revision 9 1.5.3 The SAC will promptly provide each new allegation to the Division Director with aroject technical responsibility for the. subject matter of tie allegation. This will usually be in the form of an Allegation Report. The SAC will schedule the allegation for review at an ARB as soon as practical consistent with the urgency and safety significance of the allegation. The SE will arrange the discussion of allegations at the ARB by Facility and Division to more effectively enable the Region II technical staff to manage and schedule their presentation time for the ARB.

Allegations shall be reviewed by an ARB no later than 10 day.g after the allegation was received in Region II.

1.5.4 Allecation Review Board 1.5.4.1 The ARB will consist of the Division Director responsible for the area of concern (Chairman),

the Directors (or Deputy Directors) of other Region II divisions that may have follow up responsibilities associated with the allegation, the SAC, and an OI representative for matters of suspected wrongdoing. The Regional Counsel and oi.her staff members should participate, as apptopriate.

It is particularly im prepared for the ARB.portant that the staff be This will save time during the ARB and with any subsequent discussions and decisions regarding the allegation being reviewed. The Branch Chief should ensure that an a)propriate amount of time is available prior to tie ARB to review the allegation, formulate a proposed course of action for resolution, and determine the safety significance of the allegation if true. This

• front work" by the Branch Chief is critical to conducting an effective and productive ARB meeting.

1.5.4.2 The ARB will evaluate each concern contained within an allegation, determine the appropriate course of action required for resolution, and.

assign specific responsibility for the required resolution action. The following factors should be considered by the ARB in dispositioning an allegation:

9 1

Regional Office Instruction 9

No. 1030. Revision 9 l

Concerns requiring immediate regulatory I

action Feedback to the alleger Technical issues Wrongdoing concerns and recommended OI 3rioritization

)otential for chilling effects 1

Referrals to other entities Office of General Counsel positions Actions necessary to resolve and close the allegation Basis for another ARB 1.5.4.3 Allegations of wrongdoing including employee discrimination, will be reviewed by the ARB and processed in accordance with ROI 1004

" Notification to the Office of Investigations of Potential Wrongdoing."

1.5.4.4 The ARB should be reconvened if supplemental information is obtained which changes or affects the safety significance of the allegation. ' In addition, allegations that are open for more than six months should be reviewed by an ARB at four month intervals (except DOL and OI cases in which no outstanding technical issues remain open). These timeliness reviews may also be accomplished through regularly scheduled allegation timeliness meetings as directed by senior regional management.

1.5.4.5 The SAC is responsible for preparing the ARB minutes: however, the ARB Chairman, with the assistance of the SAC as required, is responsible for ensuring that the actions assigned and that the bases for those actions are complete, accurate and technically adequate.

The ARB Chairman is required to review and a) prove all AR3 minutes during the ARB. The ARB' Clairman should also ensure that ARB minutes prepared by the SAC at the ARB meeting are complete and include, as a minimum, the following information:

Allegation number and description Date of ARB and participants Affected licensee l

Safety significance and basis

Regional Office Instruction-10 No. 1030, Revision 9 j

1 Proposed action, identification of

. individual or group assigned resolution action, and schedule for completion of action l

Recommended priority level and basis of any 01 investigation Any generic im)11 cations possibly associated wit 1 the allegation 1.5,4.6 Minutes of ARB meetings will be maintained in the allegation case file for each individual Case.

1.5.5 The assigned technical staff member or group, as directed by the ARB or senior regional management, is responsible for initiating, developing, and implementing review activities pertinent to the resolution of the allegation..

Allegation Action Plan, should be used to document the resolution strategy for performing follow up on allegations.

A copy of the Allegation Action Plan will be forwarded to the SAC for inclusion in the allegation case file. This Action Plan is intended to be an administrative tool to assist in formulating review activities and resolution strategies for more complex allegations. Allegations-requiring only basic review activities for resolution may not benefit from completion of an Action Plan.

1.5.6.

Allegations determined to be of relatively high safety

, significance should be addressed immediately. Allegations having less safety significance should be addressed during the next regularly scheduled inspection of that area at the affected facility or within six months of receipt of the-allegation.

If the next scheduled inspection is such that it will not support closure of the allegation within six months, the inspection schedule should be changed to support closure of the allegation within the required six months.

1.5.7 Within 30 days of receipt of an allegation, the SAC shall notify the alleger in writing to acknowledge receipt of the allegation and to confirm the staff's understanding of the s)ecifics of the allegation. The letter (Enclosure 7) s1ould contain the following information:

NRC limitations related to the protection of an alleger's identity (see mandatory statement in Allegation Report):

Regional Office Instruction No. 1030. Revision 9 Advisement related to filing a written complaint of employee discrimination with DOL under Section 211 of the Energy Reorganization Act:

Discussion related to the potential for the allegation to be referred to other entities, to include the licensee, for resolution:

Initial feedback on NRC actions; and.

Method for contacting the SAC 1.5.8 For allegations involving employee discrimination as a result of identifying safety concerns, the alleger shall be specifically advised that if he or she is discriminated against by their employer for reporting nuclear safety concerns to their employer or to the NRC, they have 180 days from the date' of the alleged act of discrimination to file a written complaint with the DOL under the provisions of Section 211 of the Energy Reorganization Act. The alleger should be informed that the 00L. not the NRC, provides the

)rocess for obtaining a personal remedy and relief.

rurther, the alleger shal1~ also be informed that although the NRC may investigate the allegation prior to its 3

i resolution by D0L, the NRC may choose to wait for the results of the D0L investigation which will be monitored by the NRC.

In addition, the alleger is to be informed that if he/she files a written complaint of discrimination with D0L.

that they should provide a copy of that written complaint to the SAC.

1.5.8.1 Allegers making allegations of employee discrimination for which OI has not initiated an investigation should be recontacted by the SAC before the expiration of the 180 day tolling period to determine if the alleger has filed a complaint with D0L.

1.5.8.2.

When an allegation of em)loyee discrimination is initially received as a X)L complaint the SAC will review the complaint to determine if there are any safety concerns that need to be addressed. The ccmplaint will be entered into t

the AMS and will be presented at an ARB. The SAC will provide a copy of the written D0L complaint to 01. The SAC shall also contact the alleger to determine if the alleger has safety concerns that were not included in the written DOL complaint.

s Regional Office Instruction 12 No. 1030 Revision 9 1.5.8.3.

In addition to the AMS database. EICS maintains an approved System 6 database of D0L complaints by name of complainant for enforcement tracking purposes. No listing shall be maintained that correlates DOL complainants' names with allegation numbers.

1.5.9 If the NRC receives a credible report from an alleger expressing reasonable fears of retaliation for reporting safety concerns, and the alleger is willing to be identified to the licensee, the Regional Administrator may initiate actions to alert the licensee that the NRC has received such information. This process is addressed in the Enforcement Manual in Chapter 7.

1.5.10 For allegations requiring a lengthy resolution period, the responsible branch chief shall advise the alleger of the status of the allegation in writing every six months so that the alleger is aware of and understands that the staff is continuing to pursue the allegation. This periodic contact requirement includes allegations involving an open 01 investigation. 00L complaint, or pending enforcement action.

EICS maintains data relevant to issuance of letters to allegers and can arovide information as to any status letters that may >e due. This information is available on request from the SAC or the EICS Technical Assistant.

I9 Referral of Alleoations to Licensees 1.6.1 It is NRC policy to refer as many allegations as possible to the licensee for action and response unless any of the following conditions apply:

Information cannot be released in sufficient detail to the licensee without compromising the identity of the alleger or confidential source (unless the alleger has no objection to his/her name being released).

The licensee could comaromise an investigation or inspection because of (nowledge gained from the l

referral.

The allegation is made against the licensee's management or those parties who would normally receive and address the allegation.

O Regional Office Instruction 13 No. 1030. Revision 9 The basis of the allegation is information received from a Federal agency that does not approve of the information being released in a referral.

1.6.2 Except in cases where there is an immediate threat to the health and safety of the public (including licensee employees), allegations will not be discussed with the licensee until.cflet the ARB has reviewed and evaluated the f

l allegation and authorized the referral, 1.6.3 Any allegation not meeting the criteria specified in Section 1.6.1 above shall be evaluated by the ARB for referral to the licensee using the following guidance:

Could the release of information bring harm to the alleger or confidential source?

Has the alleger or confidential source voiced valid objections to the release of the allegation to the licensee?

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

Has the alleger or confidential source already taken this concern to the licensee with unsatisfactory-results? If the answer is "yes," the concern is within NRC's jurisdiction, and the alleger objects to the referral, the concern normally should not be referred to the licensee.

Are resources available within the region to resolve i

the allegation?

1.6.4 Before referring the allegation outside NRC, the alleger should be contacted and informed of the planned referral.

Ideally, this should be done when the initial information is l

received from the alleger. The alleger should be informed i

that the allegation could be referred outside the NRC for L

resolution including a referral to the licensee, The l

alleger should be asked if he/she has any objections to such a referral. This does not mean that the NRC re permission from the alleger to make a referral. quires If an objection is ex)ressed by the alleger, the basis for the objection will m fully developed and documented in the l

l

Regional Office Instruction.

14 No. 1030, Revision 9 l

Allegation Report. Subsequent notification regarding referral should be documented by letter (Enclosure 7), if possible, and should inform the alleger that the NRC will review and evaluate the licensee's resolution activities and response and that the alleger will be informed of the final disposition.

In addition, if an allegation referral includes a copy of documentation supplied by the alleger, written permission should be obtained from the alleger acknowledging that the material they provided will be provided to the licensee. A11egers should generally be given 14 days to respond and pose their objection to the referral.

If an objection to the referral is made by the alleger, a referral may still be made by the NRC with consideration of the factors described in Section 1.6.1 and 1.6.3 above.

1.6.5 Alleaation Referral letters 1.6.5.1 Official letters referring allegations to licensees for review and action will normally be signed by the responsible Division of Reactor Projects (DRP) or Division of Nuclear Material Safety (DNHS) Branch Chief. A higher level of signature authority such as the Division Director, or the Regional Administrator. may be appropriate if the allegation is of such importance to warrant using a high level signature to convey the significance of the issue to the licensee. The ARB Chairman is responsible for making this determination.

1.6.5.2 The Branch Chief having technical oversight of the issues in an allegation is responsible for the preparation of the allegation referral letters sent to licensees. Referral letters (Enclosure 7) should clearly inform the licensee of the concern without compromising the identity of the alleger, request an evaluation, and require a written. response.

1.6.5.3 Referral letters are to be coordinated with and concurred on by the Director, EICS, prior to issuance. This coordination and concurrence may be performed by the SAC if the Director, EICS, is not available. The SAC shall brief the l

01 rector, EICS. on any such concurrence.

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l Regional Office Instruction 15 No. 1030. Revision 9 1.6.5.4 The letter referring an allegation to a licensee does not ao in the Public Document Room. A copy of the licensee referral letter is filed in the allegation case file.

1.6.5.5 The licensee referral letter instructs the licensee to send their response to the Director.

EICS. They should not send a copy to the document control desk.

1.6.5.6 The cover letter and enclosures must be marked "Contains Information Not For Public 1

Disclosure."

1.6.5.7 A determination should be made by the ARB as to what would constitute a reasonable amount of time for the licensee to respond.

Consideration must include an estimation of the amount of work involved in responding to the referral and the nature of the referral. Referral letters should provide the licensee with the option to contact the Region should the length of time for the requested response create an unwarranted burden.

The authority to adjust the response time is to be coordinated with the appropriate ARB Chairman prior to approval by the Branch Chief. Any adjustment to the required response time shall be documented in a memorandum to the allegation case file.

1.6.6 NRC Indeoendent Verification The NRC should ensure that the licensee's response to a referred allegation is adequate. The overall scope and depth of independent verification by the NRC should be based on factors such as, but not limited to a licensee's prior performance related to resolution of referred allegations.

the degree of independence of the licensee's staff's evaluation safety significance of the matter, and level of licensee management mtentially involved in the matter. The following examples s1ould be used in determining the adequacy of a licensee's response:

j 1.6.6.1 Was the evaluation conducted by a licensee entity independent of the organization in which the alleged event took place?

r Regional Office Instruction 16 No. 1030 Revision 9 1.6.6.2 Was the licensee's evaluator com>etent in the specific functional area in whic1 the alleged event occurred?

1.6.6.3 Was the evaluation of adequate depth to l

establish the scope of the problem?

1.6.6.4 l

Was the scom of the evaluation sufficient to establish t1at the alleged event or problem was/was not a systematic defect?

l 1.6.6.5 If the allegation was substantiated, did the licensee's evaluation consider the root cause and generic implications of the allegation?

1.6.6.6 Were the licensee's corrective actions sufficient to prevent, alleviate, or correct the deficiency in both the short and long term?

As appropriate, the inspection staff should independently inspect and review selected elements of the concern to i

verify the. validity of the representations stated in the licensee's response. This evaluation may most appropriately be conducted by the Resident Inspector staff.

If the NRC is not satisfied with the licensee's disposition of the l

allegation, or if the response is deemed inadequate, the issue will remain open pending further NRC inspection activity. Any licensee response deemed to be inadequate shall be reviewed by the ARB and a decision made by the ARB as to what additional action is required. The licensee may also be requested to provide additional information to clarify their response. Such correspondence would originate at the Branch Chief level.

1.6.6.7 Following review of the licensee's res>onse, and if that response is found adequate wit 1 no further follow up action required, the Branch Chief will prepare a memorandum for the allegation case file that states that the response was reviewed and that it was found to be adequate.

1.7 Alleoation Referral to State and Fedaral Entities 1.7.1 Aareement States i

4 Regional Office Instruction 17

,No'. 1030, Revision 9-1.7.1.1-Allegations against an Agreement State licensee shall be forwarded to the Division of Nuclear Materials Safety (DNMS) for coordination and i

l referral to the appropriate State agency.

1.7.1.2 The Director, DNHS,'is responsible for ensuring a review and assessment of the adequacy of the State agency's resolution response to a referred allegation.

4 J

l 1.7.1.3 Referred allegations will be closed following i

receipt of acceptable documentation from the State and subsequent notification to the alleger.

1.7.1.4 The Director, DNMS, will forward allegations made against an Agreement State official to the Director, Office of State Programs, for disposition.

t i

1.7.1.5 Consistent with Section 1.6.4 above, the SAC will inform the alleger of the NRC's intent to refer the allegation to the appropriate State i

agency for resolution.

(

1.7.1.6 in cases where employee discrimination is alleged against an Agreement State licensee, the Director, DNHS, will refer the allegation to the i

Agreement State for follow up only if the alleaer aarees to be identified to the Aareement

5. tate. The Director, DNHS, will coordinate the proposed referral with the SAC, who will inform o

the alleger that the NRC does not have jurisdiction to investigate employee discrimination by an Agreement State licensee and unless they agree to be identified to the State, no investigation will occur. The SAC will also inform the alleger that it is not possible to investigate employee discrimination if the alleger does not agree to the release of their identity to the appropriate State agency.

If the alleger does not agree to the disclosure of their identity to the State, the allegation will not be forwarded to the State.

If the alleger does not agree to have their identity disclosed to the State, the SAC will inform the alleger

.that the concern will be considered closed because of the inability to pursue action in l

j

a a

Regional Office Instruction 18 No. 1030 Revision 9 complaints of discrimination without identifying the complainant.

1.7.1.7 If the' alleger agrees to be identified to the State, the SAC will close the allegation case file after appropriate referral to the State and the alleger is informed of the referral. The SAC will provide the alleger with the name, address and telephone number of a contact at the i

State agency responsible for resolution of the allegation. For those cases where the alleger i

does not want to be identified, the case will be kept open until the State provides an adequate response and that response is provided to the alleger.

1.7.2 Other Federal Entities 1.7.2.1 Allegations within the purview of OSHA are to be handled in accordance with Hanual Chapter 1007..

Interfacing Activities Between Regional Offices, NRC, and OSHA. The Director. DNMS, will l

coordinate with the Region II State Liaison Officer (SLO) regarding the referral and any required response. The ARB should consider referring occupational health and safety issues to the licensee.

1.7.2.2 The SAC will coordinate allegations where wrongdoing has been substantiated with the Director, OI Field Office, to determine the

'results of any referral made to D0J by 01. The fact that an allegation is being considered for referral to D0J will not be disclosed to a licensee, an alleger or the public without the concurrence of the Director, OI Field Office.

1.7.2.3 Allegations under the jurisdiction of other Federal or State government entities not addressed in this Instruction should be evaluated for referral to the NRC's point of-contact for that Federal or State government entity by the ARB. The Director, DNHS and SLO, as appropriate, will effect the referral after coon" nation with the Director, EICS.

1.7,R.4 If an allegation is referred to another Federal or State government entity for which the NRC has

I i

Regional Office Instruction 19 No. 1030. Revision 9 i

no regulatory oversight, that agency will not be requested to provide a response or the results of their review of the allegation. The SAC will coordinate with the Director, DNHS, to ensure that a letter is sent to the alleger advising i

the alleger of the referral, the agency to which i

the allegation was referred and a point of contact for the alleger within the referral agency.

}

1.7.2.5 Notification of Federal, State, and local law enforcement agencies, to include the type and amount of information provided to them, is the responsibility of the Director. OI Field Office,

{

when possible criminal activity or other nationally significant information is included in the allegation.

1.7.2.6 The Director, DNMS, will ensure that allegations against an Agreement State licensee that fall within the purview of other Federal agencies are referred to the appropriate agency and concurrently transmitted to the appropriate Agreement State.

1.7.2.7 Allegations involving suspected improper conduct by NRC employees will be forwarded to the Deputy Regional Administrator (DRA) for referral to the OIG in accordance with ROI 1801, " Handling of Allegations of Improper Actions by NRC Employees or Contractors." The SAC will 5 ovide all associated documents to the DRA

..,r retention.

.iubsequent contact with the alleger regarding the issue should be referred directly to the OlG.

1.7.2.8 The Director, DNMS, is responsible for ens Jring that the alleger is promptly notified when an allegation has been referred to another government agency and when the allegation is closed by the NRC.

1.7.2.9 The Director. DRS will ensure that the resolution of allegations involving offsite emergency preparedness issues for commercial nuclear power facilities is coordinated with the Emergency Preparedness and Radiation Protection Branch, Division of Reactor Program Management, 1

Regional Office Instruction 20 No. 1030. Revision 9' Office of Nuclear Reactor Regulation (PERB/ DRPH /NRR).

J 1.8 Allecation Resolution Documentation 1.8.1 Within 30 days of the completion of all actions required for i

the closure of an allegation, the Branch Chief responsible for resolution of the allegation will advise the alleger by letter (Enclosure 7) of the results of NRC follow up.

The Branch Chief will prepare the closure letter to the alleger incorporating the information contained from the staff memoradum along with a copy of the applicable inspection report. The Branch Chief will provide a copy of the closure letter to the SAC who will then close the allegation in the AMS.

If the allegation was referred to a licensee, pertinent portions of the licensee's response may be incorporated into the NRC's closecut letter. The closure letter will be signed by the Branch Chief and sent to the alleger via certified mail (return receipt requested).

1.8.2 Allegations will normally be resolved through the inspection process and documented in an inspection report. The inspection report should not identify that an inspection is based in whole or in part on an allegation.

In most cases, the inspection facts and findings can be fully documented without reference to the fact that an area was inspected because of an allegation.

In those rare instances where there is a need to refer to an allegation or the alleger in an inspection report, the concurrence of the Director. EICS, will be required prior to issuance of the inspection report.

1.8.3 When action on an allegation has been completed by the responsible Branch Chief, a copy of the pertinent inspection documentation and an Allegation Evaluation Report (AER),

shall be transmitted to the SAC along with a copy of the closure letter to the alleger. The AER should include a restatement of the allegation, a description of the evaluation wrformed, and the conclusions reached as a result of tie review (see Enclosure 7).

In cases where there is no inspection report that addresses the allegation, the inspection report cannot be provided due to safeguards-concerns, or the allegation evaluation and results are not presented in detail in the insmction report due to identity protection concerns, the AER s1ould.be expanded to comprehensively address the actions taken to resolve the allegation.

l i

l Regional Office Instruction 21 No. 1030. Revision 9 1.8.4 The basis for closing an allegation must be reviewed and concurred in by the responsible technical Branch Chief. The Branch Chief's concurrence may be documented in an E mail or a memo from the Branch Chief to the SAC providing the basis for closure, through concurrence in the closure letter, or, in those cases where the Branch Chief issues the closure letter, his or her signature. Such documentation should be -

included in the allegation case file.

j 1.8.5 If available, electronic versions of inspection reports and AERs should be provided to the SAC in addition to the normal i

l copy. This will facilitate updating the AMS.

1.8.6 Allegation resolution documentation is used to officially close an allegation case file and shall be included in the allegation case file: however, allegation case files will i

remain open pending resolution of D0L, 01 and related

)

enforcement actions.

1.8.7 Allegation documentation should be handled with extreme care to preserve the fundcnental principle of assuring the identity protection of individuals who bring safety concerns to the NRC. AERs that are prepared by the staff could contain information that may comaromise the identity of an alleger. Therefore, the staff s1all be sensitive to the l

requirement for proper controls and safeguards for such documents, to include personal computer disks, electronic mail and reproduction.

1.8.8 Proposed language for letters to allegers when OI returns a potential wrongdoing 1.ssue to the staff becasue of a lack of resources or low investigative priority, including employee discrimination. is included in Enclosure 7.

This language may be revised to fit the particular set of circumstances but should always include a statement that the particular i

circumstances were reviewed, that there are constraints on NRC investigatory resources, and that other cases of higher priority are being pursued.

1.9 Alleoation Corresoondence 1.9.1 All allegation corres>ondence that identifies an alleger must be protected in alue folders with an appropriate warning label.

1.9.2 Allegation case files that contain the identity of a confidential source are to be stored by EICS in a secure

v 1

~

Regional Office Instruction 22 No. 1030, Revision 9 filing cabinet drawer designated solely for files involving confidential sources and shall not be stored with allegation case files that do not involve a confidential source.

1.9.3 Allegation case files containing the identity of a

- confidential source must have a RED cover sheet attached to the outside of the case file that indicates the file contains the identity of a confidential source and provides handling instructions (Enclosure 8).

1.9.4 Correspondence containing the identity of a confidential source that is separated from the allegation case file must also have the cover sheet described in 1.9.3 above, attached.

1.9.5 Correspondence containing the identity of an alleger that is separated from the allegation case file must have a BLUE cover sheet that indicates the correspondence contains the identity of an alleger and provides handling instructions (Enclosure 8).

1.9.6 To help prevent the inadvertent release of correspondence to an alleger, acknowledgment, status, and closure letters shall have the allegation number clearly typed on the front page of the letter and on the upper right corner of each subsequent ) age. This action will reduce the possibility of a staff mem)er not recognizing that the letter concerns an allegation and may identify an alleger. Additionally, any letter from an alleger or confidential source shall be clearly stamped on each page, "This document identifies an alleger (or confidential source)" as appropriate.

1.9.7 All acknowledgment and closure letters to allegers are to be sent via U.S. Postal Service certified mail. The certified mail return receipt (green card) return address should be Post Office Box 845, Atlanta, Georgia 30301 as identified in the letters to allegers.

1.9.8 The " green card" should list the name and address for the alleger and it is important to list the allegation number so that the EICS staff can file the return receipt in the appropriate allegation case file when it is returned. The certified mail " receipt for certified mail" (white and green

-slip) that shows the certified mail number should not have the name and address of the alleger instead. place only the allegation number on the white and green slip.

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Regional Office Instruction 23 l

No. 1030. Revision 9 1.9.9 No copies or distribution of acknowledgement and closure letters to allegers are to be made except one copy to EICS for the allegation case file. The allegation case file is the official NRC record for the allegation. No copies are to be retained. The Branch Chief is permitted to retain a

" sanitized copy" of the correspondence that does not contain the identity of the alleger or any other information that could identify the alleger. All documentation retained is subject to potential release under a Freedom ofInformation Act (FOIA) request.

1.9.10 After the allegation correspondence is mailed, EICS is to be provided with a copy that includes the enclosures.

Provide the SAC an e mail version of the documents.

Do not retain any copies of e mail or other correspondence that identifies an alleger or confidential source.

1.10 Allecation Procram Audits 1.10.1 The SAC is responsible for maintaining the current status of allegations in the AMS by ensuring that all open allegations are reviewed and updated, as necessary, on a monthly basis.

In addition, within 30 days following case closure, the SAC shall perform an audit of the allegation case file and AMS to ensure completeness and accuracy of all material in the allegation case file.

1.10.2 The Region II Allegation Management Program is subject to periodic audits by.the Agency Allegation Advisor (AAA). The AAA audit review will include the handling, documenting, tracking, and resolution of allegations: a review of Region II procedures and instructions related to allegation management; allegation case file administrative maintenance:

ARB activities; related staff training: and, other items of interest at the discretion of the AAA.

1.11 Allecation Records 1.11.1 The SAC is responsible for maintaining allegation case files and related documentation. Allegation case files are generally restricted for access to the staff except on a "need to know" basis.

In addition, EICS shall maintain a document check out system to record individual access to l

allegation case files. Allegation case files may be signed I

out by Region II staff members for period not to exceed five l

days. The individual staff member is responsible for the l

O I

i I

.. Regional Office Instruction 24 No. 1030, Revision 9 security of the file. Allegation case files that contain the identification of a confidential source can only be checked out of EICS with the approval of the Director. EICS.

1.11.2 OI~ maintains its own records regarding criminal / civil investigations and OI confidential sources. Access to those files will be coordinated through the Director. 01 Field Office.

1.11.3 Closed allegation case files will be maintained in the Region for a period of three years, after. which they will be retired to the Federal Records Center for retention for an additional seven years. Allegation case files are scheduled for destruction after a period of retention of 10 years.

1.12 Trainino Staff members having responsibility for implementing this Instruction are to receive training in its requirements as directed by the Regional Administrator. The Director, EICS, is responsible for providing allegation training to the staff. Currently, the Regional Administrator has directed that mendatory training be conducted on an annual basis.

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I.

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's Regional Office Instruction No. 1030. Revision 9 PROTECTING IDENTITY 2.1 Backaround A fundamental premise supporting the NRC's information gathering process is a recognition of the need to protect the identity of individuals providing the information.

Inherent in the principle of identity protection is the belief that no one will refrain from reporting information if they have assurance that their identity will not be disclosed.

The responsibility to protect the identity of individuals providing information from retaliatory action by their employers and coworkers begins with the initial contact between the individual and NRC.

While Public Law 95 601 makes it unlawful for employers to take retaliatory actions against employees reporting information to the NRC and provides the means for the employees to obtain legal remedies, the legal process can be very lengthy: so much so, that employees could be reluctant to provide information for fear of being out of work for an extended period of time while going through the legal process.

2.2 Identity Protection If an individual is concerned about identity protection, the staff member involved should explain that the NRC protects the identity of l

individuals who their employer. provide information by not revealing their identity to l

However, individuals to whom the NRC has not granted confidentiality by written agreement should be informed of the following:

1.

In resolving technical issues, the NRC intends to take all i

ressonable efforts not to disclose the identity of an alleger outside the agency unless:

The alleger clearly indicated no objection to being a.

identified.

b.

Disclosure is necessary because of an overriding safety issue.

c.

Disclosure is necessary pursuant to an order of a court or NRC adjudicatory authority or to inform Congress or State or Federal agencies in furtherance of NRC respnsibilities under law or public trust.

d.

Disclosure is necessary in furtherance of 'a wrongdoing investigation (e.g., allegations involving record falsification, willful or deliberate violations, or other

Regional Office Instruction 2

No. 1030. Revision 9 deliberate conduct in violation of NRC regulatory requirements) including investigation of harassment and intimidation allegations, e.

The alleger has taken actions that are inconsistent with and override the purpose of protecting the alleger'.s identity.

This information is also included as part of the Allegation Report to facilitate providing all mandatory elements to the alleger.

2.

Under the Freedom of Information Act (FOIA), disclosure may be necessary: however, to the extent possible, information provided under the F0IA will, consistent with the FOIA, be purged of names and other potential identifying information.

3.

The NRC will normally disclose an alleger's identity during an NRC investigation if the alleger is the victim of discrimination.

The NRC does not provide physical protection to an individual who provides information to the NRC. This is a matter for local law enforcement officials and the alleger should be so advised.

Within Region II, the identity of any individual reporting allegations, expressing concerns, or registering complaints will be withheld from the staff except on a "need to-know" basis. Allegers' names shall not appear in any report (except as noted above regarding the preparation of

' Allegation Reports or related memorandum to be included in the allegation case file) or in any internal memorandum or other document placed in normal mail distribution, nor will it be divulged to any NRC employee or outside individual who has not clearly demonstrated a 'need-to know" relative to such information. This policy is intended to reinforce regional senior management's emphasis on the responsibilities associated with protecting the identity of individuals who provide information to NRC.

I I

Any breakdown in the system which results in the unauthorized disclosure of the identity of an alleger shall be immediately brought to the attention of the Director, EICS.

Under no circumstances will the identity of an alleger be made known to l

a licensee employee or otherwise disclosed other than for the reasons outlined above without the specific approval of the Regional i

Administrator.

In addition, reasonable efforts will be made to contact the alleger and explain the need for disclosure, with the exception of wrongdoing investigations, i

If the licensee correctly guesses the identity of the alleger, staff members will respond, if necessary under the circumstances, that the NRC

s l

Regional Office Instruction 3

No. 1030. Revision 9 position is to neither confirm nor deny the validity of such guesses and decline to discuss the matter further.

Any attempts by a licensee or any other unauthorized individual to learn the name of an alleger will be reported to the Director. EICS.

2.3 Confidentiality Confidentiality is the protection of data which could directly, indirectly or otherwise identify an alleger or other individual by name and/or the fact that a confidential source provided such information to the NRC.

The NRC only grants confidentiality in very special circumstances to acquire information related to activities within its jurisdiction. However, it is NRC )olicy not to divulge to others the identity of an individual who has >een granted confidentiality, either during or subsequent to an incuiry based on the information provided to NRC.

Within Region II. conficentiality is considered so important that a need to know rule will be vigorously implemented and followed by all

)

Region II personnel.

2.3.1 The Regional Administrator is the regional authority for granting confidentiality and this authority has been redelegated to designated Region II staff members. The current letter authorizing individual Region II staff members to grant confidentiality is on file in the Office of the Regional Administrator. This letter and its enclosure should be reviewed if additional information regarding confidentiality is required.

2.3.2 Region II staff members authorized to grant confidentiality must be thoroughly familiar with the NRC " Statement of Policy on Confidentiality." dated November 25, 1985, which is appended to the delegation letter discussed above. The Regional Administrator will be briefed as soon as possible l

befcre any grant of confidentiality is made to an alleger.

If the Regional Administrator is unavailable, the Deputy Regional Administrator will be briefed.

If it is not practicable to brief either the Regional or Deputy Regional Administrator, they should be briefed as soon as practicable following the grant of confidentiality.

2.3.3 Inspectors or other Region II staff members involved with an alleger who requests confidentiality should contact the SAC.

If the SAC is not available, contact.the Director. EICS, or a senior Region II staff member who has been authorized to grant confidentiality.

i i

'/

e Regional Office Instruction 4

No. 1030. Revision 9 2.3.4 Confidentiality is in force and effect when an alleger signs the confidentiality agreement and that agreement is signed by an authorized Region II representative.

2.3.5 In those cases where an alleger requests confidentiality during a telephone conversation or it is not possible to immediately sign a confidentiality aareement, a temporary oral grant of confidentiality may be given by an authorized Region II representative: however, the SAC should be immediately notified and arrangements made to mail the alleger a confidentiality agreement.

2.3.6 The alleger must be advised that they have two weeks from receipt of the confidentiality agreement to sign it and return it to the SAC.

If the agreement is not completed with this time frame, the Executive Director for Operations (E00) will determine if the temporary grant of-confidentiality should continue. A copy of the Confidentiality Agreement is provided in Enclosure 3.

One point regarding promises of confidentiality should be clearly understood by all Region II staff members and exol*ed to the individual providing information, if appropriate. A pledge of confidentiality shall not be made W may not be honored if previously granted) if the individual provides information indicating that he intends to or has personally committed, or participated in criminal acts which may include a deliberate (knowing and willful) violation of NRC requirements.

In cases such as this, the Regional Counsel should be contacted for advice and guidance. Caution should also be exercised in this particular area as there is the possibility the individual i

l could infer he was granted immunity.

2.3.7 Communications with confidential sources shald be handled with extreme care so as not to comprise the dentity of the confidential source. Use of government statio.ary, government return addresses, or government vehit'es should be avoided when dealing or meeting wita a confide tial source.

2.3.8 Revocation of confidentiality may only be implementeJ by the Commission or the EDO. However, confidentiality will only be revoked in extreme circumstances such as failt.e to sign an agreement or alleger actions inconsistent with the purpose of confidentiality.

e.

Regional-Office Instruction 5

No. 1030. Revision 9 l

2.3.9 The granting official may withdraw confidentiality following receipt of a written request from the alleger.

2.3.10 The SAC i responsible for maintaining records of the status of snA62itial sources and signed confidentiality agr w %.

2.4 Anonymous Allecers There are instances when an alleger will not provide his or her identity even after identity protection and confidentiality have been explained.

The following points.should be explained if an anonymous alleger will not reveal their identity:

The Region II staff member taking the call may not have the t

technical expertise to evaluate the information provided to

}

determine if it is sufficient to permit adequate follow up or if it is within the regulatory jurisdiction of the NRC: therefore. it may be necessary to contact the' alleger for additional information at a later date.

It is Region II policy to keep the alleger informed of the final resolution on an allegation within the jurisdiction of the NRC, In cases where an allegation is not within the regulatory jurisdiction of the NRC. it is Region II mlicy to notify the individual of the responsible agency to w1ich the matter has been referred.

After the above points have been explained to the alleger and the alleger persists in not revealing tneir identity.- document the allegation in as much detail as possible. Advise the individual to contact the SAC collect at (404) 562 4424 or 1800 577 8510 as soon as possible to provide any additional information that may be necessary for the appropriate resolution of this matter.

Once an alleger provides their identity or if the receiving NRC repreentative is aware of the alleger's identity, the alleger will be afforded identity protection, and can no longer be treated as anonymous, even if the alleger requests anonymity.

1 i

9 Regional Office Instruction..

No.:1030. Revision 9 CONFIDENTIALITY AGREEMENT LI'have information that I wish to provide in confidence to the U S.. Nuclear.

Regulatory Commission (NRC).

I request an express pledge of confidentiality

. as a condition for providing this information to the NRC.

It is my understanding that consistent with its legal obligations, the NRC, by agreeing to this confidentiality, will adhere-to the conditions stated herein.

During the course of an inquiry or investigation, the NRC will make its best effort to avoid actions that would ciearly be expected to result in disclosure of my identity.

My identity will be divulged outside the NRC only in the following narrow situations:

(1)' When disclosure is necessary because of an overriding safety issue and I agree to this disclosure. If I cannot be reached to obtain my approval.

or do.not agree to disclosure, the NRC staff will contact the Commission for resolution..

(2)

When a court orders-such disclosure.

(3)

When required.in NRC adjudicatory proceedings by order of the Commission itself.

(4)

In response to a written Congressional request. While such a request will be handled on a case by case basis, the request must be.in writing and the NRC will make its best efforts to limit the disclosure to the extent possible.

(5)

When requested by a Federal or State agency in furtherance of its statutory responsibilities and the agency agrees to abide by the terms of this confidentiality agreement, and I agree to the release.

If I do not agree to the. 91 ease, my identity may be provided to another agency only in an extraordinary case where the Commission itself finds that furtherance of the public interest requires such release.

t (6)

When the Office of Investigations (01) and the Department of Justice (DOJ) are pursuing an investigation or when OI is working with another law enforcement agency, my identity may be disclosed to 00J or the other law enforcement agency without my knowledge or consent.

My identity will be withheld from NRC staff, except on a need to know basis.

Consequently, I acknowledge that if I have further contacts with NRC personnel. I cannot expect that those people will be cognizant of this confidentiality agreement, and it will be my responsibility to bring that

2.

t Regional Office Instruction No. 1030. Revision 9 point to their attention if I desire similar treatment for the'information provided to them.

I also understand that the NRC will revoke my grant of confidentiality if I take, or have taken, any action so inconsistent with the grant of confidentiality that the. action overrides the purpose behind the confidentiality, such as (1) disclosing publicly information that reveals my status as a confidential source or (2) intentionally providing false information to the NRC. The NRC will attempt to notify me of its intent to revoke confidentiality and action should not be taken. provide me en opportunity to explain why this Other Conditions: (if any)

I have read and fully understand the contents of this agreement. I agree with its provisions.

Date Name Address Agreed to on behalf of the U.S. Nuclear Regulatory Commission.

1 Date Signature Name:

Title:

i Enclosura 3

~

Regional Office Instruction No. 1030. Revision 9 GUIDANCE FOR RECEIPT AND DOCUMENTATION OF ALLEGATIONS OBJECTIVE To gather sufficient information Wreby another party can verify the '

facts and circumstances without recourse to the originator.

ESTABLISH RAPPORT 1.

Introduce yourself, shake hands.

2.

Maintain professionalism at all times.

3.

Be a good listener and ask questions.

4.

Your primary purpose is to gather as much information as possible.

5.

Remember that you are someone's image of the NRC.

GENERAL INFORMATION 1.

Individual's namg, address. and phgag 2.

Individual's employer,.iob/ title 3.

Facility, (Unit I, II?)

4.

Date, time (beginning end) of interview

)gjAI IS THE CONCERN?

1.

Discuss one issue at a time.

-2.

Ask questions that lead back to the issue.

3.

Use a different interview form for each issue to ensure all aspects of each issue are recorded.

4.

Specificity is essential.

5.

General statements need specifics.

6.

Remember, if you can't define the problem, you can't solve the problem.

I iftiEE IS IT LOCATED?

1.

Building, elevation, room, etc.

(

Regional Office Instruction 2

No. 1030. Revision 9 2.

Record location as accarately as possible in order for someone else to be able to ',erify.

WHAT IS THE REQUIREMENT /V!vlATION?

1.

Doe: the individual know the requirement and what is being violated?

2.

Is the problem being described by the alleger actually a personal opinion related to the way things should be done?

WHEN DIO IT OCCUR?

1.

S3ecific dates and times determine the procedures in effect at tlat time.

l 2.

Specific time frames can provide support for the circumstances and facts surrounding the issue.

WHO IS INVOLVED / WITNESSED?

1.

Other individuals lend credibility to information and they should be fully identified.

t 2.

The involvement of others becomes a critical factor when dealing with confidentiality.

HOW/WHY DID IT OCCUR 7-l 1.

The development of information for this question involves the i

individual's interpret action of the events.

2.

This question can indicate wrongdoing, falsification, or possible harassment and intimidation.

3.

Develop the sequence of events / process.

4.

Often it's not what happened that is a problem but how it happened and how it was done that is the problem.

5.

What is the alleger's interpretation of the cause of the problem.

WHAT EVIDENCE CAN BE EXAMINE 0?

1.

This question should be viewed as if you had to follow up this matter.

d Regional: Office Instruction 3

No. 1030. Revision 9 2.

Most of the time the inspector receiving the information is not going to perform the follow up activity. ' Be sensitive to this fact while gathering the initial information.

3.

The more'information you gather the easier the follow up will be.

(i.e., drawings, procedures, codes FSAR, etc.)

4.

The need for objective evidence is critical to a successful resolution of the issue.

'DID THE INDIVIDUAL EXPRESS THE CONCERN TO THE LICENSEE?

1.

If no, why not?

2.

Is the licensee's policy to encourage employees to identify concerns? If so, was the individual aware of that policy.

WHAT IS THE STATUS OF THE LICENSEE'S ACTIONS?

1-Sometimes individuals just want you to know that they have filed a -

concern.

If the individual reported the concern to the licensee find out what the individual knows in relation to the licensee's resolution of the concerns.

2.

Advise the individual if he/she is not satisfied with the results of the licensee's action they can contact RII/ SAC.

WHAT IS THIS AN ISSUE OF7 In your own mind ' differentiate. types of issues during the conversation.

NOTE: if the individual claims employee discrimination as a result of

Iaising a safety concern, you must advise the individual of the 180 day reporting requirements for filing a complaint with D0L.

- RESPONSIBILITIES 1.

-You must speak with an individual who wants to express a concern.

2.

You must document the interview on an Allegation Report, and. include the name of the alleger, if known.

3.

You must make a determination as to whether the information represents an immediate threat to the health and safety of the public or a threat l-

~

to the safe operation of the facility.

4.

You must contact RII/ SAC and your supervisor.

l{

l l

L L

i

Regional Office Instruction 4

l No. 1030, Revision 9 5.

You must act in a professional manner.

6.

You must not compromise a potential 01 investigation.

Only pursue the technical issues.

If you suspect a potential 0I issue, contact your supervisor and RII/ SAC.

7.

You must not reveal the identity of an alleger.

8.

Do not agree to meet with an alleger off site. If such a request is made, call your supervisor and RII/ SAC for guidance.

9.

Except when an allegation is received during an on site inspection and refers to work in progress, you should contact your supervisor and the RII/ SAC and await ARB review prior to performing follow up actions.

10.

If an alleger requests confident 611ty, inform the alleger that the NRC does not reveal the identity of allegers to their employer. Generally, this statement will satisfy the alleger. However, if the alleger specifically requests confidentiality, inform the alleger that his/her confidentiality request will be reviewed by staff personnel authorized to grant confidentiality.

11.

Do not withhold or protect the identity of an alleger who requested to remain anonymous if you know the identity of the alleger.

12.

Advise allegers of the 180 day D0L reporting requirement for employee discrimination complaints.

13.

Inform allegers that there are limits to their identity and that they are not considered confidential sources.

You do not have to read allegers the limits, but tell allegers that there are limits on the NRC's ability to protect their identity and that we will also provide a written description of the protection measures NRC takes and the limits of that protection.

l I

.o Regional Office Instruction No. 1030 Revision 9 ALLEGATION" REPORT 4 1

CASE ND: RII-1997-A....

FACILITY:

CONCERN ND: (1)

DOCKET ND:

ALLl?{R:

EMPLOYER:

^

ADORESS:

TITLE:

HOE PHONE: (.

)

WORK PHONE: (-

)-

DATE RECEIVED:

M IS THE' ALLEGATION?

E IS TE REQUIREMENT / VIOLATION?

WHERE IS IT LOCATED?

WHQl DID IT OCCUR 7 MjQ IS INVOLVED / WITNESSED?

HOW/WHY DID IT OCCUR 7 WHAT EVIDENCE CAN BE EXAMINED?

DID THE INDIVIDUAL EXPRESS A CONCERN TO THE LICENSEE?

Mj8I IS THE STATUS OF INE LICENSEE'S ACTIONS?

Alleger informed of NRC identity protection policy?... Y N

Di d al l eger request confidenti al i ty 7.................. Y-N-Did the alleger object to a licensee / state referral?... Y N-Was the alleger informed of DOL reporting requirements? Y N_-

7voe of Reaulated Activity: (a)- Reactor b)

Vendor (c) Materials Ld)

Safeguards (e) other:

~

Ask all above questions, do not leave any blanks. Complete one sheet for each issue. Forward this form to:

RII/ SAC. P.O. BDX 845 Atlanta. GA 30301. Do not retain any file copies subsequent to receipt by SAC.

5AC phone numbers are (404) 562 4424 or 562 4426 PREPARED BY:

DATE PREPARED:

(

Regional Office Instruction 2

No. 1030. Revision 9 ALLEGATION REPORT CONTINUATION SHEET CASE FILE NO:

FACILITY:

SUMMARY

OF INFORMATION i

ACTION REQUIRED 1

PREPARED BY:

DATE PREPARED:

i 1

• O i

Regional Office Instruction No. 1030. Revision 9 ALLEGATION ACTION PLAN RII-1997-A-FACILITY:

DOCKET:

LICENSE:

INSPECTION REPORT NO.:

TYPE OF INSPECTION: Special/ Routine / Announced / Unannounced /Back Shift / Normal Shift ALLEGATION TO BE RESOLVED:

(

) Inspector is familiar with ROI 1030 Revision 9

[ ] Yes [ ] No

(

) Locations / specific sites to be visited:

(

) Time period to be covered:

~(

) Documents / activities to be reviewed:

(

) Persons to be contacted and/or interviewed:

(

) List of questions to be answered / approach to use:

(

) Limitations / areas to be avoided:

(

) Instructions by Branch Chief:

Submitted by:

Date:

Accomoanyina Personnel:

Approved by:

Date:

Branch Chief Distribution:

. EICS ALLEGATION CASE FILE Enclosure o

o s

Regional Office Instruction No. 1030. Revision 9 ACKNOWLEDGMENT LETTER Alleger's Name Address

SUBJECT:

ALLEGATION NO. Ril 1997 A 0000 Dear Hr./Mrs./Hs.

This letter refers to your (letter, phone conversation, meeting, interview, etc.) with on/ dated in which you ex)ressed concerns related to (name of facility).

You were concerned about ()rief general description such as security, maintenance, operator qualifications, etc.).

Enclosure I to this letter documents your concern (s) as we understand it/them.

We have initiated actions to examine the facts and circumstances of your concern (s).

If we have misunderstood or mischaracterized your concern (s) as described in the enclosure, please contact me so that we can assure that (it is/they are) adequately addressed prior to the completion of our review.

FOR REFERRALS TO LICENSEES:

In addition, per your conversation with (NRC employee's name), we understand that you do not object to having your concern (s) referred to the licensee.

)

Your concern (s) is/are being referred to the licensee, however your identity-and position are not being provided. We will review and evaluate the licensee's activities and response and inform you of the final disposition of this/these matters.

ALTERNATE LANGUAGE:

In addition, we intend to refer your concern (s) to the licensee with your identity and position withheld. We will review and evaluate the licensee's i

activities and res)onse, and inform you of the final disposition.

If you have any obiection to tlid aDDroach you must contact our office within 14 days uoon rpceiDt of this letter so that we can discuss this matter further.

@TRRALS TO AGREEMENT STATES:

Because the NRC does not have jurisdiction over the activity (ies) in the State of that are discussed in your concern (s), we are referring your concern (s) to the State of Because you have requested that your l

name and address not be provided to the state, we will request that the state l

respond to the NRC. Upon receipt of the state's response, we will mail you a copy.

CERTIFIED Mall NO. XXX XXX XXX RETURN RECEIPT RE0 VESTED (Note: Should be on bottom of first page only)

I 4

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i Regional Office Instruction 2

No. 1030. Revision 9 REFERRALS TO AGREEMENT STATES (Alternate Lanouaoe):

Because the NRC does not have jurisdiction over the activity (ies) in the State of that are discussed in your concern (s), we are referring your concern (s) to the State of Based on your willingness to contact the state directly, we will provide you with a name of a contact person for the State organization assigned your concern in a subsequent letter.

Please note that the state may not be able to protect your identity to the same extent the NRC can.

REFERRALS TO AGREEMENT STATES (Alternate Lanouaoe):

Because the NRC does not have jurisdiction over the activity (ies) in the State of that are discussed in your concern (s), we are referring your concern (s) to the State of We would also like to provide your name and address to the state so the state can contact you directly.

However, please note that the state may not be able to protect your identity to the same extent the NRC can.

If you have any ob.iection to us orovidina vour name and address to the state. You must contact our o*fice within 14 days uoon receiot of this letter so that we can discuss this matter further.

~

REFERRALS TO OTHER AGENCIES:_

We have determined that the matter of your concern does not fall under NRC jurisdiction. The agency with jurisdiction is and we have referred your concern to them. For any further information on this matter, you should contact that agency at (address).

(If appropriate - Once we complete our review, we will inform you of the results.)

FOR LETTERS WITH TECHNICAL CONCERNS WITHIN NRC JURISDICTION:

An evaluation of your technical concern (s) will normally be conducted within 6 months, although complex issues may take longer.

You will be informed of the results of our review.

In resolving your concern (s), the NRC intends to take all reasonable efforts not to disclose your identity (as discussed in the enclosed brochure.

- if appropriate)

FOR LETTERS INVOLVING DISCRIMINATION Because one of your concerns involves employment discrimination for raising safety concerns, an evaluation without identifying you would be extremely difficult. Therefore, you should be aware that in evaluating your claim of discrimination, your name will be disclosed. Furthermore, the NRC's evaluation of your claim of employment discrimination may take up to 18 months to complete.

l Enclosure,

Regional Office Instruction 3

No. 1030, Revision 9 FOR LETTERS TO ALLEGERS W/0 CONFIDEKTIALITY Finally. vou are not considered a confidential source unless an exolicit reauest of confidentiality has been formally cranted in writino.

USE THIS PARAGRAPH IN PLACE OF THE PREVIOUS UNDERLINED SENTENCE IF THE DOES HAVE A SIGNED CONFIDENTIALITY AGREEMEKT WIIH THE ALLEGER With respect to the Confidentiality Agreement you signed I assure you that we will honor the Agreement.

I would like to point out that licensees can and sometimes do surmise the identity of individuals who provide information to us because of the nature of the information or other factors beyond our control.

In such cases, our policy is to neither confirm nor deny the licensee's assumption.

FOR ALLEGATIONS REGARDING IMPROPER ACTIONS BY THE STAFF With res>ect to your concern (s) regarding alleged improper actions by the NRC staff, t1ese matters have been referred to the NRC Office of the Inspector General (0IG), and if you should have any questions or other comments on these matters, you should contact the OIG directly, toll free, at 1 800 233 3497.

USE IF A"0ITIONAL INFORMATION IS NEEDED FROM THE ALLEGER In reviewing your concern (s), we have determined that we need additional information from you before we can proceed with our inquiry into your (If accurate, use We have attempted to contact you by telephone concerns.

without success and) I would appreciate your calling me toll free at as soon as possible so that we can discuss this matter further.

USE IF ADDITIONAL INFORMATION WAS PROMISED BUT NOT RECEIVED:

Based on your telephone conversation with (NRC employee) on (date) it was understood that you would provide additional information.

I would appreciate your contacting me toll free at (ohone number) at your earliest convenience so that we may proceed with our inquiry into this matter.

If I am not available at the time of your call, please ask for (NRC employee) or leave a message so I can return your call.

FOR GENERIC CONCERNS:

The staff has determined that the concern (s) you raised may impact a number of facilities and is considered generic. Because the resolution of your concern (s) will require a review of multiple facilities and may require a review of or changes to NRC policy, the time necessary to resolve your concern (s) may be extended. However, please be assured that the NRC will take appropriate and necessary action to maintain public health and safety.

l e

j I

Regional Office Instruction

'4 l

No. 1030.. Revision 9

'ALL LB TERS TO FIRST TIME AliFGERS:

l to this letter is the NRC brochure, " Reporting Safety Concerns to the NRC".- The brochure contains information that you may find helpful in understanding our process for review of safety concerns.

. It includes an important discussion (on pages 5 7) of our identity protection procedures and limitations. Please read that section.

It also includes a discussion of the right of an individua' to fi' e a complaint with the U.S. Department of Labor l

(DOL) if the individual believes she or he has'been discriminated against.for l

raising safety concerns and the. individual desires a personal remedy.

l The NRC is~ responsible for enforcement actions against utilities, vendors, or L

individuals who discriminate against individuals who raise safety concerns.

l-DOL is responsible for providing personal remedies, such as reinstatement.

backpay, etc. 'The NRC cannot orovide you with personal remedies. This tv:e-of remedy can only come from DOL.

For DOL to accept a complaint, it must :e-L in writing and it must be submitted to DOL within 180 days of the discriminatory act.

(Please see pages 810 of the brochure.) The office for processing your DOL complaint, should you decide to file, is as follows:

OSHA address XXXXXXXXXXXX XXXXXXXXXXXX If you file a complaint with DOL please send a copy to us also.

ALTERNATE LANGUAGE FOR REPEAT AliFGERS:

.In my earlier letter to you dated

, pertaining to your-allegation (s) regarding (subject). I provided you an NRC brochure entitled,

" Reporting Safety Concerns to the NRC."

It includes information on the allegation process, identity protection, and the processing of claims for discrimination against workers, handled by the Department of Labor. Should you need another copy please contact me.

ALL LETTERS:

.Thank you for notifying us of your concern (s). We will advise you when we have completed our review of this matter. However, should you have any

. questions or comments, during the interim regarding this matter, please call me toll free at 1 800 577 8510.

Sincerely, Enclosure (s): As stated Enclosure i

f Regional Office Instruction 5

No. 1030. Revision 9 FORMAT FOR THE ATTACHMENT PAGE

' Concern 1.

l (Describe the alleger's concern.)

-Concern 2.

(Describe the alleger's concern.)

[

l Regional Office Instruction 6

l No. 1030. Revision 9 STATUS LETTER Alleger's Name-and Address

SUBJECT:

ALLEGATION NO. RII-1997 A-0000 Dear Mr./Mrs./Ms.

ALL LETTERS This letter is in regard to the concern (s) you brought to the NRC in your (letter, conversation with (NRC employee XXX), interview, meeting with the resident inspector, etc.) on (date), regarding (Use these sentences if the alleger has provided information in addition to that provided in the initial correspondence or contact.) In addition to the information you provided us on (1st date), you also wrote to us on (additional date(s)) and/or met with (name) on (date).

In this/these letters / conversations you provided additional information regarding

.)

USE 1F ALL CONCERNS ARE STILL OPEN Your concern (s) is/are being reviewed by the NRC, or has been ieferred to the licensee for follow up, etc. When we have completed our review of these issues, we will notify you of our findings, actions and the final resolution of your concern (s).

USE IF SOME CONCERNS CLOSED WHILE OmERS ARE STILL OPEN We have completed our review of XX number of your concerns as noted on the attached page(s).

(List on a separate attached page each concern and describe the resolution or action taken for every issue for which the NRC's efforts have been completed since the last correspondence with the alleger.)

Your other concern (s) is/are being reviewed by the NRC, or has been referred with your concurrence to the licensee for follow up, etc. When we have completed our review of these issuer, we will notify you of our findings, actions and the final resolution of your concern (s).

If I can be of further assistance.

Please call me toll free at the NRC Safety Hotline at 1 800 695 7403, or the (Regional / Office) toll free number 1 800 577 8510.

Sincerely.

Attachment:

As stated CERTIFIED MAIL NO. XXX XXX XXX l

RETURN RECEIPT RE0VESTfQ (Note: Use only on first page)

Enclosure i

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Regional Office Instruction 7

No. 1030. Revision 9 CLOSE0(K LETTER TO THE ALLEGER Alleger's Name and Address

SUBJECT:

ALLEGATION NO. RII 1997 A 0000 Dear Mr./Mrs./Ms.

GENERAL LETTER t

This is in reference to my (date), letter which indicated that we would initiate action to review your concerns related to completed its follow up in response to the concern (s(issue (s)). The NRC has

) you brought to our attention on The attachment to this letter lists your concern (s) and describes how the NRC re Wlved the concern (s) you raised.

l SUBSTITlfrE THE FOLLOWING PARAGRAPH IN CASES WHERE THE ALLEGER PROVIDE ADDITIONAL INFORMATION. AS NEEDED OR REQUESTED This refers to our letter to you dated _

, in which we requested that you contact us to provide additional information regarding your concern (s) related to at (site / facility).

contact was/were conducted, refer to them here.)(If additional phone or personal Since you have not contacted us to provide the additional information we requested, the NRC plans no further action regarding this matter. We have, however, alerted our inspectors to your general concerns so that they can pay particular attention to those areas during their routine inspections.

USE IF NRC ACTION IS COMPLETE AND INVOLVED 2.790 INFORMATION. IN WHOLE 1

PART AND INCLUDE ON ATTACHMENT PAGE l

(However.) your (other) concern (s) dealt with (physical security matters, proprietary information, personal privacy matters about another individual, medical records, etc.) and the details are exempt from disclosure to either you or the public, so we are unable to provide you with a copy of our report.

(Hake a statement as to whether or not the concern was substantiated, unsubstantiated, or partially substantiated, without providing specific details of the findings.)

l CERTIFIED HAIL NO. XXX XXX XXX l

RETURN RECEIPT RE0 VESTED (NOTE: This should only be on the of first page.)

i

Regional Office Instruction 8

No.~1030. Revision 9 USE IF VIOLATIONS WERE IDENTIFIED During the NRC'(Inspection / Investigation). violation (s) of NRC requirements

-(was/were) identified. The-(Licensee) is required to inform us of the corrective' action (s) they have taker. of plan to take.

(Provide inspection.

report, if appropriate.) ~ Our inspectors will continue to' monitor the licensee's activities to ensure proper resolution of this matter.

USE 201 ALL OI cat:S In' nMICH OI RETURNS A PITTENTIAL WR0m]IS LS9A TO 'HE STAF :

Ot lJCK OF MRcFR OR LOW PRIORITY ENCLUDING EM)LOYEE DLSCRIMIhA" ION Based upon a review of your concern (s) of (describe wrongdoing concern (s))

and other cases needing investigation by the NRC, the NRC will not be

. expending further investigatory efforts on the wrongdoing aspects of your-concern (s). This is not a finding that your wrongdoing concern (s) does/do not have merit, rather it.is a recognition that the NP.C must focus its limit'ed investigatory resources on cases of higher priority.- (Ex with the technical aspect of the wrongdoing concern, e.g. plain what was done "The staff reviewed the impact on safety of the falsified record and determined.... etc.)

(For discrimination cases only.) Accordingly, absent a finding of. discrimination by the DOL, or any additional substantial information and/or evidence from you that would support your discrimination concern (s) (T/t)he NRC staff plans no further follow up on the concerns you have provided to the NRC.

ENDING FOR ALL LETTERS

~

Thank you for informing us of your concerns. We feel that our actions in this matter have been responsive to those concerns. We take our safety res:ensibilities to the public very seriously and will continue to do so wit 11n the bounds of our lawful authority.

Use this sentence in cases where we have not supported the alleger's' concerns (.)Unless the NRC receives additional information that suggests that our conclusions should be altered.

we plan no further action on this matter. Should you have any additional questions, or if I can be of further assistance in this matter, please call me on the NRC Safety Hotline at 1-(800) 695 7403.

Sincerely.

Enclosure (s): As stated

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i Regional Office Instruction 9

No. 1030, Revision 9 l

FORMAT FOR THE ATTACHMEMT PAGE ALLEGATION EVALUATION REPORT ALLEGATION RII-1997-A-0000 ALLEGED FAILURE TO PERFORM RADIATION SURVEYS TURKEY POIKT NUCLEAR PLANT DOCKET NOS. 50-250 AND 50-251 ALLEGATION.

Make a statement of the allegation and the facility associated with the allegation. Example:

The alleger stated that he/she had a concern related to health physics i

practices at the Turkey Point Nuclear Plant. The alleger was concerned that surveys were not being performed by qualified health physics personnel due to the strike which caused the licensee to use maintenance personnel to perform health physics activities.

DISCUSSION:

What did you verify? Discussions, observations, review of records, etc.

Example:

Through discussions, observations and review of records, the inspector was able to verify that the licensee utilized maintenance personnel to perform some health physics activities.

Surysys were performed by maintenance personnel but they received training and were under the direct supervision of senior health physics perscanel.

CONCLUSION:

1.

Based on the information provided we were able to substantiate or unable to substantiate the allegation because-2.

There were or were no violations or deviations of regulatory requirements.

3.

Allegations can be substantiated and not be a violation of NRC require-ments.

4.

Do not discredit the alleger because an allegation was not substantiated.

1 S.

Remember, you are writing this enclosure to the alleger.

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Regional Office Instruction

' 10

.No. 1030. Revision 9.

Based on the information provided this allegation was substantiated: however.

there were no violations or deviations from regulatory requirements because the maintenance arsonnel that performed surveys received appropriate training and were under. tle direct supervision of senior health physics personnel. This allegation is considered closed.

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,s Regional Office Instruction 11 No. 1030 Revision 9 LICENSEE REFERRAL LETTER c

July 14,'1997 L

Florida Power and Light Company ATTN:.Mr. T. F. Plunkett President Nuclear Division P. O. Box 14000 Juno Beach, FL 33408 0420

SUBJECT:

ALLEGATION NOS. RII 1997 A 0120 AND RII 1997-A 0121

Dear Mr. Plunkett:

1 The Nuclear Regulatory Commission (NRC) recently received information o

concerning activities at 'your St. Lucie facility. A description of the concerns is enclosed.

We request that you conduct inspections and/or investigations as appropriate to prove or disprove the concerns and that you inform us within XX days of the date of this letter of the resolution of this matter and make the records of

.your completed action available for NRC inspection.

. NRC's evaluation of your response will include a determination that: 1) the individual conducting the investigation was independent of the organization affected by the concern, 2) the evaluator was competent in the specific functional area. 3) the evaluation was of sufficient depth and scope to substantively address the concern. 4). appropriate root causes and generic

' implications were considered if the concerns were substantiated, and 5) the corrective actions, if necessary, were comprehensive.

Please send your response to Hs. Anne T. Boland. Director. Enforcement and Investigations Coordination Staff. Region II. Please do not submit your response to the Document Control Desk.

If your response contains personal privacy, proprietary, or safeguards information, such information shall be contained in a separate attachment, appropriately marked, so that it will not be subject to public disclosure.

i The affidavit required by 10 CFR 2.790(b) must accompany your response if proprietary information is included.

I Should you be unable to complete your. review within the time requested due to other operational priorities. please contact me so we can discuss the matter and make other appropriate arrangements..

The enclosure to this letter must be controlled as sensitive information and distribution limited to personnel with a legitimate "need to know."

i i

t ENCLOSURE CONTAINS INFORMATION NOT FOR PUBLIC DISCLOSURE i

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Regional Office Instruction 12 No. 1030. Revision 9 Should you have any questions, or if I can be of any further assistance in this matter, please feel free to contact.me at (404) 562 XXXX.

Sincerely, Kerry D. Landis, Chief Reactor Projects Branch 3 Division of Reactor Projects

Enclosure:

As stated bec w/ encl:

Oscar DeMiranda RII 1997-A-0120, 0121 i'NCLOSURE CONTAINS INFORMAT10N NOT FOR PUBLIC DISCLOSURE

d 5

Regional Office Instruction 13 No. 1030. Revision 9 INFORMATION

SUMMARY

FLORIDA POWER AND LIGHT COMPANY l

ST.

LUCIE NUCLEAR PLANT RII 1997 A 0120 RII 1997 A 0121 i

Region II received information related to practices at the St.

Lucie Nuclear Plant. Allegedly, the Operations Su5ervisor required an Assistant Nuclear Plant Operator (ANPO) to assume t1e duties of the backup l

Fire Team ANP0 leader and did not meet the requirements to perform the duties of the Fire team Leader.

Allegedly, the Alternate Fire Team leader on had entered containment to >erform work and if a fire were to occur, responding to it properly would >e difficult because containment was difficult to get out of.

Allegedly, there once was a Night Order that stated that the Fire Team members could not enter the containment.

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NOT FOR PUBLIC DISCLOSURE

~...

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• * *USE RED PAPER * *

• WARNING CONFIDENTIAL ALLEGATION MATERIAL THE ENCLOSED DOCUMENT CONTAINS MATERIAL RELATED TO AN OFFICIAL NRC CONFIDENTIAL ALLEGATION AND IDENTIFIES A CONFIDENTIAL SOURCE WHICH MAY EXEMPT THIS DOCUMENT FROM PUBLIC DISCLOSURE PURSUANT TO ONE OR MORE PARTS OF TITLE 10, CODE OF FEDERAL REGULATIONS OFFICIAL USE ONLY SPECIAL HANDLING REQUIRED RETURN THIS DOCUMENT TO THE SENIOR ALLEGA TION COORDINA TOR WHEN NO LONGER NEEDED THIS DOCUMENT MUST BE SECURED WHEN NOT PERSONALLY ATTENDED. ACCESS TO INFORMATION CONTAINED HEREIN IS LIMITED TO REGION 11 STAFF AS REQUIRED FOR BRIEFING AND RESOLUTION ACTION. DISCLOSURE OF INFORMATION TO UNAUTHORIZED PERSONS IS PROHIBITED

January 14,1998 DNMS ALLEGATION TIMELINESS REPORT

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20,

i 18 16 j

14l J

12l

/

eperAV

>30

>60

>90

>120

>150

>180 j 5o.

Y

• * *USE BLUE PAPER * *

• WARNING SENSITIVE ALLEGATION MATERIAL THE ATTACHED DOCUMENT CONTAINS MATERIAL WHICH MAY RELATE TO AN OFFICIAL NRC INQUIRY OR INVESTIGATION WHICH MAY BE EXEMPT FROM PUBLIC DISCLOSURE PURSUANT TO ONE OR MORE PARTS OF TITLE 10, CODE OF FEDERAL REGULATIONS

-OFFICLAL USE ONLY SPECIAL HANDLING REQUIRED j

SHRED THIS DOCUMENT WHEN NO LONGER NEEDED PLEASE TAKE THE NECESSARY STEPS TO PRECLUDE UNAUTHORIZED ACCESS TO THIS DOCUMENT. ACCESS TO INFORMATION CONTAINED HEREIN IS LIMITED TO REGION 11 STAFF AS REQUIRED FOR BRIEFING AND RESOLUTION ACTION. DISCLOSURE OF INFORMATION TO UNAUTHORIZED PERSONS IS PROHIBITED i

1 Enclosure B

l PRINCIPLES OF PERFORMANCE-BASED INSPECTION

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\\

l Refinition j

l Performance-based inspection connotes a method of comparing an activity, process, or event with a defined set of performance criteria to determine acceptable safety performance /results.

Process a.

Planning Phase

-Select safety and reliability measures (indicators) important to performance of a particular activity that is going to be evaluated.

-Identify acceptance criteria for these measures.

b.

Inspection and Report Phase Compare licensee's performance on these measures with acceptance criteria and assess whether there is reasonable assurance that safety performance is acceptable.

Exoectations durino insoections of Each Phase a.

During Planning Phase

-Select for inspection, a sample of activities most important to performance and review in order of importance.

-Balance inspection sample to include majority of key activities which will accurately reflect licensee performance.

-Develop an inspection plan as a " road map" to keep the mission in focus. Plan must list the indicators to be used to judge performance and criteria to be used to review against.

b.

During the Inspection Phase

-Focus on measures to determine whether performance is acceptable.

-Keep mission in mind (Mission: assure safe and reliable operation). 5 m

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2

-Determine root causes for performance deficiencies (i.e. examine ko see that address underlying conditions in addition to acute conditions).

L

-Follow-up on unsafe work practices until it is determined that the L

licensee has the issue under control.

-Independently verify licensee staternents.

-Make direct observation of work in progress as a preferred method of inspecting.

-Communicate findings in terms of impact on safety performance.

-Highlight importance of findings reflecting poor safety performance to licensee and NRC management.

-Support conclusions with findings related to licensee performance,

- not opinions.

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