ML20247N288

Final Rept on Integrated Matls Performance Evaluation Program Review of Region II

ML20247N288
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Issue date:	04/30/1998
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INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM

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REVIEW OF REGION 11 April 1998 FINAL REPORT l U.S. Nuclear Regulatory Commission f

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l 9805270102 980507 [

PDR- ORG lE ED g PDR g Attachment

Region il Final Report Page 1

1.0 INTRODUCTION

This report presents the results of the review of the Region ll (Ril) 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 Management Review Board (MRB) meeting, held on April 23,1998, discussed the proposed final version of this report, dated April 2,1998. It led to the following changes:

o The MRB instructed the team to consider Recommendation 5 from the 1996 IMPEP review to be closed, based on the scheduled issuance of the irradiator inspection procedure (Sections 2 and 5).  ;

i o The MRB instructed the team to add a suggestion for Ril to clarify which tie-down l conditions were to be included or excluded, in order to eliminate potential confusion for licensees (as discussed in more detail in Section 3.4, with modification to this report made in Section 5).

l o The MRB suggested an editorial change in Section 4.2.3, paragraph 3. l 1

The Rll 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 Ril's response to the questionnaire; (2) analysis of quantitative information from the NRC 1 License Tracking System (LTS), and Nuclear Materials Events Database (NMED); (3) technical review of selected licensing and inspection actions; (4) field accompaniments 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. Cection 4 discusses results of the applicable non-common indicators, and Section 5 summarizes the review team's findings and recommendations.

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' Rt.eion 11 Final Report _

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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.

Normally, a response is requested to all recommendations in the final report. In this case, Rll's response, dated March 16,1998, is sufficient. No additional response is required.

. 2.0 STATUS OF ITEMS ID8NTIFIED IN PREVIOUS REVIEWS '

- During the previous routine review, which concluded in April 1996,11 new recommendations . i were made (some directed to RIl; others to NRC Headquarters offices), with one I recommendation carried over from the 1994 IMPEP review. The results were transmitted to Stewart D. Ebneter, the Regional Administrator at that time, on August 26,1996. The follow-up review, and ensuing MRB meeting, resulted in the closure of all of these recommendations.

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

-(1) Recommendation 8, from 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 Safeguards (NMSS) sent a memorandum to Ril dated May 9,1996, describing efforts to revise inspection field notes _in inspection Procedure 87100. Ril - 1 responded with a memorandum dated June 3,1996, with an attached Regional Office Instruction (ROI) 720, Materials Event Log. Since that time, the NMED .i

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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 discussed in Section 3.5 and a related new recommendation.

(2) Recommendatiori 1, from 1996: "The review team recommends that Ril license 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'n is closed. The review team determined I I

that Ril license reviewers added written, explanatory comments for every document dated after 1996 in the tie-down condition. These comments list the s l

. applicable items in each document, and/or summarize the contents of the  !

l 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. i I

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. Region ll Final Report Page 3 (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 that in every license file reviewed, including complex and/or unusual licensing cases, the file contained appropriate documentation, including deficiency letters and respcnses, 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 intemally evaluate progress on this issue in about a year."

Current Status: This recommendation is closed. Attachment 25 to the regional response to the IMPEP questionnaire, " Principles of Performance-Based Inspection" and 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 t

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 that considerable performance-based inspections were being done, but that the documentation did not reflect this well. Ril 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 Temporarv 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."

Current Status: This recommendation is closed. NMSS issued a memorandum dated August 28,1996, extending Tl 2800/24. It is now working to incorporate this guidance in its upcoming revision of In'spection Procedure 87100.

(6) - Recommer dation 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: The MRB indicated that this recommendation is closed. 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. 1 i

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Region 11 Final Report Page 4 (8) Recommendation 7, from 1996: "The review team recommends that allegations  ;

received by the Region which are outside of NRC jurisdiction be referred I expeditiously to the appropriate regulatory authority, and that the Region follow

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MD 8.8 and guidance developed by the Office of State Programs which I specifically addresses referrals to Agreement States (Office of State Programs Internal Procedures for Management of Allegations).

Current Status: This recommendation is closed. Review of allegation f'les 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 I extended time periods to resolve."

Current Status: This recommendation is closed. ROI 1030, Revision 9, was i 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 Allegation Coordinator, in preparation for the IMPEP review, to discuss the results of the Agency Allegation Coordinator's last regional audit."

Current Status: This recommendation is closed. One of the IMPEP team i members made this contact before the review, and received a copy of the most recent Ril audit.

(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:

l o The appropriate level of documentation needed to support the staff's J decisions during license termination.

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 NMSS and i

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Region 11 Final Report Page 5 AEOD continue to investigate and consider altematives to the in-house classroom training courses currently required to qualify fuel facility inspectors (for example, attematives such as commercially-available training, video tapes from previous courses, or computer-based individually-paced training)."

Current Status: This recommendation is closed. The Office for Analysis and 3

Evaluation of Operational Data's (AEOD's) Technical Training Division, is 1 implementing new self-study programs to replace the required fuel cycle courses formerly presented in a classroom format. Two courses already have been l submitted to NMSS for final approval; and three others have been combined into another self-study course expected to become available in April 1998. Another

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is expected to be available in September 1998. The self-study courses are now l

being provided in the form of hardcopy course manuals combined with any associated audio-visual aids (if applic9ble). This format is considered the most cost-effective fonnd at the present time. As technology advances, and relative costs of this and other possible formats may change, other more technology-rich formats, such as computer-based training, may be considered.

) i 3.0 COMMON PERFORMANCE INDICATORS  !

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

3.1 Status of Materials Insoection Proaram The team focused on several factors in reviewing this indicator: (1) overdue inspections, (2) inspection frequency: (3) timely dispatch of inspection findings to licensees: (4) completion ,

of initial inspections for new licensees: (5) the decision process and implementation of regional I 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 listing 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 at 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 i are based on LTS data, tabulated in accordance with inspection Manual Chapter (IMC) 2800 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 assessment.

In response to the IMPEP questionnaire, Ril indicated that the only type of licensee it inspected I

Region ll Final Report Page 6 more frequently than what was prescribed in IMC 2800, was the Strontium-90 eye applicators.

Rll accelerated the inspection frequency for these licensees to assure proper calculation of doses by this group oflicensees.

. 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 compitted. 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 be issued no later than 30 calendar days after inspection completion (45 days for integrated reports and team inspections)." Ril reported that 7 ofits 63 inspections completed in FY 98 exceeded the 21-day goal, but only 3 of these 7 extended beyond 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 i of acceptability for IMPEP criteria, Ril identified this as a focus area for the next quarter I of FY 98.

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. The team reviewed all 21 new licenses issued by Ril in the period from January to June 1997, to determine whether the region was conducting 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 matenal or had not begun operations. Notations of these telephone contacts were found in the regional files. All three are now scheduled to be completed in the next few months.

The team reviewed an LTS printout comparing the number of licensees in each State with the number ofinspections conducted by Ril 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 inspections. % Number of Licenses. %

Alabama 2 2

, Florida 3 3 Georgia 2 2 Kentucky 2 2 Mississippi <1 1 North Carolina 2 2 L ,

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 Ril memorandum dated August 15,1995, that showed that Rll had begun

Region ll Final Report Page 7 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 extended, 32 were reduced, and 248 were left unchanged in the period since the last IMPEP review. These decisions were based on discussions of inspection 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 tecm reviewed two inspection reports of licensees who had their inspection intervals extended, Md found that the Region did follow the guidance properly in reaching its decision.

The team also reviewed the region's questionnaire response and determined that the region had completed 29 reciprocity inspections over the IMPEP review period. This matches the 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. Rll expressed difficulty in c6nducting field inspections of some of the licensees working under reciprocity, because of the last-minute nature of many of tho filings. In its questionnaire response, Ril indicated it intends to conduct some office inspections for those licensees located in Rll 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 Ril's performance with respect to the indicator, Status of the Materials inspection Program, be found satisfactory.

3.2 Technical Quality of Inspections 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 oflicensees that are inspected by the region. Categories oflicenses selected were: (1) five hospitals with nuclear medicine and brachytherapy; (2) three radiographer licenses (two operating under reciprocity): (3) two pool irradiators (one under construction, 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 a week before the IMPEP review, and others were conducted after the review, none of these inspections reports 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 accompaniment conducted.

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Region 11 Final Report Page 8 Allinspection reports reviewed by the team indicated that they were unannounced. During interviews with the four inspectors available for questioning, the team confirmed that they were unannounced inspections. Severalinspectors commented that they might phone licensees to 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 quality. 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 reporte did not include the correct check list (i.e., high-dose-rate after-loader 2800/24) but all had the appropriate quality management rula 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 uncovered a large number of misadministration 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.

This inspector is to be commended for his keen observation because the Sr-90 eye applicator 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 reviewea 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 of significant license activities.

Almost allinspection 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

Region l' Final Report Page 9 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 should have been calibrated within 3 months of the inspection, or no earlier than September 1996. . in the other instance, the inspector indicated that the meter she used to make independent measurements during a radiography field site inspection was last calibrated in February 1996, although the inspection date was April 1997, or 14 months later.

The inspector was not available to interview about the above instance, but her 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 dKi not indicate on the report; however, the content of the report is presumed to be correct, and it.had been reviewed by the supervisor. The review team recommends that Ril inspectors adhere to the guidance issued in NMSS' September 27,1996, memorandum, regarding the frequency of inspectbrs' survey _

meter calibrations.

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 tumaround time for meters dropped off for calibration. Each meter has a calibration sticker placed on it with the date and meter serial number. There is also a calibration certificate maintained in the file.

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

- 3.3 Technical Staffino and Trainina i

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 Ril'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 Ril'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 j has beer filled by a former Ril employee with extensive experience, who retums after taking a i

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 position during the IMPEP review week, but no reporting date was announced at the time of the IMPEP

~ team's exit.

Region ll Final Report Page 10

.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 for its license reviewers, its specialist inspectors, its master materials license project manager, and its project managers for terminated / contaminated sites. Copies of two Skills Lists (one for materials, and one for fuel cycle) are provided as Appendix E. These lists allow the region to identify important attributes for recruitment and can help provide backups to assure complete program coverage. Although this is desirable for most programs, this is especially important in .

a smaller program such as Rll's. For this reason, the team considers this to be a

" Good Practice."

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 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 recommendations 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 Technical 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 intentiewed, when possible, when needed to supply additional information l regarding licensing decisions 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 .

i 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 i certifications or other supporting documents; (6) peer or supentisory review, as indicated; and l (7) proper signature authorities. The files were checked for retention of necessary documents l' 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 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 l

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

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Region ll Final Report Page 11 The review team found that the licensing actions were generally thorough, complete, consistent, and of acceptable quality, with health and safety issues properly addressed. Tie-down 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 written, explanatory comments 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 excluded from the referenced document, or if the items 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:

A. Letter dated June 1,1997 (including Section 1, Personnel Dosimetry)

B. Letter dated June 2,1997 (excluding 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 deficiencies, 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.

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 Rll licenses.

The review team determined, through interviews and record reviews, that, in many instances, an incorrect date for " Milestone 22" (licensing action completion date) was entered into the LTS.

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Region 11 Final Report Page 12 This appears to be caused by a misunderstanding 'about the difference between the date a li::ense is signed and the date the action is mailed to the licensee. Therefore, the review team 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 included 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 vdth respect to the indicator, Technical Quality of Licensing Actions, be found satisfactory.

3.5 Resoonse to incidents and Allegations lha 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 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 overexposure; (2) two misadministration; (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.

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 inspections resuiting from events were well-documented, and Ril took enforcement action when appropriate. In cases with potential high safety significance, inspection reports or information provided by interview indict,ted that an onsite inspector or team thoroughly evaluated circumstances surrounding events. Less significant events were followed up during the next scheduled inspection.

The " materials event log" kept by Rll 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 Ril license events.

The review team noted no NMED reporting problems involving even% 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 l knew the system well, while others were completely unfamiliar with NMED. The review team

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noted that Rll 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 proWde supplementary training to NMSS, the Office of State Programs (OSP), the Regions, and Agreement States, in order to make the NMED system more accessible and usaole for NRC and Agreement State staff.

Region 11 Final Report Page 13 The review team made performance evaluations of allegation files in the areas of investigation procedures, implementation of these procedures, intemal and extemal coordination, and l 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, 1 . and assignment.

The review team did note one concem in a file regarding staff use of ROI No.1030, " Processing Allegations, Complaints, and Concems." 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 heve been l 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 i .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 Ril 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 performance with respect to the common performance indicator, " Response to incidents and

' Allegations," be found satisfactory.

4.0 NON-COMMON PERFORMANCE INDICATORS 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 Decommissioning Management Plan sites are found in Ril, and other NMSS program areas include only a modest level of activity in this region.

4.1 Ooeratina Plan Performance / Resource Utilintion 4.1.1 Operatina Plan Nformance This IMPEP review in' cluded a period from April 1996 through January 1998- a timeframe spanning parts of 3 FYs.- In this period, the FY 96 and FY 97 Operating Plans were structured along traditional lines, with their contents coordinated with the Offices of Nuclear Reactor Regulation (NRR) and NMSS. This section of the report discusses regional performance only

- for those areas not discussed elsewhere in this report.

With respect to materials licensing timeliness, the Region reduced the number of older cases

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Region 11 Final Report Page 14 L significantly over the review period. As of September 30,1996, the region had 17 new l 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 l- 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.

o Participation on several guidance consolidation teams, including: (1) portable gauges, (2) radiography; (3) self-shielded irradiators; (4) medical use licenses; (5) academic,- .

research and developrnent, and laboratory-use licenses of limited scope; (6) the Veterans' Administration master license 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 encillary 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 format, 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.

- 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

I Region 11 Final Report Page 15 output measures developed by the Region, NMSS has placed a higher emphasis on regional / Headquarters communication in this FY. The Region's performance was strong in this

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

4.1.2 Resource Utilization l 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.

I FY 96 FY 97 FY 97 FY 98 FY 99 Proaram Area Budget Budget Expend. Ih!dggi Budget Materials 13.7 13.0 11.8 13.1 11.8 Fuel Cycle 8.2 9.2 8.1 9.5 9.5 Waste Activities 2.0 1.0 0.9 0.8 0.3 Soent Fuel __QD E E _DA DA 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 Headquar1ers 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 Cvele 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 leamed 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 l Headquarters, there is an increased need for Headquarters and 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 seports for Headquarters inspections. NOTECHIS, the

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. Region 11 Final Report Page 16 existing. ins't itutional means for providing such access, is not satisfactory, since it involves 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 uys 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 suggestions 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 intranet. 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 carrently 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 supporting IFS.

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

Rll'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 g8 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 tirr:eliness. The Report identifies the timeliness of inspections as a focus area where Region 11 would like to improve.

Region 11 Final Report Page 17 4.2.2 Technical Staffino and Trainino 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 l operations review, based upon skill profiles similar to those used for hiring materials inspectors and licensing personnel (which already has been r,ecognized 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 facilities. When hired, it was recognized that they both needed to improve their capabilities in 4 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 l examination after viewing tapes from a previous presentation of that course. It was observed that both could benefit from additional supplemental training in nuclear criticalit/, which previous

occupants of their positions customarily have taken. For example, one such known training l experience has been considered especially valuable, because it permits personal contact with numerous expert 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 11 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 j

- these vacancies.

4.2.3. Technical Quality of Fuel Cvele Insnadians '

The reviewer observed that Ril's inspection findings were well-founded and well-documented throughout the assessment period. A cross-section of reports was eva'uated 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 managemer:t review. .

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

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 emphasize the need for licensee responses to NOVs and events to identify the root causes and document that corrective actions specifically address these root 9

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l Region il Final Report Page 18 causes and not the symptoms. I 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. Resoonse to Fuel Cvele incidents and Allegations During the review period, eight allegations were received regarding activities at fuel cycle facilities. As of January 2,1318, 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.

I 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. .Rll has a program in place to ensure full staffing of the IRC, when needed. it tracks and provides training for critical 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 Ril's performance with respect to each of the performance indicators to be satisfactory. Accordingly, the team recommends the Management Review Board find the Ril program to be adequate to protect public health and and safety.

. 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 calibrated at proper frequencies (Section 3.2).

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

Region ll Final Report Page 19

. RECOMMENDATIONS FOR OTHERS:

- 1. 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).

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 greater description of licensee operations, (Section 3.2).

2. The review team suggests that NMSS develop guidance for inspections of Sr-g0 eye applicators for distribution to the Regions and Agreement States (Section 3.2).

3. The MRB suggests that Rll provide clearer explanations in its licensing tie-down conditions for licensees. These conditions should clearly indicate which sections of referenced documents are to be included or excluded (Section 3.4),

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

5.- The review team suggests that NMSS clarify the

• Milestone 22" issue by memorandum to the Regions (Section 3.4).

, 6. 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).

. 7. 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. The review team identified the Ril 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 l.- (Sections 3.3 and 4.2).

l- 2. -The team identified the Ril detailed, written guidance targeting specKic fuel cycle plant L

operations and functional areas for emphasis during inspections as a good practice (Section 4.2).

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1 LIST OF APPENDICES AND ATTACHMENTS Appendix A iMPEP Review Team Members Appendix B Region ll Division of Nuclear Materials Safety Organization Chart Appendix C IMPEP Questionnaire Response 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 Appendix G Incident File Reviews Attachment 1 Ril's Response to Review Findings l

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APPENDIX A IMPEP REVIEW TEAM MEMBERS -

Name Area of Responsibility George Deegan, NMSS/IMNS On-Site Team Leader Status of Inspections Technical Staffing and Training Operating Plan / Resource Utilization Donald Bunn, California __ Technical Quality of Inspections Michael Weber, Rlli Technical Quality of Licensing Lance Rakovan, OSP Resporise 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 Fuel Cycle- Response to incidents and Allegations

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APPENDIX B REGION 11 DMSION OF NUCLEAR MATERIALS SAFETY ORGANIZATION CHART l

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.e APPENDIX C' INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM ,

(IMPEP) QUESTIONNAIRE RESPONSE 9

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UNITED STATES

_ ,+*p3 te49'o,, NUCLEAR REGULATORY COMMISSION

+- n REGION 11 y y ATLANTA FEDERAL CENTER e 2 61 FORSYTH STREET. SW. SUITE 23T85

$< 8 ATLANTA, GEORGIA 30303 3415 p/lp/h 3 , f.? nt &

January 16. 1998 MEMORANDUM T0: Carl J. Paperiello, Director Office of Nuclear Material Safety and Safeguards FROM: Luis A. Reyes, Regional Administrate

SUBJECT:

INTEGRATED MATERIALS PERFORMANCE EVALUATION (IMPEP)

OVESTIONNAIRE 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 note 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, Attachment- IMPEP Questionnaire cc w/att:

G. Deegan, NMSS I

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

1. Status of Materials Inspection 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 we're overdue:

Insp. Frequency Licensee Name (Years) Due Date Months-0/D 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 inspecting region since all work was done in the Virgin Islands.

With 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 t' 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 com)leted. If an inspection is not completed, the Branch Chief scledules the inspection for a subsequent trip.

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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 change.

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 Jart of the process for review of inspection 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 made errors in l determining output (rads /second) either because of improper calibration or decay of the sources. In January 1998. Region II l began special inspections of these licensees With a goal to complete them by March 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 reporting 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.

i 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 l'

have filed for reciprocity in 1998 starting in September of 1998 I if we have been una)le to ins)ect the licensee in the field. This action has been added to the )NMS tracking system.

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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 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 1997.20- 1997-7 1998-5 1998-0

5. Other than reciprocity licensees. how many field inspections of radiographer were performed?

RESPONSE

Region II 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 determinations by review of licensees records during inspections at their facility, by interaction with State representatives, and by interactions with facilities that routinely contract for radiography services (power authorities, refineries, etc.) In some cases. we have made multiple attempts (in one case four attempts) to conduct field inspections. If we are unable to observe field operations, the inspections have been closed based 3

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I on an inspection conducted at the office facilities. Listed below is the information on field inspections for the current and two previous fiscal ye6rs.

FY 96 - 6 (28 percent of radiography licensees)

FY 97 - 8 (30 percent)

FY 98 - 1 (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.

l RESPONSE:

In past fiscal years (FY) the Region II Operating Plan established two goals for inspections:

and no overdue inspections., Ournumber of. inspections performance to be completed in meeting these l

goals has been monitored during t1e quarterly self-assessments.

In addition we tracked completion of inspections throughout the I 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 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 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 inspections. The number of inspection due and actual completions for the IMPEP period are: J M ACTUAL COMPLETIONS FY 96 260 323 FY 97 250 322 FY 98 based on due list 63(thru 12/31/97) ncne overdue II. Technical Ouality of Inspections

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

RESPONSE

The main changes in Region II-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 II formalized our previous processes for 4

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l l selecting areas and ap3 roaches to inspection of fuel facilities I (see Attachment 7. Risc Informed. Performance-based Ins and Attachment 7a. Targeting Information. for details).pections, In the materials area. we began conducting inspections of Type A broad licensees with two or more inspectors based on written inspection plans and writing narrative reports for such inspections.

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

Insoector Suoervisor License Cat. Date i

RESPONSE

Attachments 8. 8a. and 8b show DNMS management site visits for 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 s0pervisory accompaniments of inspectors in the field. If supervisory accompaniments were documented, please provide copies of the documentation for each accompaniment.

RESPONSE

The Region II Operating Plan establishes goals for inspector accompaniment by su)ervisors. The DNMS self-assessments review accomplishment of tiese 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 t1e site visits by each suaervisor. Copies of such documentation is provided as Attac1 ment 9a for certain of those visits conducted in the )ast six months. We identified that such documentation was not Jeing 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.

In addition, the Branch Chief observes the performance of each inspector during an inspection before recommending the individual be qualified as an inspector.

5

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, rotatirig 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 meters, 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 traceable 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

11. Please provide a staffing plan, or complete a li. sting using the .

suggested format below of the professional (technical) person-years of effort applied to the agreement or radioactive material j program by individual. Include the name, position. and, for {

Agreement States, the fraction of time spent in the following i areas: administration, materials licensing and compliance, emergency response. LLW U-mills, other. If these regulatory responsibilities are divided between offices, the table should be consolidated to include all personnel contributing to the radioactive materials program. Include all vacancies and identify all senior personnel assigned to monitor work of junior personnel.

If consultants were used to carry out the program's radioactive materials responsibilities, include their efforts. The table heading should be:

NAtiE POSITION AREA 0F EFFORT 51

RESPONSE

l- Attachment 11 is a copy of the Region II DNMS organization chart.

In 1995. Region II reorganized to place NMSS programs and the l

l Agreement State Officer in DNMS. Coordination of escalate  ;

} enforcement and allegations was placed in the Enforcement and  :

Allegation Coordination staff reporting to the Regional l Administrator. '

\

6 t

The Table below lists the requested information for materials staff. In addition, DNMS obtains engineering support from the Division of Reactor 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 0 100 FRANKLIN RAD SPEC INSPECTION 0 100 FULLER RAD SPEC INSPECTION 0 100 HEIM LIC /SST 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

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 (enforcement) 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 FORMER DIV. BOTH 10 90 (THROUGH DIR.

MAY 7. 1997)

DECKER BRANCH CHIEF BOTH 25 75 BOLAND/URYC* DIRECTOR. INSPECTION 0 30 (Enf. and ENF. AND aleg.) ALEG.

12. Please arovide a listing of all new professional personnel hired since t1e last review, indicate the degree (s) they received, if applicable, and additional training and years of experience in health physics, or other disciplines. if appropriate.

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 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

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

i

, 8

7 - - _ _ - __ - _ _ _ _ _ __

1 Gary Humphrey (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 Deborah 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, 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 th,ese requirements.

RESPONSE

Region II is in the process of qualifying materials staff as both 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.

Andrea Jones - not qualified as a license reviewer. She is in the process of qualification, with a goal for completion in January 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

t 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 1999.

l 14. Please identify the technical staff who left the RCP/ Regional DNMS l 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 we,re:

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 two 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.

leaving.two GS-13 positions open again. Region II interviewed three applicants for the GS-13s in December 1997. The individual 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 II selected a GS-13 Radiation Specialist in October 1997. -In addition we posted a GS-14 Senior Radiation S)ecialist position in November 1997 and selected the GS-14 from Region 11 materials staff in December 1997. We posted a GS-13 in December 1997. Ap>l1 cations are currently being received and interviews will >e scheduled after the candidates are rated.

10

I Branch Chief. MLIB2 - The Deputy Division Director is acting as I

Branch Chief for this Branch. The Branch Chief position will be filled by a staff member from HQ for a five week period beginning late in January 1998. We are in the process of evaluating options

.for filling this position.

Secretary. NFS Resident Office (part time) - We posted and advertised the position, but the individual selected declined to accept the job. We have re-advertised the position.

IV. Technical Ouality of Licensino Actions

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: '

AREC0 - 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.

Ashford Pharm. - radiopharmacy. Major license.

St. Luke Pharm. - radiopharmacy. Major license.

There were four cases involving bankruptcy: Maben Energy.

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.

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

I

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 Il 11

)

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 were reviewed by NMSS via TAR from the Region. On June 30, 1997.

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

Policy and Guidance Directive FC 94-02) that did not require an emergency plan or financial assurance.

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 allegation we found that the Commonwealth of Puerto Rico did not require a license for Ashford to operate. We have sent to NMSS a TAR for review. We have reminded materials staff that we are required to verify that applicants for radiopharmacy licenses must 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.

Westinghouse de Puerto Rico/Wittnauer Worldwide - We amended the license to transfer the license to Wittnauer without first obtaining new financial assurance. In the application for transfer. Wittnauer committed to provide Financial Assurance 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 adures. As a result of our self-assessment findings, we issu such procedure during the period Licensing Procedure 1.u. , rocessing 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

There are currently none in Region II. Region II, as part of our self-assessment reviews. identified that we has several renewals 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 Allegations

20. Please provide a list of the reportable incidents (i.e.. . medical misadministration, overexposure, 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 Jeriod. For Agreement States information included in previous su)mittals to NRC need not be repeated (i.e.. those submitted under 0MB 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 AE0D 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 misadministration Ryder Hospital 52-21026-01 12/11/97- misadministration V. A. Hos) ital. 01-00643-02 12/10/97 received cont.

Birminglam. AL package WV Deat. 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 packsge 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)

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 Center. PR Ames. Inc., Scrap Yard 9/3/97 found cont steel Parkersburg WV Marshall Miller &. 45-17195-01 8/29/97 overexposure 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 I-125 Reston. VA sources in

)atient 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. WV misadministration Steel of WV. Scrap Yard 6/4/97 found cont. steel i Huntington, WV l Hospital San Pablo 52-21325-01 5/14/97 lost Cs-137.

PR Co-60. and Co-57 cal, sources Luis Vasquez Out)t. 52-16660-03 3/7/97 misadministration Svc. Clinic. P1 14

L National Hospital 45-17123-01 ' 2/27/97 received cont.

Med. Ctr. , VA package Navy, Arlington, VA 45-23645-01NA 1/27/97 lost Am-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 sources Dr. Fernandez, PR 52-25114-01 8/7/96 misadministration Centro de Card. Y 52-25075-01 5/16/96 misadministration Med., PR 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 FL P-32 PR Opth. Inst., PR 52-25114-01 3/1/96 misadministration Fuel Facilities BWXT/NNFD SNM-42 6/10/96 Alert-Tornado.

SRI Response BWXT/NNFD SNM-42 12/19/96 91-01-Mass limit exceeded in vault.

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.

Westinghouse SNM-1107 4/17/97 74.11(a)-Missing Fuel Rods. Special H0/RII inspection.

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

Special H0/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 l incinerator.

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

, 16 ,

GE SNM-1097 7/12/96 50.72(b)(2)(I).

Alert. Hurricane force winds.

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

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

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

Spectal H0/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)-

Failure of criticality alarm.

NFS SNM-124 4/2/96 Site Area Emergency-Incinerator fire.

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 drug test.

17

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

, timely PN generated?

l RESPONSE:

Materials Licensees PSI (11/8/96)- initially it appeared that there might have been a malfunction of the aortable gauge, but evaluation of the gauge by the manufacturer, oaserved 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 Noiice 96-66. Recent Misadministration 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 inadequate procedures. In each instance. Region II (frequently in conjunction with NMSS) reviewed the failures to determine if there might be applicability to other licensees. Because of the 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 evaluation of the device for an assessment of possible generic design deficiency? Please provide details for each case.

1

RESPONSE

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

l 18 l

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 11 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 01 case with OI 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.

During the IMPEP period. Region II completed enforcement action related to an 01 investigation of activities at NDT Services. In this case 01 found that the Radiation Safety Officer and former President of the Company deliberately failed to use qualified radiographer. The licensee was issued Severity Level I and Severity Levl III violations. The two individuals were issued Orders prohibiting their involvement in licensed activities for five years.

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

Attachment 24 is a copy of ROI 1030. Revision 9. Processing Allegations. Complaints, and Concerns. This ROI provides details on the implementation of Management Directive (MD) 8.8. Management 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 Administrator.

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 aaplicable sections in each old reference (i.e.. references Jefore 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 clarifications are in the tie-down conditions as part of their review of esch licensing action prior to their concurrence on the action.

(2) Region II document the basis for complex or unusual j licensing decisions. and retain these documents in the 1 licensing file (Section 3.3).

j Action: 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. J Since the last IMPEP staff have been encouraged to document 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.

(Section 3.4)

Action: Region II supervisors and managers have continued to emphasize performance-based inspection. including providing information to staff in the Division Operating .

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

In addition, this is emphasized in alanning and in discussion of results with staff.~ Region II has begun to require written ins)ection )lans for ir.spections of Type A i

I 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 l

i l

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 ex)editiously 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

(~0ffice of State Programs Internal Procedures for Management of Allegations") (Section 3.5).

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

The ARB normally designates DNMS/the Agreement State Program 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 A allegations (when required)greement is monitoredState responses weekly to through an AMS printout of open allegations, and the status is discussed weekly with the Deputy Regional Administrator.

Attachment 25a 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 (0SP). 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 re) presentation. Since the last l IMPEP. Region II was audited ay the agency Senior Allegation Advisor, and found to have generally effectively implemented f MD 8.8.

f 21 t

l

(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 each 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:

(8) Region II should reconcile its written internal procedure (Branch Guidance Memoranda 4.2) for event evaluation and its informal practices for event evaluation.

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.

Region II inspection staff have been informed that, as part i of the preparation for inspections. they are to review NMED )

for events at facilities to be inspected. We are in the l 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 3rogram's strengths and weaknesses. These strengths and weacnesses should be supported by examples of successes, problems or difficulties which occurred during this review period.

L

RESPONSE

Each Branch performs self-assessments of their program areas

, quarterly. The assessment criteria for FY 97 are provided in Attachment 26. 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 performance needs improvements. Where improvement is needed, the Branch 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

- safety 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.

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

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). I

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

j B. NON COMMON PERFORMANCE INDICATORS I. Fuel Cycle Inspections Status of Insoection 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 fr-ility and type (i.e. U =

unannounced routine. inspections x = reactive inspections. D =

decommissioning inspections, etc.). Please include the inspection arocedure number (e.g.. IP 88020). A sample format is shown Jelow.

RESPONSE

The following is a list of 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 by the Master Inspection Plan (MIP). The 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. The 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 planned in the MIP based on the work at the facility.

Licensee Dates / Procedures Tygg 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 BWXT 96-06 5/11/96 88015.88020,83822, 92901 BWXT 96-07 6/22/96 88020.88005.88015 88025.92701.

24 i

t 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 88050.88015.88020.

83822.88035.86740.

92701.92702.88045, 84850.88025,88010 BWXT 96-13 8/23/96 81934.81922.81935.

81930.81022.81912, 81914.81926.81034.

81020.81929 ,

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, 81022.81920.81914.

81917.81925.81930, 81928.81038.81916, 81919 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. l 81923.81020.81335.

81034.81038.81926 i 81913 BWXT 97-02 3/1/97 88020.88025.88055 BWXT 97-03 2/28/97 81931.81914.81921, 81927.81934.81929.

81922.81924.81932.

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

BWXT 97-05 5/24/97 88020.88005.88010.

92702.88050 BWXT 97-07 7/5/97 88020.81925.81928.

81601.81911.81916.

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 81917.81915.81501, 81930.88020 BWXT 97-11 11/1/97 88020.81022.81911.

81914.81923,81930.

81501.81601,81935, 81924.81922.81913, 81910.81020.92702.

88020 8WXT 97-12 12/6/97 88020.88005 BWXT 97-13 1/10/98 88020 FCF 96-02 3/29/96 88005.88015.88025.

36100.88020.88010 FCF 96-03 7/26/96 88020,83822.88055, 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 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.

81910 NFS 96-04 4/18/96 81501.81932.81934, 81917,81925,81914, 81916.81929.81912, i

81930.81601.81933.  !

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

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, 88025.92703.838'22.

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, I

81920.81928.81935 NFS 97-01 1/28/97 88055.88025.88020 NFS 97-02 3/7/97 86740.83822.84850 92701 28 j

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, 81931.81815.61020.

81022.81911.81932.

81935.81930.81810.

f,1913.81915.81910, 81916,81820.81915, 81912.81910. 81920, 81935 NFS 97-10 9/27/97 88020.88015.88025, 81930.88055 l NFS 97-11 11/8/97 88020.88025.88015.

83822 NFS 97-12 12/20/97 88025.83822,88015 ,

88020.81911.81916. I 81919.81923.81926.

81502.81917,81915, 81920.81038.81928. l 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

_.-...._..___-__._______D

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, 88010.88005 ,

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 Inspections

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

, 30 i

L.______________________________._..__-.. - -

f l .

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 l reviewed during the inspection. The accompaniment includes a review of the inspection plan, direct observations of the

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 )eing i 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 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 Trainino

4. Please list the professional (technical) personnel assigned to perform inspections in the fuel cycle facilities inspection program, and the fractional amount of Jerson-years of effort to-which they are normally committed in tie program. Also, include the general inspection areas of responsibility (e.g.. E -

environmental protection. N = nuclear criticality. 0 = coerations.

P = physical security. R = radiation protection. T = othe' r). For those who joined the program since the last review, and any others who have not yet met the qualification requirements of fuel cycle facility inspection staff, please indicata 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

I NAME LEVEL OF INSPECTION BACKGROUND EFFORT AREAS l AYRES* 1.0 N0 Chemical Engineering GL0ERSEN* 1.0 ER Radiological Protection GOODEN 1.0 R T(EP) Biology HUGHEY 1.0 EN0R Chemistry HUMPHREY 1.0 EN0R Industrial Engineering SEYMOUR* 1.0 N0 Chemical Engineering TOBIN 1.0 P Physical Security MCALPINE 1.0 Branch Chief Chemical Engine'ering

• Also have Project Inspector respons1D111tles.

Seymour. Humphrey and Ayres have not completed all courses in the current MC 1246 but are interim 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 or 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 goals 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),

and Gerry Troup (retired). Prior to these staff leaving. 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, in anticipation of Gerry l

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 1 32 1

I J

inspection that might be needed, and if there is substantial I reactive inspection, the schedule for inspections will be revisited. As noted in I.A.15 above, two Fuel Facility Inspector i

positions are currently being re-posted.

II. SDMP Procram

6. What is the status of meeting the milestones _in SECY-96-207 for the SDMP listed sites? Were any significant delays identified and I corrective actions put in place in a timely manner? Are policy issues being resolved in a timely manner? '{

RESPONSE

l 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, portions of t1e GE site, and part of the Framatome site.

III. Uranium Recoverv Procram

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 l Technical Quality of Licensing Actions- A.IV. 19

) Responses to Incidents and Allegations- A.V. 20-23.

RsSPONSE:

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

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 1

33

S 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.

Par.t 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 openings that the region is recruiting for. The underspending in the 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 l

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

[ RESPONSE:

In general. Region II 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 l- _ _ _ _ _ _ _ _ _ _ _

followup. We have worked to make this clear after receiving irutial 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 fi rst.

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. Decommissioning

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. Insoector 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 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 i

1. • NOW CARE 47-25152-01 'A. Jones 9/97 Radiology Services of Hampton 45-25349-01MD B. Parker 11/97 Charleston Area .

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

~#* Pharmaco 45-25314-01 0. Masnyk Bailey /J. Pelchat 1/98

12. List the decommissioning inspections that were carried out during the review period. Please indicate if the inspection schedules required by.MC 2602 were prepared for licensed facilities undergoing decommissioning and if this schedule was developed.

indicate inspections that are overdue by more than 25% of the l

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

fLAM_E SJJE REPORT NO. DAIE 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 1 97-03 3/24-27/97 1 97-07 7/14-18/97 l Gloersen NFS 96-10 7/8-12/96 96-14 11/4-7/96 i 97-05 5/12-16/97

. All entries in Item No. 11 marked by an asterisk (*) were l inspected during and/or after the licensee *s decommissioning '

activities.

• Schedules per MC 2602 were not generally required or prepared in these instances.

36 4

e There were.no inspections that were overdue by more than 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 i 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 ins activities included review of licensee'pections, s inspection 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

Region II has designated B. Parker as the Decommissioning Project Manager for all materials cases. In addition, we have designated J. Henson, and 0. Masnyk Bailey (materials) and W. Gloersen (fuel facilities) as decommissioning inspectors. These staff were qualified as inspectors under the previous IMCs 1245 and 1246.

Our plan is that these staff complete the currently required courses for Remaining Decommissioning IMC 1246 (6/7/96) Project Manacourses are:ger and Inspector Environmental Monitoring for Radioactivity - Masnyk Bailey, to be scheduled Finance for Non-Financial Professionals - Henson, Gloersen.

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

Environmental Transport - Henson Gloersen. Masnyk Bailey, and Parker (to be scheduled)

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

15. Identify by name, license number and type air licensees with -

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 submitted additional information and that information is under review by Headquarters.

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 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 adequate instrument. The licensee has encountered significant 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 Headquarters.

j' 38 L - _ -- -- --

PLEASE NOTE THAT ATTACHMENTS BEAR THE QUESTIONNAIRE NUMBER THEY ARE RELATED T0.

of i

l l

i

e ATTACHMENTS Attachment 7' Memorandum to Fuel Facilities Branch dated 7/14/97 Attachment.7a Targeting Information Attachment 8 1996 Site Visits-l- Attachment 8a 1997 Site Visits Attachment 8b 1998 Site Visits Attachment 8c Accompaniment of Inspectors FY'96

~

Attachment 8d Accompaniment of Inspectors FY 97 ,

Attachment 8e Accompaniment of Inspectors FY 98 Attachment 9 ROI 2213. Rev. 7 '

Attachment 9a Trip Reports Attachment 10 Specifications Attachment-10a Instrument Inventory Attachment 11 DNMS Organization Chart Attachment 17 Memorandum to B. Mallett dated 4/16/97 Attachment 17a Memorandum to D. Cool dated 6/30/97 Attachment 18 Licensing Procedure 1.0 Attachment 24 R01 1030. Rev. 9 l

-Attachment 25 Principles of Performance-Based Inspection  ;

' Attachment 25a' DNMS Allegation Timeliness Report  !

. Attachment 26 DNMS FY 97 Self-Assessment Plan ,

' Attachment 26a RII Operating Plan Attachment FF2 RII FFB Inspection Targeting for FY 98

Attachment FF2a RII FFB Inspection Schedule for FY 98 l

1

,< May 16,1997 p

l ' Babcock and Wilcox Company .

ATTN: Mr. J. A. Conner Vice President & General Manager l Naval Nuclear Fuel Division L

P. O. Box 785 Lynchburg, VA 24505-0785

SUBJECT:

NRC PERFORMANCE REVIEW OF LICENSED ACTIVITIES

Dear Mr. Conner:

On February 6 and 10,1997, managers and staff in Region il and the Office of Nuclear Material S"fety and Safeguards (NMSS) reviewed your program for conducting NRC licensed activities. 'The r& view evaluated your performance for the period July 1,1994, through September 30,1996, with a -

focus on performance during the last six months of the period. The review also provides you with -

- fiedback on how NRC senior management assesses your performance. The review will be used to form a basis for establishing the NRC inspection program for your conduct of licensed activities 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.

wa expect you to discuss your view of your performance in the same major areas. An outline of the rssults 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 areas of radiological controls and security was excellent. Performance in other areas was good.

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

Based upon the review, the NRC has decided to reduce the routine inspection effort in the area of radiological 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 svaluating your material control and accountability program.

In cecordance with Section 2.790 of the NRC's " Rules of Practice," a copy of this letter and its cnclosure 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, t

i Luis A. Reyes i

Regional Administrator Docket No. 70-27 License No. SNM-42

Enclosure:

Licensee Performance Review - Summary Outline Attachment 1

e .

B&W NNFD - LICENSEE PERFORMANCE REVIEW-

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 Babcoc and Wilcox Naval Nuclear Fuel Division in the conduct of NRC licensed activities.

PERFORMANCE AREA: SAFETY OPERATIONS j

This area is comprised of plant operations, criticality safety, chemical safety, fire safety and management controls.

PROGRAM STRENGTHS o Competent criticality safety staff o

Management and staff support for safety programs .

o immediate response to events o

Self-identification of deficiencies AREAS NEEDING IMPROVEMENT o

Operator adherence to nuclear criticality safety controls (postings and procedures) in uranium recovery and storage areas o

Review or walk down of procedures and equipment in uranium reca very to reduce number of spills of hazardous materials CHALLENGES TO PERFORMANCE o

Continued management oversight of the conduct of operations in the uranium recovery area 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.

PROGRAM STRENGTHS o

Response to events, including timeliness, analysis of root causes and recognition of generic issues within the facility o

Training of security force and conduct of daily operations by the security managers and staff Enclosure to Attachment 1

2 AREAS NEEDING IMPROVEMENT No significant areas needing e,irovement 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 o-Early identification of problems in radiation safety via use of the Radiation Safety incident -

Notice (RSIN) program o

ALARA program effective in minimizing radiation exposures o Control of radioactivity in effluents ARFAS NEEDING IMPROVEMENT o

Completeness of audits performed in radioactive waste and packaging areas o

Number of releases of airborne radioactivity into uranium recovery area CHALLENGES TO PERFORMANCE

' No significant challenges to performance were identified other than the issues specified under Areas l Nasding improvement.

PERFORMANCE AREA: FACILITY SUPPORT This area is comprised of maintenance and surveillance, tiaining in safety cad emergency

. preparedness:

PROGRAM STRENGTHS

-o E*fective safety training with emphasis on job function and requirements I o Strong management and staffinvolvement in emergency preparedness and training o.

' Good intemal audits and critiques in emergency preparedness resulted in performance enhancements. .

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 o

implementation of periodichefresher training in nuclear criticality safety for managers and supervisors and lessons learned for managers and supervisors and lessons leamed for operators involved in high risk operations O

l

~

Enclosure to Attachment 1

r FUEL FACILITIES BRANCH INSPECTION PLAN Revi: ion D:t3: 06/12/97 Inspection of: on Inspection Report Number:

Licensee Dates (From -a To)

On Site Hours Anticipated:

Back-shift Hours Anticipated:

TYPE oF INSPECTION TIMING oF INsPECTloN INSPECT)oN NoT)FICATioN ALLEGATION Followup INTEGRATED REPORT Routine Back Shift Announced Yes . Plan .' ' ached Yes Special Normal Shift Unannounced No No Team Both Shifts Lcad Inspector: - Accompanying Inspector (s): -

Licensee Contact Name Telephone Number

• M tel:

Name and Location Telephone Number Print, review, and attach a copy of the Site Integration Matrix (See G:tSIMP.SIM) .

Inspectors initials Attach a list of a!! open items for the facility (See G:tOPENITEM) and mark with a hichlichter 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 Branch Inspection Areas), mark with a high lighter tha areas (e.g. F1.05, S2.07, etc.) to be inspected and cross out those areas previously inspected during the Fiscal Year. .

Inspectors initials in an attachme'it, list the performance measures to be inspected fcv 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 m:asures relate to performance characteristics for this licensee that yoti 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 inspection Instructions from the Project inspector (Ayres for Framatome, Westinghouse; Bassett for RIsearch Reactors; Gloersen for NFS & ISFSis, and Troup for B&W NNFD & GE):

Project inspector Certification that 1) the inspection focus is appropriate,2) the planned inspection is based en acceptable performance measures,3) performance trends from an up-to-date SIM have been appropriately

. considered, and 4) the inspection is specified on the Master inspection Schedule Signature Date AdditionalInspection Instructions from Branch Chief:

e . wm u.a- T.

l s,-wis y

>=e.a-t.)

Pror.a kinpea-Brane Chet Br;nch Chief Approval:

Signature Date Attachment 2

i 1

Recion il Fuel Faeftities Branch insocetion Areas f

l .

1. SAFETY OPERATIONS 03 Plant Operations (88020) 03.01 Conduct of Operations 1 03.02 Facility Modifications and Configuration Controls R2 1

03.03 Implementation of Process Safety Controls Environmental Protection (88045)  !

R2.01 Monitoring Program implementation 03.04 Implernentation of Storage Safety Controls  !

R2.02 Monitoring Program Resutts 03.05 Implementation of Safefy Controls for Material Handling I R2.03 Management Audits, inspections and Controls and Movement R2.04 03.06 Ovality Control of Analytical Measurements Housekeeping R2.05 Independent Measurement Venfication (Sample 03.07 Review of Previous Events Splitting) 03.08 Foaowup on Previously identi5ed issues j R2.06 Monitoring Program Reports R2.07 Decommissioning Activities 04 Fire Safety (88055) R2.08 Fonowup on Previously ident:5ed 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 Emuent Program Controls, Procedures snd 04.03 Building Design. Construction, and Ventilation Syrtem 04.04 instrumentabon Fire Safety of Processes. Equipment, and Storage R3.02 Liquid Effluent Monitoring Results Areas 04.05 Fire Protection Systems R3.03 Airbome Emuent Controls Procedures and )j 04.06 instrumentation Fire Hazards Analysis R3.04 1

04.07 Pre-Fire Plan Airbome Emuent Monitoring Results R3.05 On site Waste Storage 04.08 Fire Brigade Training R3.06 Waste Classification 04.09 Fire Emergency Dritis R3.07 Waste Form and Characterization-3 04.10 Off Site Support 1 R3.08 Waste Shipping (Manifests, Labeling, and Surveys) 04.11 Followup on Freviously identified issues R3.09 Tracking of Waste Shipments l j

R3.10 Management Controlof Liquid & Airbome Emuents and 05 Management Organization and Controls (88005) 05.01 Solid Waste Organizational Structure R3.11 Quality Assurance Programs 05.02 Procedure Controls R3.12 Fotlowup on Previously identined issues 05.03 Intemal Reviews and Audits 0 5.04 Safety Committees R4 Transportation (88740) 05.05 Quality Assurance Programs R4.01 Preparabon of Packages for Shipment 05.06 Followup on Previously identified issues R4.02 Delivery of Completed Packages to Carriers R4.03 Receipt of Packages

11. SAFEGUARDS - Rd.04 Certi5 cates of Compliance S2 R4.05 Management Controls Physical Frotection (81000 series) R4.06 Records and Reports S2.01 Adequacy of Physical Security Plan R4.07 Followup on Previously identified issues S2.02 Implementing Procedures and Guard Orders S3.03 Management Reviews, Audits and Controls S2.04 Quality of Physical Barriers N. FACitiTY SUPPORT

(

S2.05 Personnel Management Training. Qualification, and 1 F1 Fitness for Duty Maintenance / Surveillance (88025)

F1.01 Conduct of Maintenance S2.06 Assessment Aids and Lighting F1.02 Work Control Procedures S2.07 Detection Aids and ingress & Egress Controls F1.03 Work Control Authorizations S2.08 Equipment Testing and Maintenance F1.04 Qualincations of Maintenance Personnel S2.09 Locks, Keys, and Combinations F1.05 Management Audit of Maintenance S2.10 Supply of Electncal Power to Security Systems F1.06 Survei!!ance Testing S2.11 Compensatory Measures F1.07 Calibrations of Equipment S2.12 'Atarm Stations and Communications F1.08 Fonowup on Previously identified issues S2.13 Records, Reports, and Event Reporting S2.14 Protection of Shipments F2 Training (88010)

S2.15 Information Protection )

F2.01 10 CFR 1g 12 Training S2.16 Review of Events and Exercises S2.17 FoDowup on Previously identifed issues F2.02 General Nuclear Criticality Safety Training {

F2.03 General Radiological Safety Training )

}

F2.04 General Emergency Training 111. RADIOLOGICAL CONTROLS F2.05 Operating Procedure Training F2.06 On-the-job Training R1 Radiation Protection (83822) F2.07 Fonowup on Previously identifed Issues R1.01 Radiation Protection Program implementation )

Rt.02 Radiation Protection Program Procedures F3 Emergency Preparedness (88050)

Rt.03 Radiation Protection Program Equipment F3.01 Review of Program Changes Rt.04 Extema1 Exposure Control j F3.02 Implementing Procedures Rt.05 Intemal Exposure Control F3.03 Training and Staffing of Emergency Organization R1.06 Respiratory Protection F3.04 Off site Support Rt.07 Postings. Labeling Control F3.05 Drills and Exercises R1.08 Sunreys RI.0g F3.06 Emergency Equipment and Facilities Notifications and Reports F3.07 R t.10 Fonowup on Previously identi5ed issues Implementation of ALARA Prograrn R t.11 Management Oversight of Program Rt.12 Fo!!owup on Previousty identified issues Attachment 2

U.S. NUCLEAR REGULATORY COMMISSION REGION !!

Docket No.: 70-xx License No.: SNM-xxx Report No.: Docket Number / Year-Sequential Number Licensee: Licensee's Name Fccility Name: Specific Facility Name .

Location: Town, State and Zip Code Dste: Dates of the inspection inspector: Name and Title Approved by: E. J. McAlpine, Chief Fuel Facilities Branch Division of Nuclear Materials Safety Nste: There is no page number and the word " ENCLOSURE" is right justified at the b::ttom.

ENCLOSURE Attachment 3

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 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 more than one functional area was inspected, they should be presented in the order specified below. No page number on this page, if this 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 within 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 Niatrix and ultimately in Licensee Performance Reviews (LPRs). Care and effort expended during development of the Executive Summary will pay off with less effort being required during LPRs.

S AFETY OPERATIONS For example:

Strong implementation of active engineered controlin DCP due in part to the 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 1

Attachment:

Partial List of Persons Contacted inspection Procedures Used List of items Opened, Closed, and Discussed List of Acronyms Attachment 3

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

1. Summarv of Plant Status This section contains a brief status of the facility during the inspection. For an

' integrated resident report, the status will, of course, be more detailed than for a 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 l i

parts of the facility were operating, and whether any special activities are l

underway - such as physical inventory, emergency exercises, physical security j drills, extensive maintenance on a particular area, and the like. Think of this as d simi!ar to what we provide in One-Liners each Friday. It provides a backdrop describing the environment under which the inspection was conducted. l l

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 ofinspection 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 ofinspection (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 )

Insnection Reautrements The subdivision of each area ofinspection is by inspection requirements. These are  ;

cuttined 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, Attachment 3

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

2.

Physical Protection (applicable inspection procedures) (S2) a.

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

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

Review of Events and Exercises (S2.16)

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

Inspection Scope, Observations and Findings, and Conclusions. There can b,e multiple paragraphs within these numbered subdivisions. The subdivisions are designated with numbers in parentheses. See Enciosure insonetion Scone -

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 Report, j 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 Pian, dated November 4, 1993, and implementing procedures. Particular inspection emphasis was placed on the 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.

j. Observations and Findinos l

l.

' 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 Attachment 3  !

3 report is on verification and analysis oflicensee 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 example, if the inspector determines that the licensee has 65 open maintenance work orders, this finding needs to be placed in safety perspective, is the number of open work orders increasing or decreasing? Is there a specific class of equipment that is proving to be particularly 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 ball in to rescive 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 an 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 licensee personnel complying with the approved procedures, (4) the results of functional testing of active engineered safety controls, the inspector concluded that the licensee L . 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 I

!~

worked in during functional testing of equipment. The implementation of the administrative nuclear criticality safety controls at the C8'l distillation unit, however, was marginal due to the difficulty that licensee personnel had in observing flow through Attachment 3 l

4 downcomers between plates 11 and 23. The observational difficulty will 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 contir.ues with additionalinspection requirements followed by additional inspection areas, as appropriate.

• Exit interview (307031 This section contains a brief summary of the exit interview, including the date it was held. If the licensee disagrees with a position taken by the inspector during the inspection, a clear statement of the licensee's position should be included. A statement of whether proprietary information is included in the ceport should be made. Remember, the significant issues discussed and items opened rend 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, it should be documented in this section, a

Attachment 3

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.

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.

NRC Personnel NRC personnel contacte$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.

INSPECTION PROCEDURES USED Format for this section is as follows:

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

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

Closed i

70-xxxx196-xx-xx VIO Failure to meet some specific requirement (Paragraph X.Y.2).

Attachment 3

I 4 Enclosure 1 Fuel Facility Report Structure Coverletter Safety significant issues are highlighted in the coverletter, but only if they are contained in the Executive Summasy and the Exit Interview Section.

Notice of Violation and/or Deviation Cover Pane -

Executive Summarv Items discussed in the Executive Summary should be significant findings froin 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.

Epoort Details

1. Summary of Plant Status

2. Area ofInspection #1

a. In=pecuon 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) Conclusions

b. Inspection Requirement #2 (1) Inspection Scope (2) Observations and Findings (3) Conclusions

4. Exit interview Attachment Attachment 3

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 IIst of acronyms used in 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 ,

l l

Attachment 3 i I

)

A . ,

July 14,1'997 MEMORANDUM TO: Fuel Facilities Branch i

FROM: E. J. McAlpine, Chief M '

Fuel Facility Branch

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 11 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 - specifiestion of inspection frequency 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 actual level of effort is completed independent of that process. Note also that this phase for low-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 of inspection plans for the conduct of individual 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 to permit identification of trends on a more frequent basis than the formal performance L reviews. Note that the Site integration Matrix for the entire period covered b" a l Licensee Performance Review should provide the necessary and sufficient information l to perform the review- thus reinitiating the cycle.

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 recerit example of what the finished product should look like. It is presented as Attachment 1 to this memorandum. Also, we should expect a high level of performance in creas where the risk is high.

Attachment 7

1 l

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 conducted 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 schedule 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 11 inspection schedule into the national master inspection schedule, we have estab!ished 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 j performance measures to be inspected. The planning of the inspection occurs with an eye on j 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.

l l

3 i.

Inspection 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.

l Attachment 3 presents the format for inspection reports prepared within the Region 11 Fuel l . 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 of licensee 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.

l ..

Performance Trackino 1

- 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 l mechanism by which performance can be judged dunng performance reviews and at

' intervening times. It is important to 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.

l

! 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:

l l

Branch Members

! D. Collins T. Decker C. Hosey B. Mallett J. Potter Reading File P. Ting

. P \WP51\RIPBINSP.CYC  !

A TARGETING INFORMATION A. Management Controls (88005) ,

_ 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 No particular emphasis was identified.

- Westinghouse 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 i Program emphasis should be a balance between normal plant operations and l operations associated with new work. The new work emphasis should be based i on the lessons leamed by the licensee from the inadvertent shipment of two fuel I-assemblies to Germany which resulted from failure to conduct new, short-term projects in a manner similar to the normal routine work.

l Attachment 7a

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.

I 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.

5 Framatome Cogema Fuels -

No particular area of emphasis other than to assure that the SERF facilities receive significant attention. The presence of byproduct material with its significance as a source term causes those areas to be of importance.

General Electric No particular area 'of emphasis has been identified.- Entire program area should be addressed. Of note is that the fire loadir.; in solvent extraction is lower than at other facilities because of the organic used.

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 to an automatic system.- Emphasis should also be on issues developed during 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 bumed back to U30, due to the presence of oxygen in the collection system.

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 Emphasis should be on changes to controls for the 300 complex as the new naval fuel process becomes ready for operation.

1 E. HEU Alarms and Barriers (81910,81911,81913,81918,81919,81920,81921,81923, l 81924, 81926, 81927, 81928, 81931, 81401, and 81402) l 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

6 i

I 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 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.

Spent Fuel Shipments l

No particular area of emphasis has been identified.

l

7 1.

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 airbome radioactivity.

Framatome Cogema Fuels 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 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 l Emphasis on proper waste characterization and program assessment.

8 l- -

General Electric 1

Emphasis on proper waste characterization and program assessment.

Nuclear Fuel Services Emphasis on proper waste characterization and prog.e.n assessment.

Westinghouse Emphasis on proper waste characterization and program assessment.

I K. Low-Level Waste' Storage (84900) -

B&W NNFD 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 of emphasis was identified.

L. Transportation (86740) l -

B&W NNFD l

Shipment to Envirocare. Compliance with CoC requirements.

Framatome Cogema Fuels Compliance with CoC requirements.

l l -

General Electric Compliance with CoC requirements.

l 4 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. -

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 of emphasis was identified.

N. Environmental Protection (88045)

B&W NNFD 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.

.. . i

• 10 Westinghouse No particular area of emphasis was identified.

O. Decommissioning (88104)

Nuclear Fuel Services Work associated with North Site and Pond 4.

P. Operator Training (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.

Nuclear Fuel Services Emphasis on training associated with new or non-routine work.

Westinghouse 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.

l 11 Nuclear Fuel Services Emphasis on maintenance of safety related controls associated with HEURF.

t, Westinghouse Emphasis on maintenance of safety related controis.

R. Emergency Preparedness (88050)

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 No particular emphasis was identified.

Westinghouse No particular emphasis was identified.

l S. ISFSI inspection North Anna .

l Emphasis on dry run of case loading.

T. NNFD Resident Emphasis in accordance with LPR U. NFS Resident Emphasis in accordance with LPR G$ SCHEDULE \98 TARGET.

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a ACCOMPANIMENT OF INSPECTORS BY DNMS MANAGERS IN FY-96 NAME DATE OF ACCOMPANIMENT 1 Materials Licensing / Inspection Branch 1 l

l J. Ennis 7/96 1

A. Jones 8/96 W. Loo B. Parker 11/96,6/96

~

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 5/9fi O. Masnyk Bailey 12/e5,9/96 Fuel Facilities Branch D. Ayres started 9/1/96 C. Bassett 3/96, 9/96 W. Gloorsen 10/96,9/96 A. Cooden 3/96,9/96 D. Kasnicki 9/96 W. Tobin 3/96 C. Hughey 9/96 G. Troup 9/96 Attachment 8e

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 Materials Licensing / Inspection Branch 2 H. Bermudez 9/97 D. Collins licensing, reciprocity J. Diaz 10/96 L Franklin 3/97 J. Henson O. Masnyk Bailey 4/97,7/97,8/97 Fuel Facilities Branch D. Ayres 10/96,12/96,6/97,9/97 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 l

l C. Hughey 10/96,7/97,9/97 '

G. Troup 11/96,1/97,6/97,7/97 i l

Attachment 8d ;

I

l ACCOMPANIMENT OF INSPECTORS BY DNMS MANAGERS IN FY-98 l NAME DATE OF ACCOMPANIMENT Materials Licensing / inspection Branch 1 J. Ennis A. Jones W. Loo O. Masynk Bailey 1 B. Parker 12/97 J. Pelchat 1 Materials Licensing / Inspection Branch 2 j H. Bermudez D. Collins J. Diaz L. Franklin 12/97 J.Henson  ;

~

l Fuel Facilities Branch i D. Ayres C. Bassett W. Gloersen 12/97 A. Gooden W. Tobin 12/97 i

G. Humphrey 12/97 C. Hughey G. Troup j

Attachment 8e

- _ _ _ _ _ _ _ - _ _ - ___ _ a

UNrrED STATES

1. pe* 881oq'b, NUCLEAR REGULATORY COMMISSION O ^

REGloN ll 5 o 101 MARIETTA STREET, N.W., SUITE 2900

( j ATLANTA, GEORGIA 30323.o199

'h,

[ August 7, 1996 4

)

l Reaional Office Instruction No. 2213. Rev, 7 MANAGEMENT OVERSIGHT OF INSPECTION AND LICENSEE ACTIVITIES

~

A.

Purpose:

I 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; l Regional management visibility at licensee facilities, and inspector l objectivity.

This Instruction applies to all Regional managsrs and supervisors responsible for inspection program activities at nuclear power plants, l non-power. reactors and fuel facilities.

l This revision incorporates the guidance of MC 0102, dr'ad March 15, 1996.

l This Instruction incorporates the Regulatory Imput Reporting Form j

(Attachment C). This form, to be filled out by Division Directors, the l Regional Administrator, and their Deputies will be used to document l feedback, both favorable and unfavorable, obtained from licensee l 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, I 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 during the course of implementing the inspection program. Judgment should be used to achieve the desired goals for NRC management 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 j managers to verify inspector and examiner performance and objectivity by

' l 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

1 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 activities.

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 f.eedback from reactor l licensees, and ensuring that on-site activities are performed as intended.

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.

/

un u Stewart D. Ebneter Regional Administrator

Attachment:

Management Oversight Responsibilities w/ Appendices .

Distribution List D 4

MANAGEMENT OVERSIGHT RESPON'IBILITIES S

Procedures

1. Division of Reactor Proiects (DRp) ,

a. Division management and supervisors will visit reactor sites 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 krigf 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 tiistribution.) 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.

l The Division Director or Deputy is responsible for making quarterly l 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.

d. For all team inspections, a regional manager at the Branch Chief level or higher will at' tend 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.

1 e. Branch Chiefs shall perform the following: make at least a monthly visit, at one of the assigned sites (see Table in Apper. dix 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-s'ite activities are initiated to ensure the employee's activities are

properly scheduled, coordinated and focused.

l ATTACHMENT 2 ,

I

2 Discuss the findings and concerns with the inspectors assigned to the activity before the facility's exit meeting 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,

~

' activities for which they are responsible. . .

Attend the exit briefing for their subordinate resident and specialist inspections if significant inspection or examination findings (e.g., possible escalated enforcement or unsatisfactory requalification examination ) will be discussed. A cognizant line

! manager shall attend significant . team inspection exit meetings as

-l. directed by their Division. Directors and should supplement the j discussion, as necessary.

-f . Line managers responsible for an inspection acti'vity should promptly and thoroughly debrief the assigned inspectors after the inspectors

. 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

' necessary.

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 for and presentation of an exit interview. The Branch Chief should l focus on the following 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 l .- knowledge 'of applicable regulatory requirements, procedures I and guidelines (e.g., NRC Inspection Manual procedures, UFSAR, l 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 9

i 4

3

l. -Inspector Objectivity Focus:

(1) Does the inspector independently verify licensee provided information?

l 0 (2) Does' the inspector adhere to NRC regulatory positions and

' 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?

l (4) Has the inspector provided an accurate and balanc'ed account of-licensee performance, and plant conditions, in communication i with NRC regional . management via inspection reports, l telephone, or other means? ,

ll b licensee staff and manageme6t respond to the l (5) How do inspector's questions or concerns?

l (6) Is the inspector focused on safety significant concerns, applying the enforcement guidance when required?

l (7) Does the inspector appropriately respond to issues or events i duririg normal and off normal working hours? -

l l (8) Does the inspector develop ' issues fairly and objectively l without biased interpretation of facts? j l

' Are findings adequately supported by the facts and are (9) assessments of licensee performance adequately supported by j

, the findings? '

l g. .'T he Branch Chief shall ensure the following:

l l l (1) NRR manager is informed of all significant issues  !

'(2) Inspectors, team leaders, chief examiners, and other staff who j 1ead NRC on site activities (including headquarters based l

l staff) use an appropriate inspection plan, brief and receive l approval from the line supervisor responsible for the activity l on their planned activities and provide a copy of the l inspection, examination, or audit plan to the responsible l regional office Division of Reactor Projects (DRP) supervisor i before the on-site activities begin.

(3) All NRC staff (including headquarters staff) who lead NRC on-

l site activities conduct an entrance meeting with the l a'ppropriate facility personnel before beginning on-site

, l activities. The senior resic'ent inspector (SRI) should be l 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 responsible for the activity and the SRI regarding their

• l findings before any . exit meeting with the facility licensee takes place.

(5) brief their.immediate line manager on resident SRIs ' routinely'ues inspection iss and findings and keeps their supervisor

informed of scheduled exit meetings. '

' SRIs keep abreast of all NRC on-site activities at the (6) facility to which they are assigned. ,

, (7) SRIs attend entrance and exit meetings. If the SRI is l unavailable, other resident inspectors should attend in their 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 l inspection activities at another site. This may be l accomplished by participating in a team inspection at another l site, or during backup site familiarization visits.

.(9) The resident inspection staff maintains access to and familiarity with their backup 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 lic.ensee performance and problems and elicit licensee l . comments regarding 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 identi.fying the licensee, person (s) contacted, inspection or* licensing staff observed, and any identified problem (s) or concern (s) "Se Appendix B for distribution.) At the conclusion of each tric i sen 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.

e 4

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. .

e. Branch Chiefs should ensure that their. Division Director' and the Division Director of DRP are. informed of significant issues identified by insp'ec' tors and examiners whom they supervise.

l f. Branch Chiefs should attend exit interviews with licensees if significant inspection or examination findings - (e.g., possible i 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 onsitt 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, profe.ssionalism, interpersonal skills Inspector Objectivity Focus:  !

(1) Does the inspector independently verify licensee provided '

information?

h (2) Does the inspector adhere to NRC regulatory positions and policies when discussing issues with licensee management or i NRC management?

(3) Does the inspector maintain a professional relationship with

i the licensee using good interpersonal relationship skills?

4 (4) Has the inspector provided an accurate and balanced account of licensee performance, and plant condi.tions, in communication

- _ _ _ . _ _ _ _ , - - . _ - . _ - . . . A

6 L 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 requ-ired?

J' .

(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?

- (9) Are findings adequately supported by the facts and are l assesments of licensee performance adequately supported by j the findings?

h. DRS Branch Chiefs should brief the DRP Branch Chiefs (for Power Reactor Facilities) of significant inspection or examination findings.

3. Division of Nuclear Materials Safety (DNHS1

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 j 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 obserye the implementation of l NRC activities and programs in the f,jeld and the effectiveness of

, j NRC staff communications with the licensee.

I I At the conclusion of each trip, prepare a krj.gf 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

\ ,

t L _ _ _ _ _ _ - _ _ _

I t

7 one inspection to evaluate the adequacy of the inspector's effective l

implementation of the program. The manager or supervisor should i l 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 b'rigf trip report (Appendix B) for the Deputy Regional Administrator

, identifying the licensee (s), person (s) contacted, inspector (s)

. observed, and any identified problems or concernss (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 me'eting 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 they supervise.

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 f activities, including preparation for and presentation of an exit interview. The Branch Chief should focus on the following j performance and objectivity attributes:

safety. perspectiv'e and the application of safety principles during conduct of onsite activ.ities the adequacy of technical training and preparation for the l onsite activity being conducted (See Appendix B for '

distribution) knowledge of applicable regulatory requirements the ability to apply performance-based inspection /examinati'on )

techniques to enhance safe and reliable facility / operation '

l adherence to agency-wide regulatory positions and policies and I avoidance of personal interpretations and opinion  !

objectivity, demeanor, professionalism, interpersonal skills

8 l

l Inspector Objectivity Focus:

l l '

(1) Does < the inspector independently verify licensee provided information?

(2) Does the inspector adhere .to NRC regulatory positions . and policies .when discussing issues w'ith licensee management or u

NRC management? -

s , .

(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 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?

l l (6) Is the inspector focused on safety significant concerns, l applying the enforcement guidance when required?

l l (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 l without biased interpretation of facts?

l l (9) Are findings adequately supported by the facts and are

! assessments 'of licensee performance ' adequately supported by l the findings?

. l. i.

DNMS Branch Chiefs should brief the DRP Branch Chiefs (for Power

.j' Reactor Facilities) of signific. ant inspection or examination findings.

l j 4. Insoector Inspection Focus While preparing and conducting an inspection, the inspector should consider the following:

Is the inspector focused on safety significant issues?

y l

Has the inspector prepared to conduct the inspection, and does the j

inspector have the necessary training and tools to conduct the inspection?

Does the inspector display a working level knowledge of applicable

'i regulatory requirements, procedures and guidelines?

i l

. Does the inspector use a performance-based approach to conduct inspection activities that stresses safe and reliable facility operation?

) .

Does the inspector adhere to agency-wide positions and policy 1

avoiding personal interpretations and opinions? j

' . Does th'e inspe'ct'or tise the l'icensing and des'ign bases information.

? for the facility including the Updated FSAR in preparation for and during conduct of inspections? ]

i

. Does the inspector conduct exit interviews in accordance with NRC i policies and practices? -

j 5. Rgg4,onal Administrator's Office

a. The Regional Administrator and Deputy Regional Administrator will visit reactor sites in accordance with the sch'edule 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 l ensure that the appropriate NRR manager is informed of all  !

l significant, 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.

l d. ras must ensure that facility adverse comments are validated and I l appropriate corrective actions are initiated. The feedback obtained ,

l from the licensee shall . be forwarded using Appendix C to the NRR l l Division of. Inspection and Support Programs (DISP), Inspection

' Program Branch (PIPB). This feedback will be used in the continuing assessment of the regulatory impact of HRC activities on reactor l l plant operations.

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APPEN' DIX B TRIP REPORT MEMORANDUM TO: Deputy Regional Administrator FROM:

SUBJECT:

, REPORT ON TRIP TO DATE(S) 0F VISIT:

PURPOSE OF VISIT:

INSPECTOR (S) OBSERVED:

SENIOR LICENSEE PERSON CONTACTED:

STRENGTHS OR WEAXNESSES NOTED WITH PLANT:

l OTHER COMMENTS:

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 i . DATE:

ORIGINATOR (NAME/ORG) ,

LICENSEE (NAME/ TITLE)

FAVORABLE FEEDBACK UNFAVORABLE FEEDBACK (ISSUE OR PROBLEM) _

COMMENTS RECOM4ENDATIONS/ RESOLUTION 4

cc:- Cognizant Senior Resident Inspector Cognizant DRP Branch Chief Technical Division Directors Deputy Regional Administrator Regional Administrator Cognizant NRR Project Manager j , NRR/ DISP /PIPB 3

a

l

(

January 9. 1998 l TRIP REPORT l

MEMORANDUM TO: Bruce S. Mallett. Deputy Regional Administrator FROM: Charles M. 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:

Hospital Metropolitan -Racheline A. Gonzalez Administrator San Juan Cement Co. - Rolando Melendez. Administrator Bernardo A. Puebla. MD - Dr. Puebla. Dwner Universidad Central del Caribe - Dr. Richard Hann. Chairman. Department of Biochemistry STRENGTHS OR WEAKNESSES NOTED WITH PLANT:

Hosoital Metronolitano Hospital exercising little control over Oncology Department San Juan Cement Co.

RSO involved in radiation safety on a daily basis, well maintained program Bernardo A. Puebla. MD Little use of source. Good records and user very knowledgeable of requirements.

Universidad Central del Caribe Small amount of research. Users very Knowledgeable of requirements. Well managed program OTHER COMMENTS:

None cc: Regional Administrator DNMS Division Director Attachment 90u

APPENDIX B TRIP REPORT MEMORANDUM TO: Deputy Regional Administrator FROM: P ' A/[ ///1T

SUBJECT:

REPDRT ON TRIP TO [rt mp-/, fytE -

DATE(S) 0F VISIT: 12./14 f4 ~1 PURPOSE OF VISIT: L f n/Nu, 2/E n4 ((Ld, A -/m41

~

INSPECTOR (S) 0BSERVED: Alom ,w s be -

/~ U V hhoh Gu w,w str> mesh 1/h s vi Nuw//

ir f oh i f5 SENIOR LICENSEE PERSON CONTACTED: khSee STRENGTHS OR WEAKNESSES NOTED WITH PLANT:

!%d l~b0 pD. suu pvW Jhf a n9 ,

$Ntf1 Cl-fwhhY2C VC / H )/ 9lW, i O f i/ DV\ $

OTHER COMMENTS:

0 Ifibf$

Signature I/Date cc: Regional Admin'istrator Technical Division Directors Cognizant Senior Resident Inspector Cognizant DRP Branch Chief Cognizant NRR Project Manager

l APPENDIX B TRIP REPORT MEMORANDUM TO: Deputy Regional Administrator FROM: O M h/!/MC

SUBJECT:

REPDRT ON TRIP TO MF(

DATE(S) 0F VISIT: 9!! $7

• PURPOSE OF VISIT: $4urd ri /td/ riaj)f/27-INSPECTOR (S) OBSERVED: [r, /d4tf.fft.4fl ~

/ (/

SENIOR LICENSEE PERSON CONTACTED: /), huu tmA STRENGTHS OR WEAKNESSES NOTED WITH PLANT: ,

ltYl/k Co7' ih n') A0f10lLf< W O'I- L l

.0)VN BIS 1y l

f(o LU SI$ l Imdbu jp?potbd Ad CfMktil$~~

Jf'J}lblL M ~ hf]?lM'yif k lyW C r[r.%1 -f5VYitWA -

OTHER.C0MMENTS:

hnt V f, t, yJ)(( [ g a f g gj __. g N.l(+t Al , V0dW $21Wf(7 N ( b t f N .IN h Ii $ tf k[ 0 %

E h A) Eb71jr-SA90N/^

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)^f 54 .

l qQ Jty Sj2utN(C Dkbm'j h{khlf]M jSignature i fllff{

yDate l cc: Regional Administrator Technical Division Directors

(( %

Cognizant Senior Resident Inspector

/

Cognizant DRP Branch Chief Cognizant NRR Project Manager

APPENDIX B TRIP REPORT MEMORANDUM TO: Deputy Regional Administrator FROM: 3 kI ($,/firlf I

SUBJECT:

REPORT ON TRIP TO 6f DATE(S) 0F VISIT: /4[78f97 PURPOSE OF VISIT: /Irv/ Juo , 188 O/vsn4M 7%

^

INSPECTOR (S) OBSERVED: A/d A tz.<

7 r < r M S A/ -

O /

SENIOR LICENSEE PERSON CONTACTED: b [i f) t'

//

STRENGTHS OR WEAKNESSES NOTED WITH PLANT:

I4 00Nhf .)2h* N hkgf M k h D(f TV E NMS n - CSlf In CN hf . p Q y j', y g Q ., f .yo h hit th&

hM $lklut [ h [hf dido 71

• OTHER COMMENTS:

M/Sethu Signature liuId

'/Date cc: Regional Administrator Technical Division Directors ((p$pgt Cognizant Senior Resident Inspector Cognizant DRP Branch Chief Cognizant NRR Project Manager  !

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 kith the date of calibration. date of expiration, and the identity of the person performing the calibration. Beta correction factors shall be 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 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.

Attachment 10

,7 ,

INSTRUMENT INVENTORY Manufacturer /Model On 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 Eberline PRM-6 2 w/HP-270 Eberline RM-14 4 w/HP-260 .

Eberline RM-19 1 w/HP-270 Eberline RM-21-1 2 w/HP-270 Ludlum 3 5 w/ pancake GM Ludlum 2401-P 2 '

Berthold LB122 1 w/100cm: alpha / beta and beta / gamma detector (gas proportional)

Ludlum 2221 2 w/100 cm 243 68 detector (gas proponional)

RATEMETERS (Dose rate)

Eberline 6112B 2 Eberline E-500B 4 Xetex 305 61 Ludlum 2431 EC 4

- MULTI-PROBE / FUNCTION METERS Eberline ESP-2 4 2 w/HP 260, HP-270, PG-2 2 w/HP 260, SPA-6, LEG-1 DIGITAL DOSIMETERS Dosimeter 1888B 6 Stephen 6000 10

. ALPHA METERS l

l Eberline PAC-1 3 w/AC-3 i

Eberline PRM 5-3 3 w/AC-3 NEUTRON METERS Attachment 10a f L J

2 Eberline PNR-4 -- 1- w/ neutron rem ball Eberline PRS-2 1 w/ neutron rem-ball MICRO-R METERS Eberline PRM-7 3 Ludlum '19 5 ION CHAMBERS

~

Eberline. RO-2 5 Eberline RO-2A 4 Ludlum 9 3 AIR SAMPLERS RADECO H 809V-II 5 RADECO H 809C 4 RADECO C 8528 1 RADECO C 828 2 PORTABLE MCA Oxford Prospector 1 i

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? psraco, . UNITED STATES 4  %*a NUCLEAR REGULATORY COMMISSION O REGION 11 AT NTA. dlA 199

%,,.+ April 16.1997 MEMORANDUM T0: Bruce S. Mallett. Director Division of Nuclear Materials Safety FROM: Charles M. Hose . Acting Deputy Director Division of Nuc ear 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 a3 proved in a NMSS Policy and Guidance Directive (PG&D) or in response to a Tec1nical Assistance Request (TAR).

In all cases reviewed, if exemptions were granted, they were either approved by a PG&D or in a response to a TAR. A list of the files reviewed and the exemptions contained in each is attached.

Attachment:

List of Files i

i 1

Attachment 17 L________--_____ _

MATERIAL LICENSE FILES REVIEWED 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 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 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 l

I e

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t

/piacug% NUCLEAR REGULATORY COMMISSION UNITED STATES 8 #

'n REGION 11 E ATLANTA FEDERAL CENTER

$h  %*g'

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,8 61 FORsYTH STREET. sw. su!TE 23T85 ATLANTA. GEORGIA 30303

• • • • • June 30, 1997 MEMORANDUM TO: Donald A. Cool, Director Division of industrial and Medical Nuclear Safety, NMSS FROM. Douglas M. Collins, Acting Director hSY 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 11 licensee exemptions to 10 CFR requested, granted or denied frorn January 1,1997 through June 30,199.7, 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. 4719142-02 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 i 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 I

i i l )

l Attachment 17 a l l l j

,e :

June 30, 1997 ME.MORANDUM TO: Donald A. Cool, Direr tar Division of Indust'ial and Medical Nuclea, Safety, NMSS FROM: Douglas M. Collins, Acting Director (original signed by Division of Nuclear 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 il licensee exemptions to 10 CFR requested, granted or denied from January 1,1997 through June 30,19.97, as listed below:

1.

University of Virginia, No. 45 00034-30, was granted a t.andard 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 130.35,30 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, 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 y30.35,30 day

. exemption from Financial Assurance requirements for a teletherapy source change.

cc: A. Blough, RI R. Caniano, Rlli R. Scarano, RIV EE RII RII RII fg 5IGNATURE ggg NAME DHein JPotter TDecker

r iATE 6/ /87 6/ /97 6/g {S7 6/ /97 6/ /97 6/ /97 6/ /97 CO*V7 YES NO YES NO YES (NW YES NO YES NO YES NO YES NO OFFICIAL RECDAD COPY DOCUMENT NAME: Ga\DNMS\LICKEMP.MEM

-#/ "'%*o UNITED STATES

. g NUCLEAR REGULATORY COMMISSION 1D E 101 MANETTA S E .W.. SUITE 2900 J* ATLANTA. GEORGIA 3024190 ,

' %g .f%. -

,,4 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

~a ddition,.the Region may grant exemptions to the regulations by inclusion of a

' 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 reviewers in Materials. Licensing / Inspection Branches 1 and 2. on granting exemptions to NRC regulations.

s 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 NHSS 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&GO 93-02. The request will be signed by the Branch Chief.

APPROVED BY:

,s

, V Denn P. Pot er, Chief, MLIB2

$A %.j W Charles M. Hosey, Chief, MLIBl Attachment 18

UNITED STATES

[ma mac\o NUCLEAR REGULATORY COMMISSION

/ ,

REGION il y ATLANTA FEDERAL CENTER a

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 Hanagement Directive (MD) 8.8. "Hanagement 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 thb 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 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 may 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 sensitivity to allegations paying particular attention to any public health and safety aspects of allegations.

An allegation is a declaration, statement, or assertion of impropriety or inadequacy associated with NRC regulated activities, the validity of which has not been established. This term includes all concerns identified by J.ources 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 NRC contractors: non radiological occupational health and safety issues; 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 Attachment 24

Regional Office Instruction 3 No. 1030. Revision 9

{

t l documentation within five workino days of receipt of the 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

[ the Director, EICS, at extension 24421.

F.

References:

1. Regional Office Instruction (ROI) 1004, " Notification to the Office of Investigations of Potential Wrongdoing"

2. HD 8.8 "Hanagement of Allegations" '

3. HD 9.2, " Office of the Inspector General"

4. ROI 1801, Revision 2. " 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 FBI," and No. 13 " Coordination with

" Witnessing Unsafe Situations"

7. Allegation Guidance Memorandum (AGM) 96 01, Revision 1.

"Additiona', Heasures to Protect the Identity of Allegers and Confidential Sources"

8. AGM 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. i

,f

- // l,

j. Luis A. Rey e Regional A mi strator

Enclosures:

(See Page 4)

4 Regional Office Instruction No. 1030. Revision 9

. RECEIVING AND PROCESSING ALLEGATIONS 1.1 Incomino Allegations 1.1.1 Teleohone 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 i personnel who open and screen mail will forward all incoming correspondence which appears to contain an allegation to the l' Director, EICS. Both the letter and envelope will be delivered and no copies of such documents / correspondence will be made. Any Regional staff member who receives documents or correspondence, including internal NRC memoranda, which contain allegations, shall forward the

.l documents to the Director EICS.

1.1.3 - A11ecations 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 .

Enclosure 1

{

I i

Regional Office Instruction 3

, No. 1030. Revision 9 i

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.

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 ation within 30 themThe days. to alleger acknowledge receipt also should be advise of the alleg.d of the NR on identity protection and that they will be notified of the NRC findings at the completion 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 and that they have received an allegation. The supervisor shall ensure that the SAC is promptly notified of the allegation.

1.3 Documenting Allegations 1.3.1 It is important to obtain as much information as possible '

i from the alleger concerning 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 Enclosure 5) should be utilized to document all allegations where practicable. A memorandum format may also be used.

1.3.3 The importance of obtaining all possible details concerning an allegation cannot be overemphasized. Evaluation of the 4 allegation as well as the proposed course of action that will be initiated to resolve the allegation will be based on j this initial information. In some instances, the I i

information may be so substantial, technically complex, or l

t Enclosure 1 I u_________. _ _ _ _ . -

' 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 If the be readily-individual receiving and documenting tne 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 i 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 conversation 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, OI Field Office, Region II.

1.4.6 Normally, the receipt of allegations shall not be addressed in Preliminar If, however, ysuchNotifications entries are(PN) or Daily deemed Reports the appropriate, (DR).

Enclosure 1

Regional Office Instruction 7-No. 1030,' Revision 9 organization in the capacity of an NRC licensee: .

Allegations referred to the Office of the Inspector General (OIG):-and Allegations referred to the Occupational

Safety 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_ employee discrimination (as defined in the Energy Reorganization Act)

• may be maintained under the same allegation number if the allegations ar'e 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. '

However, for technical allegations, a new case file should be opened. This is to preclude i 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 l 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.

9 Enclosure 1 i l

l 1

_ _ - _ - _ __ - _ - _ _ _ - - _ - _ _a

Regional Office Instruction 9 No. 1030. Revision 9 1

Concerns requiring immediate regulatory action Feedback to the alleger Technical issues Wrongdoing concerns and recommended OI prioritization Potential for chilling effects 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 3 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. 1 The ARB Chairman is required to review and l l

aaprove all ARB minutes during the ARB. The ARB j 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

! Enclosure 1

Regional Office Instruction 11 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.n as a result of identifying safety concerns, the alleger shall be specificcily 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 D0L under the provisions of Section 211 of the Energy Reorganization Act. The alleger should be informed that the D0L. not the NRC. provides the process for obtaining a personal remedy and relief.

Further, the alleger shall also be informed that although the NRC may investigate the allegation prior to its resolution by DOL. the NRC may choose to wait for the results of the DOL 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 DOL.

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 recontracted by the SAC before the expiration of the 180 day tolling period to determine if the alleger has filed a complaint with DOL.

1.5.8.2. When an allegation of em)1oyee 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 complaint will be entered into the AMS and will be presented at an ARB. The SAC will provide a copy of the written DOL complaint to 01. The SAC shall also contact the l

alleger to determine if the alleger has safety concerns that were not included in the written DOL complaint.

l Enclosure 1 t

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 l licensee until allegation andafter the ARB authorized thehas reviewed and evaluated 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 valia otjections 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 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 received from the alleger. The alleger should be informed that the allegation could be referred outside the NRC for resolution including a referral to the licensee. The 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 Je fully developed and documented in the Enclosure 1

Regional Office Instruction 15 No. 1030 Revision 9 1.6.5.4 The letter referring an allegation to a licensee does not oo in the Public Document Room. A copy of the licensee allegation referral letter is filed in the 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 "Conta".ns Information Not For Public Disclosure. "

1.6.5.7 A determination skald 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 a]propriate 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. j 1.6.6 NRC Independent 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 l performance related to resolution of referred allegations. 1 the degree of independence of the licensee's staff's l evaluation, safety significance of the matter, and level of j licensee management mtentially involved in the matter. The l following examples s1ould be used in determining the adequacy of a licensee's response: l 1.6.6.1 Was the evaluation conducted by a licensee i

entity independent of the organization in which l the alleged event took place?

Enclosure 1 l

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 referral to the appropriate State agency.

1.7.1.2 The Director. DNMS is responsible for ensuring a review and assessment of the adequacy of the State agency's resolution response to a referred allegation.

1.7.1.3 Referred allegations will be closed ~following receipt of acceptable documentation from the State and subsequent notification to the alleger.

1.7.1.4 The Director. DNMS, will forkard allegations made against an Agreement State official to the Director. Office of State Programs, for disposition.

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 agency for resolution.

1.7.1.6 In cases where employee discrimination is alleged against an Agreement State licensee, the l Director. DNMS, will refer the allegation to the Agreement State for follow up only if the allecer acrees to be identified to the Acreement t

Etat.e. The Director. DNMS. Will coordinate the proposed referral with the SAC, who will inform the alleger that the NRC does not have jurisdiction to investigate employee i

discrimination by an Agreement State licensee and unless they agree to be identified to the ,

Statt, no investigation will occur. The SAC will  !

also inform the alleger that it is not possible i 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 1 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 Enclosure 1

u I

Regional Office Instruction - 19 l No.11030.. Revision 9-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 r- coordinate with the Director. DNHS. to ensure that a letter is sent to the alleger advising 4

the alleger of the referral, the agency to which the allegation was-referred and a point of. j l 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 l

amount of information provided.to them, is the responsibility of the Director. OI Field Office.

when possible criminal activity or.other nationally significant inforination 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 DIG in accordance with ROI 1801. " Handling of Allegations of Improper Actions by NRC Employees or Contractors." The SAC will prnvide all associated documents to the DRA.for retention.

i Subsequent contact with the alleger regarding the issue should be referred directly to the OIG.

l i

1.7.2.8 The Director. DNHS. is responsible for ensuring i 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.

Enclosure 1

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.

1.8.5 If available, electronic versicas of inspection, reports. and AERs should be provided to the SAC in addition to the normal 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 ke included in the allegation case file: however, allegation case files will remain open pending resolution of DOL, 01 and related enforcement actions.

1.8.7 Allegation documentation should be handled with extreme care to preserve the fundamental 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 compromise 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 mail and reproduction. personal computer disks. electronic 1.8.8 Proposed language for letters to allegers when OI returns a potential wrongdoing issue 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 circumstances were reviewed, that there are constraints on NRC investigatory resources, and that other cases of higher priority are being pursued.

I 1.9 Allecation Correspondence 1

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 l confidential source are to be stored by EICS in a secure Enclosure 1 1

i Regional Office Instruction 23 No. 1030. Revision 9 1.9.9 No copies or distribution of acknodedoement and closure letters to allegers are to be mad'. except one copy to EICS for the allegation case file. Tne 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 Act (FOIA) potential request. release under a Freedom ofInformation 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 bf 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 Alleaation Records 1 l

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 i "need-to know" basis. In addition EICS shall maintain a document check-out system to record individual access to  ;

allegation case files. Allegation case files may be _ signed  !

out by Region II staff members for period not to exceed five l days. The individual staff member is responsible for the Enclosure 1 l

l

I 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 empidyers 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 l

If an individual is concerned about identity protection, the staff member involved should explain that the NRC protects the identity of individuals who their employer. provide information by not revealing their identity to However, individuals to whom the NRC has not granted confidentiality by written agreement should be informed of the following:

1

1. In resolving technical issues, the NRC intends to take all reasonable efforts not to disclose the identity of an alleger outside the agency unless:

a. The alleger clearly indicated no objection to being identified.

b. Disclosure is necessary because of an overriding safety issue.

1

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 responsibilities  ;

under law or public trust.  !

d. Disclosure is necessary in furtherance of'a wrongdoing l investigation- (e.g., allegations involving record j falsification, willful or deliberate violations, or other  ;

Enclosure 2 '

i

Regional-Office Instruc'tion 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 mlicy not to divulge to others the identity of an individual who has :een granted confidentiality, either during or subsequent to an inquiry based on the information provided to NRC. Within. Region:II, confidentiality 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 L

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 before 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 nvolved with an alleger who requests confidentiality should ontact the SAC.

If the SAC is not available, contact.the' Dir ctor EICS, or a senior Region II staff member who has been authorized to grant confidentiality.

Enclosure 2 i

l . Regional Office Instruction- 5 l No.-1030,-Revision 9-'

i 1

2.3.9 The granting official may withdraw confidentiality following receipt of a written request from the alleger.

2.3.10 The SAC is responsible for maintaining records of the status l of confidential sources and signed confidentiality.

agreements.

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 n

not reveal their identity:

The Region II staff member taking the call may pot have the i

L technical expertise to evaluate the information provided to l

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 )olicy to notify the individual of the responsible agency to w11ch the matter has been l referred.

i After the above points have been ex)lained to the alleger and the alleger persists in not revealing t1eir identity, document the -

allegation in as much detail as contact the SAC collect at (404)possible. Advise the individual to 562 4424 or 1-800 577-8510 as soon as possible to provide any additional information that may be necessary for L the appropriate resolution of this matter.

i

' Once an alleger provides their identity or if the receiving NRC representative 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.

l i

Enclosure 2 l

1

i Regional Office Instruction No. 1030 Revision 9 point to their attention if I desire similar-treatment for the information provided to them.

j 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 an 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.

1 Date Name Address Agreed to on behalf of the U.S. Nuclear Regulatory Commission.

Date Signature Name: 4 l

Title:

i t

Enclosure 3

i Regional Office Instruction 2 No. 1030, Revision 9

2. Record location as accurately as possible in order for someone else to be able to verify.

WHAT IS THE REQUIREMEffr/ VIOLATION?

1. Does the individcal 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? ,

l@ff! DID IT OCCUR?

1. Saecific dates and times determine the procedures in effect at tlat time.

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.

2. The involvement of others becomes a critical factor when dealing with-confidentiality, i

HOW/WHY DID IT OCCUR?

1. The development of information for this question involves the '

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. 1

5. What is the alleger's interpretation of the cause of the problem.

WHAT EVIDENCE CAN BE EXAMINED? -

1. This question should be viewed as if you had to follow up this matter.

Enclosure 4

(

Regional Office Instruction 4 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 01 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 confidentiality, inform the illeger 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 DOL 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 reed allegers the limits, but tell allegers that there are limits on the NRC's ability to protect their identity and that we will also 3rovide a written description of the protection measures NRC takes and t1e limits of that protection.

I I

l Enclosure 4 l

1

Regional Office Instruction 2 No. 1030. Revision 9 ALLEGATION REPORT C0KTINUATION SHEET CASE FILE NO: FACILITY:

SUMMARY

OF INFORMATION ACTION REQUIRED l

PREPARED BY: DATE PREPARED:

Enclosure 5

Regional' Office Instruction No. 1030. Revision'9 u.

i' ACKNOWIFnGMENT LETTER-Alleger's Name

Address

SUBJECT:

ALLEGATION NO. RII-1997 A 0000

Dear Mr./Mrs./Ms.  :

This-letter refers to your (letter, phone conversation, meeting, i.nterview, etc.) with on/ dated in which you expressed concerns related to (name of facility). You were concerned about (brief general

' description such as security, maintenance, operator. qualifications, etc.).  ;

Enclosure 1 to this letter documents your concern (s) as we understand it/them. I 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 LICENSFFK:

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 activities and res:ense, and inform you sf the final disposition. If you have any obiection to t11s aooroach you must contact our office wit 11n 14 days uson receipt of this letter so t1at we can discuss this matter furt ier.

Rt.rumALS 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 name and address not be provided to the state. we will request that the state respond to the NRC. Upon receipt of the state's response, we will mail you a copy.

CERTI:ID MAIL O. XXX XXX XXX ETURt tiCEIP" E00ESTED (Note: Should be on bottom of first page only)

Enclosure 7

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l 1

Regional Office Instruction 3 No. 1030. Revision 9 FOR LETTERS TO ALLEGERS W/0 CONFIDEN'fIALITY  !

Finally. l vou are not considered a confidential source unless an exolicit I reauest of confidentiality has been formally oranted in writino.

USE THIS PARAGRAPH IN Pl ACE OF THE PREVIOUS UNDERLINED SEKTENCE IF THE NRC DOES M VE A SIGNED CONFIDENTIALITY AGREEMENT WITH THE ALLEGER I

With respect will honor the to the Confidentiality Agreement you signed. I assure you that we Agreement.

I would like to point out that licensees can and l

- sometimes do surmise the identity of individuals who provide information to us because of the nature of the information or other factors beyond oQr control.

In such cases, our policy is to neither confirm nor deny the licensee's assumption.

I

\

i FOR ALLEGATIONS REGARDING IMPROPER ACTIONS BY -

THE STAFF With resaect to your concern (s) regarding alleged improper actions by the NP.C 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 ADDITIONAL INFORMATION IS NEEDED FROH THE ALLEGER t

In reviewing your concern (s), we have determined that we need additional information concerns.

from you~ before we can proceed with our inquiry into your without success and) I would appreciate your calling me toll free at(If a 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 (chone number) at your earliest convenience so that we may proceed with our inquiry into this matter. If I am not available I at I canthe return time of your your call, call. please ask for (NRC employee) or leave a message so 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) m3y be extended. However, please be assured that the NRC will take appropriate and necessary action to maintain public health and safety.

Enclosure 7 L---------_------- -)

Regional Office Instruction 5 No. 1030. Revision 9

' FORMAT FOR THE ATTACHMENT PAGE ~

Concern 1; (Describe the alleger's concern.)

Concern 2.

(Describe the alleger's concern.)

0 g

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i

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Enclosure 7

Regional Office Instruction 7 No. 1030. Revision 9 CLOSE00T LETTER TO THE ALLEGER Alleger's Name and Address

SUBJECT:

ALLEGATION NO. RII 1997 A 0000

Dear Mr./Mrs./Ms.  :

GENERAL LETTER This is in reference to my (date), letter which indicated that we 'would initiate action to review your concerns related to issue s)). The NRC has completed its follow up in response to the concern (s() you(brought to our attention on .

The attachment to this letter lists your concern (s) and describes how the NRC resolved the concern (s) you raised.

SUBSTITUTE THE FOLLOWING PARAGRAPH IN CASES WHERE 'IHE ALLEGER PROVIDE ADDITIONAL INFORMATION. AS NEEDED OR RE00ESTED 1

This refers to our letter to you dated _ , in which we requested that you contact related to us to provide additional information regarding your concern (s) 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 tho.se areas during their routine inspections.

USE IF NRC ACTION IS COMPLETE AND INVOLVED 2.790 INFORMATION. IN WHOL PART AND INCLUDE ON ATTACHMEffT PAGE (However.) your (other) concern (s) dealt with (physical security matters, proprietary information, pers.eal 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.

-(Make a statement as to whether or not the concern was substantiated, unsubstantiated, or partially substantiated, without providing specific details of the findings.) l l

l CERTIFIED MAIL NO. XXX XXX XXX RETURN RECEIPT RE0 VESTED (NOTE: This should only be on the of first page.)

l Enclosure 7 1

H I Regional Office Instruction 9 No. 1030. Revision 9 1 t 1 FORMAT FOR THE ATTACHMENT PAGE ALLEGATION EVALUATION REPORT ALLEGATION RII-1997-A-0000 ALLEGED FAILURE TO PERFORM RADIATION SURVEYS TURKEY POINT NUCLEAR PLANT DOCKET NOS. 50-250 AND 50-251 .

ALLEGATION:

Hake 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 k 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 activities.

caused the licensee to use maintenance personnel to perform i

health physics DISCUSSION:

What Example:

did you verify? Discussions, observations, review of records, etc.

Through discussions, observations and review of records, the inspector was able tohealth some verifypnysics that theactivities.

licensee utilized maintenance personnel to perform Surveys were performed by maintenance personnel but they received training and were under the direct supervision of senior health physics personnel.

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 ments.

can be substantiated and not be a violation of NRC require-

4. Do not discredit the alleger because an allegation was not substantiated.

l S. Remember, you are writing this enclosure to the alleger.

Enclosure 7

_ _ _ _ _ _ _ _ _ _ _ _ _ - _ - - _ _ _ - _ _ _ _ - - _ - _ - - - - - - - - - l

4 l

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Regional Office Instruction - 11 No. 1030, Revision 9 i

LICENSEE REFERRAL LETER July 14, 1997 Florida Power and Light Company ATTN: Mr. T. F. Plunkett -

President Nuclear Division P. O. Box 14000 Juno Beach, FL 33408 0420

SUBJECT:

ALLEGATION N05. RII-1997 A 0120 AND RII 1997 A 0121 ~

Dear Mr. Plunkett:

The Nuclear Regulatory Commission (NRC)' recently received information concerning activities at your St. Lucie facility. A descr,iption 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 datecompleted your of this letter ofavailable action the resolution for NRC of this matter and make the records of 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 concert:, 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 Ms. 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. The affidavit required by 10 CFR 2.790(b) must a company your response if proprietary information is included.

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."

ENCLOSURE CONTAINS INFORMATION NOT FOR PUBLIC DISCLOSURE Enclosure 7

I

)

l Regional Office Instruction 13 No. 1030. Revision 9 j

INFORMATION

SUMMARY

FLORIDA POWER AND LIGHT COMPANY ST. LUCIE NUCLEAR PLANT RII 1997 A 0120 RII-1997 A 0121 Region II received information related to practices at th'e St.

Lucie Nuclear Plant. Allegedly, the Operations suaervisor required an Assistant Nuclear Plant Operator (ANPO) to assume the duties of the backup Fire Team ANP3 Leader and did not meet the requirements to perform'the duties of the Fire team Leader.

Allegedly, the Alternate Fire Team leader on containment to wrform work and if a fire were to occur,had entered responding to it properly would a difficult because containment was difficdit to get out Allegedly, there once was a Night Order that stated that the Fire Team of.

members could not enter the containment.

4 NOT FOR PUBLIC DISCLOSURE Enclosure 7 1

• * *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 OFF!CIAL USE ONLY SPECIA _ F:ANDLING REQUIRED 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 ,

1 Enclosure 8

PRINCIPLES OF PERFORMANCE BASED INSPECTION Definition 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.

Expectations durina Inspections 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 bs 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.

l

-Keep mission in mind (Mission: assure safe and reliable operation).

Attachment 25

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1 i

2

-Determine root causes for performance deficiencies (i.e. examine to .

see that address ulderlying conditions in addition to acute conditions).

-Follow-up on unsafe work practices until it is determined that the licensee has the issue under control.

-Independently verify licensee statements.

-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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L_----------------------------------------

January 14,1998 DNMS ALLEGATION TIMELINESS REPORT 1

k 20 18j .

16 ,' .

1 8f i 6' -

i g i

// AfNfl7 k

>30 >60 >90 >120 >150 >180 Attachment 2 b.

I DIVISION OF NUCLEAR MATERIALS SAFETY FY97 SELF-ASSESSMENT PLAN l

l Attachment 26 c - _ - - - -- - -

-DNMS Self-Assessment Plan for Fiscal Year 1997 l

. l Objectives:

1 L1. . To establish a process by which the Division of Nuclear Materials Safety (DNMS) conducts its periodic assessment of performance.

2. _To provide a systematic approach to evaluate strengths and weaknesses in the programs assigned to DNMS.

- 3. To provide input into decisions where the performance should be modified to make work better or improve to the expected level.

Process:

The routine process consists of the following:

1. Quarterly evaluations and reporting of results to the Division Director by each Branch, the Agreement Stata Program Officer, and the Technical Assistant (for laboratory activities) using the performance indicators and measures specified in this plan. Some elements and their measures must be reviewed monthly to effectively correct poor performance. These'are indicated by an "*" next to the standard.

2. Annual evaluations at the Division Director level, independent of the Branches, in program areas listed below for Fiscal Year 1996:

a. Allegation plan timeliness and implementation (scheduled for March 1997).

b. Inspection report quality (two peer reviews scheduled for December 1996 and June 1997).

c. Review of implementation of IMPEP corrective actions (scheduled for January 1997).

d. Review of license exernptions issued (scheduled for February 1997).

e. Materials licensing action quality (conformance to SRPs, etc.)

(scheduled for May 1997).

f. Review of fuel facility security and emergency plan changes (scheduled for November 1996).

. g. Security of Financial Assurance documents (required annually by MD 8.12) 4

_____._m.___ _ . _ __ _ _ _ _ ._..___..-.__.__c-_

2 Performance will be measured in a " windows" format with an overall " roll-up" indicator for each Branch based on performance indicators for each element. The definition for the overall and each element indicators is as follows:

For Ratino Overall Performance in Each Branch GREEN All indicators in the elements are green.

YELLOW One or more yellow ratings for elements indicators.

RED One or more red ratings for element indicaton.

For Ratina Each Element Indicator in Each Branch GREEN Performance meets or exceeds the expected standard.

YELLOW Performance generally i.aticfactory, but needs improvement to meet or exceed the standard.

RED Performance is unsatisfactory, since it does not generally meet the standard.

PERFORMANCE ELEMENTS AND STANDARDS Proaram Area: On Site

1. Performance Element: On site time Standard

-For the materials program the Branch hours expended on inspections meets 28% of the time allocated for inspection.

-Onsite time in accordance with Regional goals for fuel facilities.

-Backshift inspections performed in accordance with Regional goals.

-Licensing site visits for significant changes to programs.

l -lMPEP reviews assigned to the Agreement State Program Officer (ASPO) completed in accordance with assigned schedules.

-Support to Agreement States provided when requested by States and agreed to by Region 11 management.

2. Performance Element: Use of technically qualified staff Standard:

Attachment i

3

-Staff training completed in accordance with MC 1246 (or MC 1245

- for staff previously qualified). .

-For.those staff' qualified under MC 1245, completion of courses in.

MC 1246 in accordance with the Training Plan.

-Staff used are qualified for job assigned.

-Incident response training completed as identified in regional training procedures. (10/3/95 memo from AEOD)

-Management oversight of staff in field in accordance with ROI and MC.

-Annual IMPEP training completed for IMPEP team members.

3. Performance Element: Appropriate backup for functions Standard:

-Qualified backup individuals for each key fu'nction performed by Branch.

-Individuals available to perform key functions each day of business (e.g.,. classified document handling in FFB, safe closure each day, processing license applications, processing reciprocity requests, evaluation of events).

4. Performance Element: Adequate use of budgeted FTE's Standard:'

-Actual expenditures meet. budgeted FTE's in Regional Operating Plan.

Proaram Area: On Time 1.. Performance Element: Allegation follow-up Standard:

-Allegations timely closed in accordance with MD 8.8 and ROI 1030.

-180 day total for closure

-plans approved prior to inspection

-referrals to Agreement States within 30 days.

l

2. . Performance Element: - Inspections performed Standard:

-No overdue inspections (in accordance with IMC 2600,2800 and/or 2545).

Attachment  !

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= _ _ _ _ _ - _ _ _ _ .__ _ _ _ 1

1 I

4

-Inspections of new materials licenses in accordance with IMC 28bo.

-inspections of Navy and reciprocity licenses in accordance with IMC.

-Survey meters calibrated and sample analyses completed in accordance with schedules established.

l

3. Performance Element: License reviews Standard:

-New materials licensing cases completed within timeliness specified in Regional Operating Plan. Effectively reduces backlog of old cases.

-Security plan reviews for fuel fa'cilities and research reactors completed within the timeframes specified in Regional Operating Plan.

-Materials lic.ense and security plan change applications processed timely.

-Reciprocity' reviews timely processed. (Within two working days of receipt).

-Acceptance reviews completed within 30 days of receipt.

4. Performance Element: Open items Standard:

-Unresolved items closed within six months of identification.

-lFl's closed within 12 months of identification in most cases with less than 10 cases over 12 months old and no case over two years old.

5. Performance Element: Event Response

-Events responded to in accordance with safety significance.

-Response to medical events and abandoned sources meets timeframes specified in IMC.

-Abnormal occurrences identified within quarter of occurrence and processed in accordance with timeframes in MD 8.1 and guidance from AEOD.

-Coordination of significant events to program office within one t

working day.

-PNs and Morning Reports meet timeliness goals of ROls.

6. Performance Element: Documentation of results Standard:

-Inspection reports issued within timeframes in IMC (max = 30 days for routine).

Attachment

S

-Materials field note inspection reports reviewed and issued within 30

' days of end of inspection.

-inspection reports and materials licenses timely fileM io docket files.

-Draft IMPEP reports provided to SP within 30 days of. exit (for those  !

IMPEPs where ASPO is team leader). - For those cases where-Region 11 ASPO is'a team member, draft inputs to the report in five. working days.

7. Performance Element: ' Enforcement actions Standard: -

-Routine enforcement' cases delegated to Region completed within 49 days of inspection completion date.

-Routine enforcement cases not delegated tg Region - memorandum to OE within 42 days if inspection completion date.

-Exempt cases (less than 100 days total)

8. Performance Element: Action items Standard:

-Completion of action items (DAFFYs and DAITs) within timeframes i established by the requestor. '

PLooram Area: On Taroet ~!

1. Performance Element: Technical quality l

Standard:

-inspection findings well-founded (supported by facts and relationship to regulations clear).

-inspection safety issues identified and followed up; generic safety e

issues addressed.

-Follow-up inspections address open items from previous inspections. i

-inspections and license review performed in accordance with guidance in IMC and NMSS P&G Directives.

-Results and scope of inspections and license reviews are performance-based.

-Licenses address request or communicate difference to applicant.

-Inspection and license review findings reviewed by management.

-lMPEP reviews in accordance with MD 5.6 and IMPEP Manual.

Recommendations to Management Review Board well founded technically and performance-based.

Attachment

i 6

-Sufficient number of operable survey meters a

2. Performance Element: Allegation follow-up Standard:

-Closure packages and documentation address allegations and reference inspection reports.

-inspection plans adequate to address allegations and not disclose alleger.

-Findings reviewed by management. .

{

-Safety significance addressed.

3. Performance Element: Completion of planned program Standard:

-Completion of budgeted core and total materials license casework (from C-3).

-Completion of budgeted core and totalinspections (from C-3 and Due List).

-Maintenance of fuel facility site activities matrix and review for trends.

-Technical assistance to states, state regulation reviews, and exchange of information is provided as needed.

4. Performance Element: Inspection report and license documentation Standard:

Management review and signature in accordance with ROl's.

-Reports and licenses contain few typographical errors.

-Peer review results indicate reports consistent with IMC.

-Licenses consistent with NMSS P&G Directives and SRP's.

5. Performance Element: Enforcement actions Standard:

-Final actions taken in accordance with enforcement policy.

-Violations have basis in requirements and written to have parallelism between requirement and " contrary to" statement.

-NCV's issued in accordance with criteria in enforcement policy.

Attachment

7

6. Performance Element: Event response Standard:

-Incoming events evaluated and safety significance identified.

-Safety issues followed up.

-Special inspections (e.g., medical misadministration, AIT's) follow guidance in MDs and MC's.

-incident to ponse procedures for agency response followed.

-Generic safety issues addressed.

4 1

i i

Attachment w_=____--____-_____________-_-___ _

.,s.

October 20. 1997 NOTE T0: Regio Manager FROM:

'9 s A. .Reyes. Regiona 4

ministrator

SUBJECT:

R ION II OPERATING Lc FOR FISCAL YEAR 1998

' Attached is a copy of the Region II Operating Plan for this fiscal year. It is important that you review with your staff and that you and your staff understand how the )lanned accomplishments, output / outcome measures and targets relate to tie Agency's Strategic and Performance Plans.

Now that the Operating Plan is issued. you should initiate actions to track progress toward completing the accomplishments and measures in accordance with the targets. In addition, you should incorporate the measures in your next self-assessments and provide input for the program offices

• quarterly reports to the Per.formance Review Committee.

If you have any questions please contact Bruce Hallett or me.

Attachments Region II Operating Plan -

1 I

e l

i Attachment 26a l

. [*

• u UNITED STATES

/ jam arc 'o NUCLEAR REGULATORY COMMISSION s' 8 5

k REGION 11 E ATLANTA FEDERAL CENTER

{ 5 #

$ 61 FORSYTH STREET. SW. SULTE 23T85 ATLANTA. GEORGtA 30303-3415 October 17, 1997 MEMORANDUM T0: Hugh L Thomp ,

Jr.

Dep Exec iv Di tor for Regulatory Programs FROM:

s A. R es. Regio ministrator

SUBJECT:

REGION II OPERA N PLAN

^ ~

Attached is the Region II Operating Plan, which implements the' goals and strategies in the Agency's Strategic and Performance Plans. The planned accomplishments and associated measures are listed for Fiscal Year 1998 and the resources are projected through Fiscal ' Year 2000.

As indicated in earlier discussions. the Operating Planiincorporates the guidance contained in the August 26, 1997 memorandum from Joe Callan and the guidance contained in documents submitted by the Offices of Nuclea; Reactor Regulation and Nuclear Material Safety and Safeguards. We have also had the Plan reviewed by these offices and held discussions with the Office of Enforcement to incorporate their input. The alanned accomplishments and output / outcome measures are consistent with tiose in the Operating Plans submitted by)the other Regions.

We appreciate your support in developing this approach to the Operating Plan, since we believe it provides to all employees a visual linkage between the Agency goals and the Regional planned accomplishments. If you have any questions, please contact Bruce Mallett at (404) 562-4411.

Attachment:

FY 1998 Regional Operating Plan cc w/ encl:

S. Collins. NRR C. Paperiello. NMSS T. Martin. AE00 J. Lieberman. OE R. Bangart. OSP P. Norry. DEDM A. Thadani. DEDE H. Miller. RI A. B. Beach. RIII E. Herschoff RIV

,a o

Y 1998~ 1 GIONA_ 03 E RA I VG 3 AN _

REGION II -

l l

1 l

u 4 l

i In accordance with the Office of Management and Budget. Circular No. A-11. the  !

contents of this document are not publicly releasable. Requests for the document should be referred to the Director. Division of Resource and Administration. Region II. USNRC.

1 l

L_-__-----______-_------____---------_---___-

.x TABLE OF CONTENTS INTRODUCTION PAGES PART A: PLANNED ACCOMPLISHMENTS BY PROGRAM AREA SECTION I: PLANNED ACCOMPLISHMENTS AND OlfTPUT HEASURES LINKED TO THE NRC PERFORMANCE PLAN GOALS

1. Program Area: Reactor Licensing -

1

2. Program Area: Reactor Inspection 4

3. Program Area: Reactor Performance Assessment 17

4. Program Area: Fuel Facilities Licensing & Inspection 21

5. Program Area: Nuclear Materials Users

40 Licensing & Inspection

6. Program Area: State Programs 56

7. Program Area: Reactor /Haterials 58 Enforcement Actions

8. Program Area: Independent Performance Evaluations 65 SECTION II: SIGNIFICANT REGUl.ATORY EFFECTIVENESS / EXCELLENCE INITIATIVES PART B: REGIONAL MANAGEMENT /0 ORGANIZATION ACTIVITIES 73 i

INTRODUCTION The Region II Operating Plan provides the major planned accomplishments of the Region for Fiscal Year 1998. It also ]rovides projected resources through the Fiscal Year 2000. The plan reflects tie guidance provided by the EDO in an August 26. 1997 memorandum. The plan will be used to provide overall direction for Regional operations. It is structured to show a direct linkage to the goals and strat5gies described in the NRC Strategic Plan (NUREG-1614.

Vol. 1. September 1997) and FY1999 Performance Plan (Issued September 1997).

The Operating Plan is divided into two major parts: Part A is divided into two sections.Section I lists the planned accomplishments with performance output measures and targets that will be conducted in the Region. They are organized first by Program Area. Within each Area, the planned accomplishments are listed under each FY1999 Performance Plan Goal and Strategic Plan Strategy so that the reader and user can visualize a direct link to the goals and strategies.Section II lists the significant regulatory effectiveness / excellence initiatives that will be conducted by the Region.

Part B provides the Regional / Organization Activities planned by the Region.

n In accordance with the Office of Management and Budget. Circular No. A-11. the contents of this . document are not publicly releasable. Requests for the document should be referred to the Director. Division of Resource and Ad7 Ministration. Region II. USNRC.

1 i

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B. Goals / Planned Accomplishments /0utput Heasures By Strategic Arena

1. Strategic Arena: Nuclear Reactor Safety Gene?5VGdsly ?:Pr'eventiradi~athn7 'rb1htedideath5?or%.i1Tnesieifd6~e:t6pt.~?S@

--%M.<.a-edci'v.i.1:ianenticlear..re'act6rs0(Go~alLI-)C

-: .  : =-

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---

+%=..- ms m +.

c. a a. .na vvw :- - -. . r vr w w re.m.

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• i-*

.& 2 y . ' %R :

• -"~Zero'ni W' =V.d.??

civilian nuclear ' .+J+*$5Ex.W reactor accidents R+% ~(Goal *I)r " ~"""*

- .w . . , .. s -. w.w -. . ~ .a. ~. 2. .- - - _~. --.:-~, .- -- -

• b Haintaji n k.1 oMfrequenc'yf ofee' ents v Whi ch "coul d si e ad Ttoi:a isev e're7 hcci dent 3.t !.(Goal 3 -A.-1)A/7z'"* "~ ' ~ C '- S ~ '

.c~~':.:. :E.i.ll*

3,* b ;. %*::T.yd.:.Q':-f:

• ~ C Zero deaths ~rdue:to radiation;or1 radioactivity releases from civilian

~ ' nucl ear rea~ctors ~'(Go81'I . A) ~~'~' -~ ~ ^ y- ' ' ^~"""'--~"" ~

..-v a r.: .v .e -

• Zero significant radiation exposures due to civilian nuclear reactors

.fGoal;I.B.1);

. -.v- -. .. .

Strategy NRS 1.1 - Assure that licensees discharge their primary I

)

y. . 6- ~ . - . 06n:f..respon5ib.iljty}for;,3 conducting shfe. operations.

.- . . . .. p . . . . . . . . , .

~

Substrategy',NRS.1'.T:3~ TRegUlady assess',9bjectivsly measurb,'and:reportion .

. A':. F .~S J . f~D *f:.,"-licensees.'.~.per.formance'. fuse this tinformat~ ion -to M.%-C

~ -

x.:w ;.: W~i'dentify-adverse' safety; trends-and to . identify-early l l

individual plants with declining p'erformance.

Increase our regulatory attention o'ri th6s'e'licsris'ees with marginal performance, including halting . i

- o. : - u

' . -t ~

~6per:ations if perforinance; falls' below an acce) table i level, and distributing inspection resources aased i on licensee performance. -

1 I J

I

..s Planned Accomplishments:

NRS 1.1.3.1 Meet licensee demand for initial operator license examinations.

Measure: Percentage of requested examinations that are

- \

conducted. (Target: Conduct 90 percent of i

requested examinations) ,

l

2. Strategic Arena,: . Excellence Gendral YG6al ffInUhe3 NRC': rig ~ul~atofygpfo'gr'annwillibe2 AfficibhtWndisill?9W set 39e?!3Mbil ciwjthe] Nat30n3tols,afe,]y 31 T: .cy;w&a%@a. w!.u.cf7131 a.n.ma:purp,oses.

r n.c.m .. m PeM.or. v .,nc.5.Lnucleil

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.,.~M. :

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' '. t

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' u .. -$ : .: ' -1 4WImpl; medtl.thejalg' enc;&T ~'"y'cs;pl anifdriregul ithry-: excel l ence e

&&R MW.~ .. . ;-;~.L 4. : . . .

, . :+ ~ .

E LEQiluatefan'dfi lement'rnee'dedtiin ~ "'f.

d$EjirFclids's's%WJ yM219'99WP(GEaktovemsnts"for.IfiO67ms'i6r.tNRC3. -

VII-:BT)Wm"*% Mi#96-M' .

i S.tfatB'gy'EXU:21 F e W:n-@WiMi.G1.TWetsilMmake.s egulatory;exc'and "MMfoi: allfbf."bitrbstrategies ell' encelthiYc6fn'eFXt6ned factiviti sMaiWW:69 Sub.sttategy@Xd:Elf 1: <.s

..#7 " .39We;williproactively.exiniinecourEprogFams#ndk performance in. order-to: improve.the way we:do.our - .^ f

" work'through comprehensive,. systematic; agency-wide i

- . .: 4. '- t -. . )

m-, .

approach.to program assessment and improvement. - ~

Planned Accomplishments:

EX 7.1.1.1 Conduct quarterly self-assessments of operator licensing performance on the basis of specific. criteria with performance measures to ensure programs meet management expectations for on site. on time, and on target.

Measure: Completion of self-assessment each quarter (Target: One per quarter) e 'E 1 Sub.strat'.c_D.y'

, - .. e 7p.X7.g.c2:C.'We:wi.l.1;"imple~meht

.e chang'esito-impf.ov~e:theM'g;p+

m m;;gz+;.~-M..w, xyu .f.fe.ctiyen..es~s. :an.d feff.ic~ie6cy of: our,.re~gulato.ry '

m.e c <

programs and our. management and support: activities.,..> .

Planned Accomplishments:

EX 7.1.2.1 Implement changes to internal processes on the basis of lessons learned and the results of self-assessments in FY1997.

2

l Measure: Number of changes / improvements implemented (Target: 2 process changes in FY98)

Substrategy EX'7.1.4: Provide training and development-:toidUr."_itEff..to -

n,.- .

.~. _ . u.:

~ gnable us, to ach.ieve exce]lence.jnjour.__.. organization'aban a :.:.:-;

Planned Accomplishments: , , , ,, , _ , ,_ ,.

EX 7.'1.4.1 Plan and implement training in accordance with MC 1245

, requirements. or operator. examiner standards. .. .

1 Measure: Individual training requirements that meet all MC 1245 requirements or operator examiner.

standards. (Target: MC 1245 requirements met for refresher training in 90 perc6nt of cases:

-required non-technical training co7plete in 90 percent af cases)

EX 7.1.4.2 Complete the FY 1998 training plan. ,

Measure: Completion of planned training activities fdr region-based license examiners. (Target:

90 percent completion of training designated by the Regional training co7mittee.)

a k

3

B

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B. Goals / Planned Accomplishments / Output Heasures By Strategic Arena

1. Strategic Arena: Nuclear Reactor Safety

.I General : Goal: Prevent radiation related deaths or illnesses due to civilian nuclear reactors Perforrnance Goals: ,

Zero civilian nuclear reactor accidents.

- (Goal I.A) -

>Haintain-' low probability.of events'which could lead _tsa : severe.

"~ '~

. accident.:".'.(G. oal :I, A.1) ' '.- ;;

~.. . .

• ;-Zero deaths"due.t'o. radiation-or radioactivity releases from. civilian '

': nuclear . reactors. -(Goal'.I.B) u.- -

• Zero;significant. radiation exposures due -to civilian.nuclearJreactors.

- (Goal 1 B3)

~

. c- '

Strategy NRS.l.1:.~

~ - .We williassure that licensees discharge their" primary ~ responsibility for conducting safe

. operations.

Substrategy NRS 1.1.2: We will communicate with licensees to facilitate a clear understanding of existing and emerging regulatory requirements.

4 l .

Planned Accomplishments:

NRS 1.1.2.1 Conduct an NRC/ Utility workshop for Region II licensees to discuss current and emerging regulatory issues.

Measure: Canpletion of NRC/ Utility Workshop (Target: One

. Workshop canpleted in FY 98)

NRS 1.1.2.2 Meet with site management during periodic visits and communicate existing and emerging regulatory requirements.

Measure: Number of management site visits (Target: Each site receives a visit by a senior manager once per year and by a DRP Branch Chief once per quarter) 1 Substi'ategy,NRS;1?ll.~3:MWe.wil.Lregular-lytas'sss5. ~6bjectively measure ~.Tand' ~

" *~* ' 3,2$-%.Ereport;6niliden'sehs':/ performance.- We will use this

. ~J -information -t'o.. identify adverse. safety trends and to 4

'.".EW. M'@d}b .aidentify, ear.lysindividual

.$@[i d..;. f iperfpfmapce.h

3. k@NGr,qtt.ention We plants.withJdecTining",

f-gfst ion.fho.iillse-inerease",'60r regulatory::-

1,1censees with marginal,

~,.y; ' :m ce; per.formance.. including halting operations if:

.. .,.w.; -

id.Nfhe: . . L:mg6dh-$.disti.ibutingges,6drcis M: 0- based,;on Aicensee ~.w:per

~ '

performance.

Planned Accomplishments:

NRS 1.1.3.1 Maintain a plant issues matrix (PIM) for each plant in order to capture and to aid in the evaluation of objective plant inspection information.

Measure: Timeliness of PIM entries (Target: PIMs updated within two weeks after issuance of each inspection report for 90 percent of PIMs for each SALP and PPR)

NRS 1.1.3.2 Conduct management meetings with poor performing plants to communicate NRC's concerns and to evaluate corrective actions.

Measure: Number of management meetings (Target:

Bimonthly meetings at designated plants)

NRS 1.1.3.3 Review INP0 evaluation reports to verify that the assessment is consistent with NRC evaluation results and to identify any unreported safety issues.

l l Measure: Timeliness of review of INPO report (Target:

l Review of final report by SRI within 30 days of report issuance and by DRP Branch Chief within 90 days of report issuance for 90 percent of reports issued) 5

i NRS 1.1.3.4 Monitor allegation receipt to identify early indications of declining performance.

l Measure: Conduct detailed analysis of the number of l allegations and their character for plants indicating an malies in allegation received.

(Target: Twice per year)

'NRS$1:114:ZWefwi P:

Substriitsgy$.'MMf3Nnwith-o]lfmaksClicenseeiperiornianceland

" * * $MS cdmpl.ian y.3 .' / T F O.thelins d.;vy$9NYN.F$$assissil5Ection

% frbguency:foh:g'ood.performei's'and1.-:-i ngpiialtissM6 poo6'p.erfoFmers: " ? </< T .

Planned Accomplishments:

NRS 1.1.4.1 Allocate the regional initiative inspection res'ources following PPRs and SALPs so that the combined inspection effort reflects the performance for each site.

Measure: Caplete regional initiativg inspections as listed in last two PPR letters (Target:

60 percent of planned initiative inspections)

NRS 1.1.4.2 Support headquarters inspections for poor performing plants and generic issues, and respond to significant events in other regions.

Measure: Number of requests for inspection support outside Region II (Target: 80 percent of requests supported)

NRS 1.1.4.3 Identify and take enforcement against licensee's who fail to comply with regulatory requirements in accordance with NUREG-1600 and the Enforcement Manual.

Measure: Conduct enforcement panels to coordinate potentiel escalated enforcement. (Target: As needed on a weekly basis with appropriate panel material provided to participants 48 hours5.555556e-4 days <br />0.0133 hours <br />7.936508e-5 weeks <br />1.8264e-5 months <br /> in advance)

Measure: Timeliness of Non-exempt escalated enforcement (Target: Process 90 percent of cases within the timeliness goals established in Section 5.6 of the Enforcement Manual with all non-exempt cases issued within 90 days, except those case types with a goal of 105 days)

Measure: Review OI investigative findings for appropriate enforcement action. (Target: Review 01 report within 45 days of Of Report issuance for potential enforcement) 6

Measure: Issue Confirmatory Action Letters as needed to confirm licensee corrmitments regarding emergent safety issues. (Target: CALs issued within two days of receiving co7mitments frcm licensees 90 percent of the time)

Measure: Review non-escalated enforcement for consistency and compliance. (Target: Participation in 1 Peer Review and completion of 1 audit of a

. representative satrple of inspection reports)

NRC 1.1.4.4 Implement the "N+1" resident inspector policy.

Measure: Number.of resident inspectors assigned (Target:

All sites staffed to N+1 with exception of those sites with approved exemptions)

~

Subs ~tratbgy?NRS$14.'6'MWeTwill finsp~e.ctrlicen.s'ees.*l-loperat' ions and*idtiVities

W : ; r .c 7. ;. J 2to : help ~ ensure that-licenseesidentify..and ' resolve -

Yahi s? ' * '

Planned Accomplishments:

NRS 1.1.6.1 Complete the core inspection program at each facility.

,^ Measure: Percentage of plants where core inspection procedures are coqpleted. (Target: All core inspection procedures completed for all SALP cycles that ended during the FY)

NRS 1.1.6.2 Complete baseline inspections at all sites for the maintenance rule.

Measure: Number of sites where baseline inspections for the maintenance rule are ccmpleted. (Target:

All Region 11 sites by end of 1998)

NRS 1.1.6.3 Conduct restart inspections at Crystal River as defined by the restart matrix included in the Manual Chapter 0350 minutes.

Measure: Coqplete MC 0350 restart matrix for Crystal River. (Target: Complete prior to authority given to restart plant)

NRS 1.1.6.5 Conduct regional initiative inspections based u)on the results of the plant performance reviews and SA_P board meeting conclusions.

Measure: Planned initiative inspection hours at each facility (Target: Total inspection hours at the Region 11 facilities ccamensurate with conclusions from board) 7

I NRS 1.1.6.6 An augmented inspection team (AIT) will be sent to investigate each event as determined by agreement between AE00. NRR, and Region II.

Measure: Number of AITs conducted (Target: AITs conducted in accordance with criteria specified in MD 8.3)

NRS 1.1.6.7 Maintain on site coverage by qualified inspectors at each operating commercial nuclear power reactor site durim the site's normal working hours.

Measure: Number of instances where tt.ere is more than one consecutive normal workday in which there is no covera Zero) ge by a qualified inspector (Target:

NRS 1.1.6.8

" Expeditiously determine the safety significance and validity of allegations received.

Me.asures: Proriptly assess and acknowledge allegations received. (Target: 90 percent of all cases will be reviewed by the Allegation Review Board and acknowledged within 30 days of receipt, and 18 months for allegations involving wrongdoing)

Measure: Timely closure of allegations. (Target:

n Closure of all assigned allegations, not involving wrongdoing or dis:rimination. within 180 days of receipt)

NRS 1.1.6.9 Assess events both at the site and from the regional office to ensure safety issues are identified and addressed early.

Measure: Timeliness of reviews of licensee event reports (Target: 90 percent of LERs reviewed within 90 days of report issuance)

NRS 1.1.6.10 Identify and address generic significance. plant-specific safety issues that have Measure: Number of proposed information notices and p(otential generic Target: Five issues information proposed forwarded tonotices NRR or Task Interface Agreements in FY98)

NRS 1.1.6.11 Document the results of the inspections conducted.

Measure: Timeliness of issuance of inspection reports (Target: Reports issued within 30 da 1

of inspection in 90 percent of cases,ys andof45 end days for team inspections) l 8

I NRS 1.1.6.12 Implement temporary instruction inspections.

Measure: Percentage of temporary'instructfans completed within established schedules. (Target: 90 percent) j NRS 1.1.6.13 Support 01 investigations.

Measure: Percentage of support requests conducted.

. (Target: Provide requested technical support to 0180 percent of the time).

~

NRS 1.1.6.14 Control and monitor employee's radiation dose and implement controls for use of radioactive materials by staff.

Measure: Implementation of MD 10.131. (Target:

Implementation af ROI 2130. Radfation Protection

. Manual and ROI 2132. Region II Personnel Monitoring Program)

NRS 1.1.6.15 Ensure that supervisors accompany inspectors on a periodic basis.

Measure: Number of inspection accompaniments. (Target:

Branch Chiefs will accompany an inspector quarterly and each inspector each fiscal year and will acca7pany new inspectors more a frequently)

Substrategy NRS.1.1.8: We will . maintain and exercise an incident. response capability to. ensure that licensees and the NRC are prepared to respond to radiological emergencies.

Planned Accomplishments:

NRS 1.1.8.1 Sup) ort each incident response exercise by providing tecinical managers and staff personnel qualified to function in the incident response center.

Measure: Number of exercises performed (Target: four exercises per year)

NRS 1.1.8.2 Respond to incidents with qualified individuals to assess radiological emergencies and provide accurate assessments to >

response managers.

Measure: Membership and training qualifications of all reactor safety team and protective measures team. (Target: completion of semi-annual training)

NRS 1.1.8.3 Maintain sufficient number of qualified individuals for emergency response in the Region.

9

Measure: Nurber of personnel designated for each position.

(Target: Maintain depth of three people in each position)'

'NRS 1.1.8.4 Review changes to licensee's Emergency Plan.

Measure: Quality and timeliness of all &nergency Plan (Target: 80 percent of licensee's

- +

• changes.

energency Plans reviewed within 60 days of receipt)

. e O

9 it

?

4 4

10

2. Strategic Arena: Common Defense and Security and International Involvement GeneralIGoali~! ::-Prevent'theloss;or ' theft 'of!special. nuclear. materials ,

. <-N:

- ' m5'Mregdlat'ed'by. the NRC'f?and ' support'U:S!? national.. interests-

.# .iin ths.sife:uss:offnuclear. materials and.-in.non -. ,-

.$.M/,, d& proliferation.f :(Goal.!IV).' .

- .' ..;.c

z;,t.t?jp:1. .-

~

. ..' .a, a.z

. ; v .m.

w .

- .:. _. -,u x.j

>.-- .- _? z- y .u,_.

w..

_ ;..-.-e .. m r.rk;. , ..........:- y + : .-

Performanc,e "Gdals:;.;.

.-  : w ;.m .,.

g.g,.fsprs:Drurh@@35t"&l1TdtGFC.3IN7 r-T430'rMUCA. Q .: @...W.L'~ . .

i $. ;IProvide11Eadership7to'.<strengthenindclearfsa'fety.'and's e-

~.c : .9,.,6iidside@. (G.oaliIV.B);1,.n.

.. t; ec.%^W i;

/.75%. .,. .,'. ..." 2 i m.-.= g:+.n_ e w..,n. w:r e tint. :u.~ernationaTprog' w w e w.

P c.MSupport ra;;ms.: e..:s;:.

n.. : . -: :; h:thit 7and:researc ve.benef.icibl r ~ 9:

WIimpa ctPoniiuTcl ea rfrea cto riand ihdcl sar :materi al s' s a fet976(Go61 GI V. C) F Strategy ~-4rl:-We vill-provide-leadershipf.to-strengthen nuclear-safetym

. . :.zGiand:safeg0ards-worldwide'; G l' # .% car.n c m a Substrategy.4:1:4:1- . rWe-wil.1rsu) port-international-programs and research '

~ ;iG0;bdpre;;;q.uitrthatihaveoenef.icial finipacts onsnu~cleiF;reactpr.-:and

- 4 5 e. W n.r:39tt-W::niscl ear.tmater.i al s tsafety.' - - '-- , .-t*--

P1anned Accomplishments:

CDSII 4.1.4.;1. Provide assistance to international regulatory organizations.

Measure: Percentage of requests for support (Target:

Support provided for 80 percent of requests) 11

3. Strategic Arena: Protecting the Environment Genera 11Goeh. g_; Protect,the.env.ironment.;in connect. ion with.civ.i.l.ian use of .

..u..e:Lw source , _ byproduct ..'and . speci al ; nucl ea r, mater.i al s -through

.-M.M.Cf d. w.c Wthe.. implementation:of:th.e? Atomic Energy Act'.and"theC -

C.

&lcce.dr.lvNatipnaljEnvironmental;

. g. ll v :. - .

Policy

~:in; m :i;t3 Acti, r m ..:(Goal:

@ .-.a.i V)h R. 's4;5.L N.; ji -

Performance -Goals:

. T.1..s . ",K'.<<;.+ ;i.-;:f)t,W:

. . ._,> K.-.w,:jfi7;c.:

... - w. . ll ' , ; , . t, y?i.

. d e.1,C. G,. ,..;4;

. ::..;; H : 3. .m,).-

. .m.

.q ~ 9w

, ;. : < r-

. :w , = y.e ..'

m; .operating (facilities:of er,adi,o..~:1. ,

s. *f ' :.- - <: .. 9 A

+cZero:offsir:te:relea,ses:. fro:.-r.p.

AJ-

• TNaatecialiih~atshavegth~e

' $2siiilir6ninent$(Go'~1iV. )Yi Md;NMDG potent'ialhtoicausesad

, a

..$.Y.%.WM3.hE.~ J M.fW5mW96c. s.N,.nQbS .

e QDX.

• %N6%i ncRia's61 nithe inumber20ff offsite.-rdl eases .'ting from"spe ra~Wcif:.?M:,

@.M.'f.';'

gen:fa cil i ti esiofiradioa ctiye., mater,i altthat; exceed FIO :.CFR spa rt

• • (Goal SV A?1FW---*-~~'~"'"""j20hl..imitsi ~' " -~

Stratsiy?,PE.25f2:.'T:q We will..assureithatilicense'es~; protect)the7dx f.ri .

- -- . .= environmentiduring'operationsr ~ ' : = T *- --- " -

Substr.stegyiPEiSJ21.2:: r.We:wil.1;iinspectctoiensurethat/.licenseesti'delitifys

.. ~ .e

.-WM:;i). e,=

- ^ . and . mitigate giotentia11 adverse eimpactssn'.'the!. .0 4 ..

= environment-from"their operation ~s-as'Tequired*by'the NRC. u. '

. . . : . . r m Y . . . ?. .

Planned Acconiplishments:

PE 5.2.2.1 Monitor the licensee *s onsite activities to ensure potential adverse impacts on the environment Measure: Percentage of core inspections in environmental procedures. (Target: Core inspection procedures cornpleted for all SALP cycles that end.during the FY in accordance with inspection manual chapter for power reactors) 12

4. Strategic Arena: Public Confidence GenefsliGoW1: 7The!public. "those wbir~egulate. and other stakeholder in

'~

. dthe national and international community,.will have clear.

- '7/i.7 7".E,5g and accurate information about. .a. meaningful .rolelin, .:and arespectifor'Ind? conf

. ~. : .:

. m .> .w * * *:(G.oaliVI);

-s n ..

. .=. .:..,.- .- r- '=g..

"%,idence?inUNRC'siegul.atory c  :: . -

(Fogr

.d:N 5i w . p1 b

. . y.

M n S b . s - n.; c. =

p Performance'e+w}.:: Goa ,g,rk.):g-Wlpg.5h=.Yhd%it. .! My:1;cgg

.1

_ _, gyggg.-;pgry  ;. .pg .f; ;

w ^tA& W 1-Pscr.w. .~- :r -

. .?

• :p;42pggfImpsndw?the

. .c;q.m . .. lement Agency.s:,planJol.1mprove how :it:.1nforms a.wnd --

.- W~-2: involves:the public..:those we regulate, and otherJstakeholde'rs'!

• VCE

. . in:NRC'Ureg0lat3rycprog' r ahili(GoaENI. AL.kMhM n@ ' F'?

StFategfPC#6'Mi N siwe'williobjectibelf demonstrate *that NRC'.s: efforts

. ,r g . .;&wd+y.M HEE' enabling'tf@-hafibn to use nuclear; mate.r.ials y j. . isafety. -

6 , . .- .

Substrategi:PC-6f1?2i?%tWehfil.1) measure and' report the: performance;of both

%5GbiteJ9Fp.GagNRCend;itssliteris'e'e's:and share this:per.formance :~

M&4:d@i'3.td.U}3hinformationiin7a fair 9and focused way with 7.?.s -

.L. . . : r.,

...~ finterested stakeholder.-

' <- ~

P1anned Accomplishments:

a PC 6.1.2.1 Promptly disseminate clear and accurate information regarding nuclear reactor events.

Measure: Type of Preliminary Notifications and press releases issued (Target: Issue PNs in accordance with criteria specified in NRC Inspection Manual Chapter 1120)

Measure: Timeliness of issuing PN (Target: within 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> fran event report)

PC 6.1.2.2 Conduct periodic press conferences in location where there is anticipated interest.

Measure: Nunber of conferences. (Target: Quarterly) l 13 l

PC 6.1.2.3 Conduct public exit meetings for significant inspections.

Measure: Percentage of public exit meetings conducted for each AIT or significant inspectfon. (Target:

80 percent)

~

PC 6.1.2.4 Conduct periodic meetings with local officials to share performance information.

Measure:

. Timeliness of meetings. '(Target: New SRIs meet with local officials within 90 days of

, assigivnent and affer followup meetings each 180 days)

PC 6.1.2.5 . Respond to inquiries from the public.

Measure: Timeliness and quality of response'(Tars et:

. Respond within 30 days of receipt)

PC 6.1.2.6 -

Provide notice of meetings held with licensees.

' ' ^

Measure: Timeliness and type of notice. (Target:

Notices issued in accordance with Mana Directive on meetings with licensees) gement PC 6.1.2.7 Disseminate information to public on significant actions, a Measure: Timeliness and quality of press releases.

(Target: Press releases issued within two days of issuance of civil penalty or order)

(Target: Press releases issued for each open pre-decisional enforcement conference) 1 l

14  ;

i

5. Strategic Arena: Excellence l General: Goal: c- The NRC-regulatoryyprogram willebe efficient *and will -

mir .a.e_. n. s f ~all ow :.the '. Nati on :to !sa fely; use'.'nucl e a rJ ma'teri al s ?fo f 'W l

-,w n/aiMWeivilian purposes; G(GoalJVII)? -

. l

~ 7 -:c. x . s  : m. : w ; m.i..u. m, .

Perfo5aHEd G6'aWi~~"~"~~'~""~~~~~~~~~~~ -

~

~ ~ ~

.::r.u % - m H~r ct-

? Implement the agency's plan for regulatory excsilence.

9.,9f.ggy_i(GoalgIIjA)x 3.r.g;;;p.ditg .ccm ;gf .';-p : .

3. w ,-Ji G 5

e i%@@ processes by.'< July-1.t.c1999n-:(GoalcVII:B).. revaluate:and implemen 'e Strat.egy;EX 7.11:a 9r.v..We.will make~ regulatory. excellence the cornerstone ~..

. 7. ._ p . ... w y .

fgg .a llioftourlstrategies' and Ja'ctivities.

Substrategy.EX.7.11:' We will proactivsly examine our programs and 4:pQ_:_ ..g.re . .M..;ew.1:-

.;. . -.- ~worEthrolighW6m'pYeh'e'nsii/e, performance .in corder to .. improve- the.way 'we

do. our. ...

r

~~

. " . .ia'pproach:to"ptograhm rassessme.-syst'ematic, nt and improvement. agency wide:

Planned Accomplishments: j t

EX 7.1.1.1 Conduct quarterly self-assessments of performance on the I a basis of specific criteria with performance measures to ensure programs meet management expectations for on site, on time, and on target.

Measure: Corrpletion of self-assessment. (Target: One per quarter)

EX 7.1.1.2 Conduct periodic reviews of the quality of inspection reports.

Measure: Number of inspection reports reviewed for quality (Target: Each site will receive a peer review at least once per year)

EX 7.1.1.3 Conduct inspector objectivity visits in accordance with MC 0102.

Measure: Number of objectivity visits by each resident inspector (Target: 90 percent of the residents will spend at least one week per year at another site)

EX 7.1.1.4 Observe National Nuclear Accreditation Board meetings and INPO accreditation team visits.

Measure: Number of Board meetings and team visits observed. (Target: One regional manager will I

15

I observe a board meeting each year and observe team visit every two yearsl' Substrategy,7

~

7 l1:4.:ff. . Wewill:providi. training-and development to oud. '

-+ ~

staff to enable-usito achieve excellence .in our . ,;

~

organizational and individua~1 ' performance. 7 Planned Accomplishments:

NRS 7.1.4.1 Train and qualify inspectors in accordance with MC 1245.

Measure: Percentage of qualified inspectors with requirements maintained current (Target:

95 percent) ,,

Measure: Percentage of sites with at least one. resident inspector who has attended course P-111. ~PRA

. Technology and. Regulatory Perspectives (Target:

100 percent.by end of CY98)

NRS 7.1.4.2 Provide training to managers in accorda'nce with NRC program

.. .and Region II supervisory addendum.

Measure: Individual training requirements in procedures met. (Target: Requirements met in 90 percent of cases within 24 months of assignment as supervisor)

NRS 7.1.4.3 Conduct periodic training for resident inspectors to clarify expectations and provide refresher training.

Measure: Number of resident meetings (Target: two meetings in FY98)

NRS 7.1.4.4 Conduct rotational assignments to the Chairman's and ED0's office.

Measure: Number of rotational assignments to the Chairman's and E00*s office (Target: one per year)

NRS 7.1.4.5 Develop and maintain a pool of highly qualified reactor inspections from which resident inspectors can be drawn.

Measure: Average length of program participation for those candidates who attain program certification. (Target: 12 months for internal candidates.18 months for outside candidates) 16

REACTOR PERFORMANCE ASSESSMENT PROGPAM A. Resources i

Ta.~rjet'e.gAfeads. g,c,1FY;1999.'s2;m 1FnF.Yl.1999.de-i f 0.:4Yd200.0.;. ~&-

. ~ - . -gg-3 M ? m d hg3.. ,.@: PS 5(k)- FIE ' t :PS'5(k) FTE PS.5(k): ETE SAi.@$5@QM2 ~ -

14 J2'

• 3.1.. 4.2 -

4;2 -

DRTrilsTe@y@j

'4.5. ' . _ ' ~--

i Ov[ersishtMM!MlIP.ergor.manceP.m g '"-

a:e -

2.:c'm E. W:'

2 , =2"

~4. 6

. 'e -

-a

.4. 5 e.s- > !

i B. Goals / Planned Accomplishments / Output Measures By Strategic Arena 1

1. Strategic Arena: Nuclear Reactor Safety General '. Goal:. . v;Preventiradiation related. deaths or i.11nesses due to A

,s. . a:

- " ~ '. civilian nuclear reactors; .(Goal:ll) 2 Per'fornian'ce Goals:79 0. ;d;:c.y.- sr. m 7w.. - m .: -

. . .. . u- m :u n . :.,f~ r T- c: *..

.Ze'ro civilian. nuclear reactorc.accidentsc--(Goal I. A) -

{

4

.Zero qeaths..due to radiation orkra' bioactivity releases .from.civilianT nuclear reactors. (Goal I.8) ,

, . t e . ..  !

'Haint'ain low frequency of events.which could lead to a severe I accident. (Goal.I.A.1)

Zero significant radiation exposures due to civilian nuclear reactors.

-(Goal . I .B.1) - -

..**'-  : 'c -. .

Strategy NRS_1.1: .

,We.will, assure .that licensees discharge their-

' d e . . .. ' ' ' , , . , ;Primarj. resp,onsib.1,lity for cond0cting safe operations.. , .

Substrategy NRS 1l1.3:- We .wilUre501arly assess.. objectively measure; and ~ i report on licensees" performance.' 'We will use this

{

N ,/:

information to-identify adverse. safety trends and to

~

". -identify,ea ly Mndividual plants with declining

' . performance!. We 'willcincrease our regulatory

~ : ' q~ . '

i '

attention.on.those : licensees with marginal i

performance. ' including halting operations if i a: -

i

' performance falls below an acceptable level..and

- distributing'reiodrces-based on licensee performance.

l 17

Planned Accomplishments:

NRS 1.1.3.1 Conduct a SALP board for each operating facility on about a 18-month schedule.

Measure: Timeliness of SALP's conducted and reports issued (Target: All SALP cycles in accordance with M0 B.6 requirements and 90 percent of the reports issued within 60. days of the end of the period) -

NRS 1.1.3.2 '

Conduct Plant Performance Reviews on a somiannual basis for all operating reactors.

Measure: Timeliness of Plant Performance Reviews conducted and letters issued (Target: PPRs conducted for all plants on a semiannual basis:

PPR letters issued to licensees within 30 days of PPR cornpletton for 90 percent of cases)

NRS 1.1.3.3 ' Provide input into the Senior Management Meeting prior to each meeting.

Measure: Cornpletion of input into SI+1 process (Target:

St+1 input provided for all sites to be discussed)

NRS 1.1.3.4 n Conduct SALP observations in other Regions.

Measure: Percentage of scheduled SALP observations that are conducted. (Target: Cornplete in accordance with guidance frorn Program Office; each SALP Board Member to observe one per year)

NRS 1.1.3.5 Provide assessment information for Commission and Senior Management site visits.

Measure: Timeliness of information to visitors. (Target:

Information provided five working days before visit in 90 percent of cases)

NRS 1.1.3.6 Hold meetings with licensees to discuss performance during SALP period.

Measure: Licensee self-assessment meetings and bi-monthly meetings to followup on identified problems. '

(Target: One self-assessment meeting with each 1icensee during SALP pertod: bi-monthly meetings with each licensee identified by RA as needing specific followup on performance.

I 18

Strategy NRS1.2:'" JMWeWillhincrEmbntally11mpl6 ment 41sk' informed. and.

where.;.a pproprjate. penfor_mance:.basedotegulatory_..

~ ,t.c.2:t:#A 3,~ + L.R.approacles for; power _ reactors. : .

64-u.a u.e-+ :. .

'~

Substrategy:NRST2:1:mWe:Will . focus?on?those'regulatediactivities'.that- -

~ y'Qy ~

//+ pose..the sreatest'. risk to,thea public.fbuild.i.ng on s

. ?f62.bs%q:lf?'9jprobabilistic.r.isk'

ass ~essinentTconcepts;andi6ther:+c k.Md.sgd:,s;,99 :s:9 appro a ches3forg.determi ni ng #1 ghuand S1 owgi s k .!ggi.

.r:MNGEsteh4Mslactivities%J& dam:# v%fMIN 2MES599 Planned Accomplishments:

NRS 1.2.1.1 -

Senior Reactor Analysts will evaluate events reported in accordance with 10CFR50.72 and 50.73 to determine which of those events warrant. additional inspection effort.

Measure: Review 50.72 and 50.73 reports. (Target:

Reviews conducted within one work week)

NRS 1.2.1.2 Senior Reactor Analysts will evaluate' enforcement actions to provide risk-informed assessments to the enforcement panels.

Measure: Risk assessment included in Enforcement Action Worksheets. Attendance at enforcement panels.

(Target: Complete review and attendance of 90 percent) a Substrategy NRS'1.2.5: We 'will refled a risk-informed, performance based approach in our inspection, licensing, and performance' assessment process.

Planned Accomplishments:

NRS 1.2.5.1 Senior Reactor Analysts will provide a risk assessment in each of the plant performance review inputs.

Measure: Quality of input and attendance at review meetings. (Target: Senior Reactor Analysts will attend 90 percent of SALP boards and PPRs .

to provide risk-informed insights and to gain performance insight from the meetings) i 19 l

l c- _ _ _ _ _ _ _ _ _ _ ._

6. Strategic Arena: Public Confidence General'Goali. ~

' .Thelpublicy ~.thoseZwe' regulate'5and

~~Tths"risti6n5T~in'dTinternat'i6ns ~coindunityother? stakeholder .inWi11 hi

~

""*'&"arfdiaccurat' 7.1hformiti ~-

e n"ab~out3mes6ing~fdlif5Te o ihra~ rid - '

..MiVEF.JM#r~esixictiforfa'nd iconf.idenc'e'li ri.T NRC =tregul stciry jrogram . ,

goa3 y3y ::.;* e ~;wu .c-  : .. -m -

• *%tinq::,  % n r. %y 4.G;(. n f >;1 .s .* **kh 4$h?Z .

1C2D%iT

• D i.T*Y C 5 U~. M + f. Y ' ' -E i Y p'php nfp $].M M.@.N N-$DIk b 'N' N k N M N S N.').- N N)[N  :

nn._x WWs:

n_u 'R,. erstEV?.2@.4mcc

~~~:w = .4f~mn.~~

M:tn:WSzwu... a .

e-

, ' / ^.1mpi ment -theiAgency.'s; plan 1.tokimprove.how it informs and '. - -

. ":" i: involves the.public. .those we regulate,J and ~oth6r'Yt'dkeh'oTderE

- / 'J -adnlNRC's' regulatory 1 program.'";(Goal .VI. A) : . . . . . . .,; :a Strategy;P.Cd6.1 : cr.rs We:will; objectively: demonstrate that NRC's' efforts

~ - : 1  ? .are' enablingthe:

mu.& n.gre.,;.saiety.'i:'. ^%nation

;;:'* to 'use nuclear mate' rials

~

SubstrategyfC 6a.2,:cp3We .willemeasure'.:and: report -the. performance .of. both;.'

Wg6T&.#67:r;mn-MRCc.ancDjits).l.icensees.and share 5this performance

, . . . - ;- . .-1nformation in a fair"a'nd focused way with. -

. ,.14

. .c.c *.: 6 interestedsstakeholders. '- .. ~ '-

Planned Accomplishments:

PC 6.1.2.1 a Conduct public SALP meetings with invited local officials to discuss NRC oversight activities and to share performance information.

l Measure: Number of meetings conducted (Target:

80 percent of SALP reports issued each year)

PC 6.1.2.2 Provide notice of assessment meetings held with licensees.

Measure: Timeliness and type of notice. (Target:

notices issued in accordance with MD on meetings with licensees) 1 20

FUEL FACILITIES LICENSING AND INSPECTION PROGRAM A. Resources Jargjt d.gfeggi[ $pyF.YA998?#2s -15i.4F&-299952 .TfGFJJ2.000.yi41%

'nni(M2512"MEMRFJ Miggg ~

ssgum fut EFiTffities - i~

. '. 9 ?J' S ' 7. " *J "~

g g ye ."w?59

~

mig;g5---e- m =y cr . = 19.

.. m 5. ::.' ' . .

D A> NN %'

~

hWdMfispection , .

~'

B. Goals / Planned Accomplishments / Output Heasures By Strategic Arena

1. Strategic Arena: Nuclear Materials Safety, GeneralcGoal:1Pfe'

. 4 . x, ,.:- f vent. radiation related deaths or illnesses"due'to"~ '

~~; \.s. * %

scivil.ian;use.of. source ; byproduct.;and.;special nuclear.

q -:yg;?.;;-Wy's -datefiblsi' *;(Goal ~..~;'.1.....! ~IIMll:.b.:

' T:.. ' *: * ~ '

Q '.f-9. n s- ~ 'G.W ~~~'.:

~.  %.--

Performance' Goals: g .' i.. . _ e _:... . 3,

~ . .

. m y ,- ,7.,..m . N % . y -. . +;. . ; , _.

~

• l,' W3Ze7dyr'idia'ttofEd1defdfa't'hEidubMo civilian use of. source,

. . . . Z.' ' .by ~

.y.;@

.pr.oductMnd ispeci

. al

nucl (Goal II.'A)

.;x~ ;..wn;:. ,._ ; ear; .[: ,. materi

_.- al s .

' ..' . . Nd incr'e'se a in the number"of significant radiation exposures due

, . to loss or use of source,; byproduct. and special nuclear materials. (Goal II. A.1)'

. #. ..No increase in the number of losses of licensed material as

- reported to"Co' ngress atinuallyJ ~(Goal. II.A.1.a)

, involving licensed material.

...'..,.'.7a.a.

.N(Goal.)II No. accidental A;1.b)'" ..., ... . criticality?.d.,. f~-l .

. . . . . . . ...~.. . . . . .. .4 ..

' 'No~iMrebse .in'the number;.of misadministration events which

-;icause significant radiation exposures. (Goal II A.2)  ;

g Strate' y.NMSf251CWe;wilhassure.tlia~taicerise'esidischargeftheid pnimar-i.'~' .

._.k-$AlA.EJ.h cresponsib'il i ty.:forfusyg'. ma t eri al s .s a fetp 2 .

.m.~,. .....

l Substrategy NHS 2.1.2

~ : . ... .s We will communicate with licensees to facilitate a

- W _a.- . f clear understanding of existing and emerging

. regulatory requirements.

21

J Planned Accomplishments:

NMS 2.1.2.1 Conduct an NRC/ Utility workshop for Region II licensees to discuss current and emerging regulatory issues.

Measure: Canpletion of NRC/ Utility Workshop (Target: One workshop canpleted in FY98)

NMS 2.1.2.2 Meet with site management during periodic visits and

, communicate existing and emerging regulatory requirements.

. Measure: Nunber of management site visits (Target: One site visit per year for each senior manager)

Sub.st rategy :liMSf 2;4l3MWe twtl liregul a rily tmeasure dhe .J eveliofts,a fet.y? ./;

mi . b . . .. m. - *

. . . performance ' exhibited .by. material slicensees;and '

' L _ f .ima; .Gslshareithis&information.with.ith'em4n p#.r 64 ?

Planned Accomplishments:

NMS 2.1.3.1 Conduct periodic Licensee Performance Reviews (LPRs) for fuel facility licensees.

Measure: LPRs in accordance with IMC 2604. (Target: The LPRs will meet the quality standard of IMC 2604 will be conducted in accordance with the schedule in MC 2604 (annual for high enriched facilities and every two years for low enriched facilities), with LPR meetings with licensees held within 90 days of the end of the LPR period)

NMS 2.1.3.2 Provide input into the Senior Management Meeting once every six months.

Measure: Completion of input into SM1 process (Target:

Screening meeting and SM1 input in accordance with input requirements and schedules provided by date requested by l#155.)

Substrateb9-NHS '2. C4WWei wiWm~aWTi censee p'r.formance "and ioinplib nEeW '

• withirbquirei5ent's eon'Psequent'ial3by!' decreasing'the:

"* ~'

. ; inspection;fr.equency_for!. good compliers;and;,..;2 . . .

assessing penalties for non compliers.

NMS 2.1.4.1 Maintain a plant issues matrix (PIM) for each fuel facility in order to capture and to aid in the evaluation of objective plant inspection information.

Measure: Timeliness of PIM entries (Target: All PIMs updated within two weeks of issuance of resident inspector reports for fuel facilities with t 22

resident inspectors and monthly for other fuel faci 11tles)

NMS 2.1.4.2 Adjust the Master Inspection Plan (MIP) for fuel facility licensees based on the LPR results.

Measure: Timeliness of revision of MIP. (Target:

Development of revised MIP within 45 days of LPR meeting)

NMS 2.1.4.3 Identify and take enforcement against licensee's who fail to

. comply with regulatory requirements in accordance with NUREG-1600 and the Enforcement Manual.

Measure: Conduct enforcement panels to coordinate potential escalated enforcement. . (Target: As needed on a weekly basis with appropriate panel material provided to participants 48 hours5.555556e-4 days <br />0.0133 hours <br />7.936508e-5 weeks <br />1.8264e-5 months <br /> in advance)

Measure: Timeliness of Non-exemot escalated enforcement (Target: Process 90 percent of cases within the timeliness goals established in Section 5.6 of the Enforcement Manual with all non-exemot cases issued within 90 days. except those case types with a goal of 105 days.)

n Measure: Review 01 investigative findings for appropriate enforcement action. (Target: Review 01 report within 45 days of 01 Report issuance for potentfal enforcement)

Measure: Issue Confirmatory Action Letters as needed to confirm licensee c3mitments regarding emergent safety issues. (Target: CALs issued within two days of receiving ca7mstments from licensees 90%

of the time.)

Measure: Review non-escalated enforcement for consistency and compliance. (Target: Participation in one Peer Review and completion of one audit of a representative sample of inspection reports)

Substrategy NMS'2.1.5P.;We willflicen,s:e~ and inspect facilities 'and materials m

"Osers'to" help 7ensur.e .that they operate and decommission safely. arid develop safe products.

NMS 2.1.5.1 Perform timely evaluation of events including on-site inspections as needed to identify causes and root causes of events. risk precursors. evaluate licensee compensatory measures and corrective actions, determine if there are generic implications, document findings, review NRC processes, procedures and performance to determine if 23

actions are necessary to improve NRC performance, and develop. recommendations.

Measure: Quality and timeliness of licensee event report reviews and NRC process evaluation. (Target:

Preliminary Notifications. Horning Reports, and Input to NEED system in accordance with the

^

quality and timeliness requirements of IMCs and Directives. Responses will be commensurate with the risk significance and site specific / generic implications of the event. Review 95 percent of

. licensee events reported to NRC within five working days. For events classified as A0s or other events of interest considered as A0s. a lessons learned evaluation will be performed)

NMS 2.1.5.2 Conduct Augmented Inspection Team (AIT) inspections to review each event that meets the thresholds established in MD 8.3.

Measure: AIT inspections conducted to review significant events. (Target: AITs conducted in accordance with MD B.3 and IMC 0325 and 90 percent of AIT reports issued within 45 days of the end of the inspection)

NMS 2.1.5.3 Expeditiously determine the safety significance and validity n

of allegations received. .

Measure: Promptly assess and acknowledge allegations received. (Target: 90 percent of all cases will be reviewed by the Allegation Review Board and acknowledged within 30 days of receipt)

Measure: Timely closure of allegations. (Target:

Closure of all assigned allegations. not involving wrongdoing or discrimination. within 180 days of receipt)

Measure: Provide periodic status to allegers. (Tar Issue status letters at 6 month intervals)get:

Measure: Maintain management focus on allegation timeliness. (Target: Weekly meetings with senior Regional management focusing on allegations open greater than 90 days)

NMS 2.1.5.4 Support 01 investigations.

Measure: Timeliness in completing investigations.

(Target: Provide technical support to OI on the schedule requested by OI 80 percent of the time)

NMS 2.1.5.5 Schedule and complete fuel facility inspections in a timely manner to determine regulatory compliance and early 24

indications declining licensee performance and issue timely inspection reports.

Measure: Quality and timeliness of safety-related inspections. (Target: Cornpletion of 90 percent

- of the safety-related inspections scheduled in the Master Inspection Plan (MIP) on time in accordance with the appropriate procedures.

Cornpletion of inspection reports in accordance

' with the quality standards and timeliness of MC 0610 (21 days for routine and 30 days for team) with less than 10 percent overdue)

NHS 2.1.5.6 Draft revisions to fuel facility security inspection

]rocedures in the areas of access controls and alarms and 3arriers and draft revision of MC 2681. -

Measure: Quality and timeliness of revisions. (Target:

Drafts of revisions will be in accordance with NMSS guidance and will be provided to NMSS by September 30, 1998) -

NHS 2.1.6.7 Provide comments to NMSS on selected fuel facility license applications.

Measure: Quality and timeliness of coments to NMSS.

(Target: Coments provided to NMSS in n ,

accordance with N4SS due dates 90 percent of the time)

NMS 2.1.5.8 Ensure that supervisors accompany inspectors on a periodic basis.

Measure: Nanber of inspection accornpaniments. (Target:

Branch Chiefs will accornpany each inspector each fiscal year and will accanpany new inspectors more frequently)

NMS 2.1.5.9 Ensure that inspectors are adequately trained and fully I qualified to perform inspections.

\

i Measure: Timeliness of staff qualification and maintenance of staff qualification (Target:

Staff qualification 1246 (or IMC camleted and maintained in accordance with IMC 1245 for previously qualified staff). For staff in qualification, camletion of courses in accordance with the Training Plan. 80 percent of staff vill be qualified within two years of continuing qualification maintained.)

25

______-_ a

l NMS 2.1.5.10 Identify safety issues that have generic significance.

Measure: Timeliness of draft Information Notices forwarded to Headquarters (Target: 60 days fran identification)

RS 1.1.5.11 Support each fuel facility incident response exercise or drill by providing technical managers and staff personnel qualified to function in the incident response center.

- MeasDre: Nurnber of exercises performed (Target: one

, exercise per year)

NRS 2.1.5.12 Control and monitor employee's radiation dose and implement controls for use of radioactive materials by staff.

Measure: Implementation of MD 10.131. (Target:

. Implementation of ROI 2130. Radiation Protection Manual and ROI 2132. Region II Personnel Monitoring Program) c L... We wil.Dregulate.uses consistent with .the :. level oft.:

Strategyg.NMS2.21_:

c-?f q.; r a.p.y' 7 Er'iskMn061ve'd:by decFdhsing :oversightLof-lthose . "

-'C >?. . .. materials that~ pose the~10 west'radiolog'ic~al: risk to YNiN. (.kcY h h.Y' -

~

Substrategy NMS 2.2.2 We will assess _our ~ regulations and arocesses to

...--... . identify those that are now of can Je risk informed, performance ba' sed 'or' risk-informed, less "

prescriptive.

Planned Accomplishments:

NMS 2.2.2.1 Support the revision of fuel facility and materials regulatory requirements including the revision of 10 CFR Part 70. by reviewing and commenting on the draft proposed rule changes.

Measure: Quality and timeliness of review provided to WISS. (Target: Coments provided to NMSS in accordance with requested schedule 80 percent of the time) 26

}

f

)

2. Strategic Arena: Nuclear Waste Safety General Goal: 7

,3m.

. ' ;.TEnsure' treatment,sstorage,.

. by. civilian and disposal use.'of-nuclear material of that in ways wastes produced donnot

- . . .- .'adverselypaffectith,isj .of future generations. (Goal.III) ,

~

Performance Goal g..'. 3y - ,.g . . ,,... ,. ,,g. {

.m,.7 ,

_ l

.,.-...a.

. a . - n . .w. .y :u.

1.l;,.u"No;.

I

... 4:i sign,1f.icant 'accidhnta'Erslea,ses;of radioactive m'ater.iaIfrom '

v.'29EI.Ystorage?and

~E tfanspor.tiitioniofdhigh21evel waste-(inclu' din

. Efuel)ror lou'leiel kastb7 (Goal III.A)

Straf66y: MNo specific'str5tegy9n' o

~

performance plan. " '

l

~

~

Planned Accomplishments:

NWS 1 Schedule and complete ISFSI inspections in a timely manner and issue timely inspection reports.

Measure: Quality an'd timeliness of' inspection of ISFSI licensees and reports of inspections. (Target:

90 coqolete inspections in accordance with IMC 2681 with less than 10 percent overdue as defined in the IMC. Completion of inspection reports in accordance with the quality standards n

and timeliness of MC 0610 (21 days for routine and 30 days for team) with less than 10 percent overdue)

NWS 2 Schedule and complete spent fuel transportation inspections.

including route surveys. in a timely manner and issue timely inspection reports.

Measure: Quality and timeliness of inspection licensees and reports of inspections. (Target: Ca71plete inspections in accordance with IMC 2681 with less than 10 percent overdue as defined in the IMC. Completion of inspection reports in accordance with the quality standards and timeliness of MC 0610 (21 days for routine and 30 days for team) with less than 10 percent overdue)

NWS 3 Identify and take enforcement against licensee's whv fail to comply with regulatory requirements in accordance with NUREG-1600 and the Enforcement Manual.

Measure: Conduct enforcement panels to coordinate potenttal escalated enforcement. (Target: As needed on a weekly basis with appropriate panel material provided to participants 48 hours5.555556e-4 days <br />0.0133 hours <br />7.936508e-5 weeks <br />1.8264e-5 months <br /> in advance) i 27

Measure: Timeliness of Non-exenpt escalated enforcement (Target: Process 90 percent of cases within the timeliness goals established in Section 5.6 of the Enforcement Manual with all non-exempt cases issued within 90 days. except those case types with a goal of 105 days.)

Measure: Review OI investigative findings for appropriate enforcement action. (Target: Review 01 report within 45 days of 01 Re potential enforcement) port issuance for

' Measure: 1ssue Confirmatory Action Letters as 'needed to confirm licensee comitments regarding emergent safety issues. (Target: CALs issued within two days of receiving cmmitments from. licensees 90 percent of the time.)

Measure: Review non-escalated enforcement for consistency and carp 11ance. (Target: Participation in one Peer Review and completion of one audit of a representative sanple of inspection reports)

NWS 4- ' Control and monitor employee's radiation dose and implement controls for use of radioactive materials by staff.

Measure: Implementation of MD 10.131. (Target:

n Implementation of ROI 2130. Radiation Protection Manual and ROI 2132. Region II Personnel Monitoring Program)

E l

, 28 I

3. Strategic Arena: Common Defense and Security and International Involvement Gener51 ' Goal: .,J.-3 Prevent the .los~s '.or . theft of. special nuclear materials

2. ,. .. .~ -.a'egulated by ,the' NRC7and . support U.S. national interests "14:f. '~~.'

7. i .lin the safe.use .of-nuclear 1. materials and in non '

, .2. pro. li.fe. rat. io.n.~ -(Go..a.l

.,.IV) .:

.c .. .v Performance Goa1s.,.:

_ , pa-g.g.3 . ,. . gg,p,, .7a q. . .

.;. ., a.. 3 4:g

.-e sqas.r.w+a+w. . v.u.-nyc.a.a - - : m.

--~ v . . e. - ..

m&, 1.:';'.Zero70'ss?orl. theft.of specialinuclear mater

~ials regulated by the

' T.7 "~ '

~^

.eff NRC'.T(Goal IVTA)T .

- m v. ,; : .. J. ;. h. h., L. m . . J . s c;- 4 : .r, g w O. : ":Norsu;bstantiilicase. of'attWmptiditheft 'or ~diversio'n.of -form 01a' ~

.i!.?lM J. quantities:of, strategic's~p(ecial.iuclear materials., .

' 5$$.(Gdalj% Ajp,l3;Wg f3;-jft .

,".c:..y w w -. ,-,.;,. w .. ., q.. w ~

>- N.',.U.No:: substantiated.breikdowntoh '

.... j. . J':coiltfoln(i.er.accbssJ. control, physical security or materialcnntainme CQggysyst'esis)ithitisignificiritWweaken'ed the protectioniagainst. .<

~ - -

~

~

T..%. .944.J.thsftior.'div rsionlof; formula 7q0antitids of strategic

. special

-~.~, '

Enu~cleir mate ~fial?2(Go'511IVfA!2)7:

Strategy!CDSII 4:2o."We will"assiire thatilicensees control. face'ount fop;L ~

.je . .c..w:av . < End protect:fiticleaFm'aterials fr'om'being

. 7 misplaced.

Substrategy!CDSII4.2.1 We:willainspect and complete license reviews

-to ensure.. licensees prevent the theft or diversion of nuclear materials.

Substrategy.CDSII:4.2.2 -

We will require that licensees be prepared to.

, .u.. . :r.espond to.. threatening situations involving

-theft or . sabotage of nuclear materials.

Planned Accomplishments:

CDSII 4.2.1.1 Complete timely security plan change reviews and document the bases for decisions.

Measure: Quality and timeliness of reviews. (Target:

Cornplete reviews on minor plan changes in 90 days and major plan changes in .180 days 90 percent of the time)

CDSII 4.2.1.2 Schedule and complete security inspections of fuel l facilities and ISFSIs in a timely manner and issue timely inspection reports.

Measure: Quality and timeliness of security inspections.

(Target: Cornpletion of 90 percent of the fuel  !

\ facility security inspections scheduled in the 29 I

Master inspection Plan (MIP) { including those in other regions when requested) and ISFSis in accordance with IMC 2690, on time in accordance with the appropriate procedures. Cornpletion of inspection reports in accordance with the quality standards and timeliness of MC 0610 (21 days for rnutine and 30 days for team) with less than 10 percent overdue)

CDSII 4.2.1.3 Ensure that security inspectors and license reviewers are adeq0ately trained and fully-qualified to aerform and complete inspections and licensing caseworc actions.

Measure: Timeliness of staff qualification and maintenance of staff qualification. (Target:

Staff qualification canpleted and maintained in accordance with IMC 1246 (or IMC 1245 for

, previously qualified staff). For staff in qualification, completion of courses in accordance with the Training Plan. 80 percent of new staff will be qualified within two years of beginning assignment. Staff continuing

. qualification maintained)

CDSII 4.2.1.~4 Perform timely evaluation of security events including on-site inspections as needed to identify causes and root causes of events, risk precursors, evaluate licensee n compensatory measures and corrective actions: determine if there are generic implications: document findings: review NRC processes, procedures and performance to determine if actions are necessary to improve NRC performance; and develop recommendations.

Measure: Quality and timeliness of licensee event report reviews. (Target: Preliminary Notifications, and Morning Reports in accordance with the quality and timeliness requirements of IMCs and Directives. Responses will be ca7mensurate with the risk significance and site specific / generic irpplications of the event. Review 95 percent of licensee events reported to NRC within five working days. For events classified as A0s or other events of interest considered as A0s. a lessons learned evaluation will be performed.)

CDSII 4.2.1.4 Conduct Augmented Inspection Team (AIT) inspections to review each event that meets the thresholds established in MD 8.3.

Measure: AIT inspections conducted to review significant events. (Target: AITs conducted in accordance with MD B.3 and IMC 0325 and 90 percent of AIT reports issued within 45 days of the end of the inspectfon.)

30

CDSII 4.2.1.5 Evaluate and respond to security allegations.

Measure: Quality and timeliness of allegation reviews.

(Target: Coqq1ete 80 percent of the allegation

• reviews in accordance with and within the quality and timeliness requirements of MD B.B.)

CDSII 4.2.1.6 Support 01 investigations of security issues.

Measure: Timeliness in co security issues.mpleting (Target:investigations of Provide technical support to 01 on the schedule requested by 01 80 percent of the time}

CDSII 4.2.1.7 Schedule and complete spent fuel transportation inspections, including route surveys, in a timely manner and issue timely inspection reports.

Measltre: Quality and timeliness of inspections and reports of inspections. (Target: Complete inspections in accordance'with IMC 2681 with less than 10 percent overdue as defined in the IMC. Completion of inspection reports in accordance with the quality standards and timeliness of MC 0610 (21 days for routine and 30 days for team) with less than 10 percent overdue)

CDSII 4.2.1.S Coordinate threats against licensed facilities with the IAT.

Measure: Quality and timeliness of threat assessment and coordination with 1AT. (Target: All threats assessed in accordance with IAT process and procedures)

CDSII 4.2.1.9 Identify and take enforcement against licensee's who fail to comply with regulatory requirements in accordance with NUREG-1600 and the Enforcement Manual.

Measure: Conduct enforcement panels to coordinate potential escalated enforcement. (Target: As needed on a weekly basis with appropriate panel  ;

material provided to participants 48 hours5.555556e-4 days <br />0.0133 hours <br />7.936508e-5 weeks <br />1.8264e-5 months <br /> in i advance) ~

Measure: Timeliness of Non-exerrpt escalated enforcement l (Target: Process 90 percent of cases within the timeliness goals established in Section 5.6 of

\ the Enforcement Manual with all non-exempt cases l issued within 90 days. except those case types with a goal of 105 days.)

Measure: Review 01 investigative findings for appropriate enforcement action. (Target: Review 01 report 31

~

( within 45 days of 01 Report issuance for potential enforcement)

Measure: Issue Confirmatory Action Letters as needed to confirm licensee comitments regarding emergent safety issues. (Target: CAls issued within two days of receiving comitments from licensees 90 percent of the time.)

Heasure:' Review non-escalated enforcement for consistency and cwpliant.e. (Target: Participation in one

. Peer Review and cwpletion of one audit of a representative satrple of inspection reports)

4. Strategic Arena: Protecting the Environment l General Goal: - ~~ Protect the: environment-in' connection with civilian use of w tw. . ' c<sourceNbyproduct..and,special nuclear materials'through lamentation of:the Atomic ~Energi Act'and the

! ^ ..w.w..:

TM.NW.,D:.pgthe ' q m fNat'ioriam:x:.r: w = p +

. imp?Envif.onmenltsifPolic-- ..

!P4YMr$a~rieUGo8194NFN@4 .

Y s-:. ,. y: Act. :(Goal'.V)

• rbi.. w . _:7.mm.. %" %- .7'fi , --

. . ,. ...., ~.. .g .,2,ac

~

i .. a,- ,i=..'.

! >. - Hg'TZdro*offsite

-y

. . ~

,a-u. . .._ .. .... -

rsle'asss.'ffoEoperat'ing facilities:of.ra'dioactive

' mater.ial th'at h'a ve.the: potential.:to cause adverse impact.on the

'j 7_. "T:."f6Nenvironinent#;(G6a19V:A)ig

~?#

~

~

1* .. . .

'. JNo, increase ;in.the.numberz.of-offsite releases from operating:-

facilities of radioactive' material that exceed 10 CFR Part 20 "

..... . limits.

. ; .-  ;(Goal V.A.1)..

Environmental . Impacts have been identified through NEPA process before regulatory ~ action.is taken. (Goal V.8)

.. No; sites.will .be released .untiLsatisfactorily remediated in

' * 'accordance".with'.NRC release': criteria.. (Goal. V.C)

Strategy PE 5.1 We will improve-the process-by which licensees

. - m=%. m=Kt'es'.:n ;k:. _3 *'MW:* e. mpe-su'ccWsifdllp*?ciimplete:/ decommissioni Planned Accomplishments:

PE 5.1.1 Schedule and complete decommissioning inspections in a timely manner and issue timely inspection reports.

Measure: Quality and timeliness of inspection of licensees undergoing decommissioning and reports of inspections. (Target: Complete inspections in accordance with IHC 2605 with less than 10 percent overdue as defined in the IMC.

Corpletion of inspection reports in accordance with the quality standards and timeliness of 32

(

_1

MC 0610 (21 days for routine and 30 days for team) with less than 10 percent overdue)

PE 5.1.2 Maintain an adequate supply of operable and calibrated portable survey instruments to support independent surveys during inspections and to support incident response.

Measure: Number of operable and calibrated instruments.

(Target: The ctnplement of instruments

' necessary for incident response will be maintained at all times. The supply of other instruments will be in accordance with the documented minimum inventory requirements 80 percent of the time.)

PE 5.1.3 Maintain capability to do screening analyses of samples for beta / gamma activity, low energy beta activity, and alpha

' activjty. Coordinate with Region I other radiological analytical services. Develop and implement counting equipment 0A/0C procedures.

Measure: Operability of instrument $ and timeliness of transmittal of samples to Region I. (Target:

Beta /ganma 10w energy beta, and alpha counting instruments will be operable and calibrated or will be sent for repair within ten working days of identification of inoperability. Samcles a will be sent to Region I within ten working days of receipt in Region.)

PE 5.1.4 Ensure that decommissioning inspectors and license reviewers are adequately trained and fully-qualified to perform and complete inspections and licensing casework actions.

Measure: Timeliness of staff qualification and maintenance of staff qualification. (Target:

Staff qualification completed and maintained in accordance with IMC 1246 (or IMC 1245 for previously qualified staff). For staff in qualification. completion of courses in accordance with the Training Plan. 80 percent of new staff will be qualified within two years of beginning assignment. Staff continuing qualification maintained)

PE 5.1.5 Control and monitor employee's radiation dose and implement

< controls for use of radioactive materials by staff.

Measure: Implementation of MD 10-131. (Target:

Implementation of ROI 2130. Radfation Protection Manual and ROI 2132. Region II Personnel Monitoring Program) 33

Substrat,egy":PEl5.5.'2 ?? 'We wil19nspect to ensure that licensees. identify

~ ~

~ " ~~' 'and mitigate potenti'al adverse impacts.on the

.a ronmen omggei30perationsasrequiredbythe

].;-y wif.f , , _

Planned Accomplishments:

PE 5.5.2.1 Schedule and complete fuel facility effluent control.

environmental monitoring and decommissioning inspections in a timely manner and issue timely inspection reports.

Measure: Quality and timeliness of effluent control and environrnental monitoring inspections. (Target:

Cornpletion of 90 percent of the effluent control and environmental monitoring inspections scheduled in the Master inspection Plan (MIP) on

. time in accordance with the appropriate procedures. Cornpletion of inspection reports in accordance with the quality standards and timeliness of MC 0610 (21 days for routine and 30 days for team) with less than 10 percent overdue)

PE 5.5.2.2 Ensure that inspectors are adequately trained and fully-qualified to perform inspections and complete licensing casework actions.

Measure: Timeliness of staff qualification and maintenance of staff qualification. (Target:

Staff qualification cornpleted and maintained in accordance with IMC 1246 (on IMC 1245 for previously qualified inspection staff and Directives for licensing staff). For staff in qualification cornpletion of courses in accordance with the Training Plan. 80 percent of new staff will be qualified within two years of beginning assignment. Staff continuing qualification maintained.)

PE 5.5.2.3 Perform timely evaluation of environmental events including on-site ins)ections to identify causes and root causes of events, risc precursors, evaluate licensee compensatory measures and corrective actions, determine if there are generic implications, document findings review NRC processes, procedures and performance to determine if actions are necessary to improve NRC performance, and develop recommendations.

Measure: Quality and timeliness of licensee event reports reviews. (Target: Preliminary Notifications. i Morning Reports, and input to NMED system in accordance with the quality and timeliness l

\

requirements of IMCs and Directives. Responses will be ca7mensurate with the risk significance 34 1

I' -

(

and site specific / generic implications of the event. Review 95 percent of licensee events reported to NRC within five working days. For

? events classified as A0s or other events of interest considered as A0s. a lessons learned l , evaluation will be performed.)

PE 5.5.2.4 Conduct Augmented Inspection Team (AIT) inspections to review each event that meets the thresholds established in MD 8,3.

Measure: AIT inspections conducted to review significant events. (Target: AITs conducted in accordance with hD B.3. IMC 0325 and 90 percent of AIT reports issued within 30 days of the end of the inspection) -

PE.5.5.2.5 Evaluate and respond to effluent control, environmental or decommissioning allegations.

Measure: Quality and timeliness of-allegation reviews.

(Target: Complete 80 percent of the allegation reviews in accordance with and within the quality and timeliness requirements of MD 8.8)

PE 5.5.2.6 Support 01 investigation of effluent control. environmental or decommissioning issues.

n Measure:

Timeliness in com effluent control pleting investigations of environmental. or decommissioning issues. (Target: Provide technical support to Of on the schedule requested by 0180 percent of the time)

PE 5.5.2.7 Identify and take enforcement against licensee's who fail to

-comply with regulatory requirements in accordance with NUREG-1600 and the Enforcement Manual.

Measure: Conduct enforcement panels to coordinate potential escalated enforcement. (Target: As needed on a weekly basis with appropriate panel material provided to participants 48 hours5.555556e-4 days <br />0.0133 hours <br />7.936508e-5 weeks <br />1.8264e-5 months <br /> in advance)

Measure: Timeliness of Non-exempt escalated enforcement (Target: Process 90 percent of cases within the timeliness goals established in Section 5.6 of the Enforcement Manual with all non-exempt cases issued within 90 days, except those case types with a goal of 105 days.)

l l Measure: Review 01 investigative findings for appropriate enforcement action. (Target: Review OI report

(

within 45 days of 01 Report issuance for potential enforcement) 35

Measure: Issue (%firmatory Action Letters as needed to confirni oicensee cwmitments regarding emergent safety issues. (Target: CALs issued within two days of receiving cmmitments frorn licensees 90 percent of the time.)

Measure: Review non-escalated enforcement for consistency and cornoliance. (Target: Participation in one Peer Re' view and completion af one audit of a

. representative sample of inspection reports)

5. . Strategic Arena: Public Confidence r fJhe Gene q . 7..--~..

~ sl?Gdalf(3He'jubliE,T.thoseNe21egulzite,

and:other. stakeholder's

natiorial . a' nd 'intbrnatidnal:lcomiiiunity,-sil) have iclear .in

, } '.5 . - 5.'dand accurate:. information)about ca meaningfurr'o leiin', and . ,

,. / n -

F?r- 3 respect ;.forj*and " .' con f.i dence i.i n ; ; NRC 's . r;egul atoryl, program ..-- -

TW # ' ' W ~ f.

.efff@: 4.e. R: a '!VI)~'. .c:22 r ~-n

~ (G6.

Gl.L. .~. ; . w..

P'"

. u -.

.u =.y:. 7_ -

, ..c .

m ... ~ - . -

c.e w '.-. . .

.c.

Performance Goal:;pg,t.g7,gg

, .gpygg .pg.  ; .. ..g.y.,.j.y '3-f; .

.-. -- s a,...- o ::: . ..,... , -.;.. <., w , n .. . >.- +

e/~~.?;Ey.Dmplement thsMgency'sfplon%td.im. . prove' h'ow .it L. -informs and- -

u. q.  ;, .I)$_2 . 'id NRC's" regulatory' prograKO(Goal VI.A) -_I.'invoWe6thel

.  : +-

Strategy PC 6.1: . - We will.ob3detively demonstrate'that.NRC's efforts

~

.y : .!. . , 8..j e. .(.. , . . are enablingJhe. nation to.use nuclear materials safely.

Substrategy PC 6.1.2: We will . measure and report the performance of both NRC'and its licensees and share this performance information .in a fair and focused way with

-m. -

-interested . stakeholder. -

Planned Accomplishments:

PC 6.1.2.1 Hold meetings open to the public with licensees to discuss the results of fuel facility LPRs or to discuss significant 1 licensing issues, and hold open pre-decisional enforcement j conferences.

Measure: Number of public meetings conducted (Target:

Meeting conducted for each LPR and for each pre-decisional enforcement co:iference that meets the criteria of the Enforcement Manual to be open)

PC 6.1.2.2 Disseminate information to public on significant actions.

Measure: Timeliness and quality of press releases.

(Terget: Press releases issued within two days \

of issuance of civil penalty or order) '

36

)

\

(Target: Press releases issu3d for each open pre-decisional enforcement conference)

PC 6.1.2.3 Conduct public stakrSolder meetings for significant decommissioning activi+.ies.

Measure: Number and timeliness of meetings. (Target:

Meetings held as specified in IMC 2605)

PC 6.1.2.4 Conduct periodic press conferences in location where there is anticipated interest.

Measure: Number of conferences. (Target: Quarterly)

PC 6.1.2.5 ' Conduct public exit meetings. for significar.t inspections.

Hymre: Percentage of public exit meetings conducted for each AIT or significant inspection. (Target:

80 percent)

PC 6.1.2.6 Conduct periodic meetings with local officials at sites where there is a Senior Resident Inspector (SRI) assigned to q share performance information.

Measure: Timeliness of meetings. (Target: New SRIs meet with local officials within 90 days of assignment and affer followup meetings each a 365 days)

PC 6.1.2.7 Respond to inquiries from the public.

Measure: Timeliness and quality of response (Target:

Respond within 45 days of receipt of a written request 80 percent of the time and promptly (within two work days) to verbal requests 80 percent of the time)

PC 6.1.2.8 Provide notice of meetings held with licensees.

Measure: Timeliness and type of notice. (Target:

Notices issued in tccordance with Mana Directive on meetings with licensees) gement 37

9

6. Strategic Arena: Excellence General Goal:, .The NRC; regulatory 4 program.will be efficient 'and.will -

^

• ~

75110w the' Nation tocsafely.'use. nuclear materials .for-

"7- . civilian:purposssT f(Goal 'VII). "?

.u.<::. : .......w .

.. . -- m , . n . .- . - .

Performance Goals:),.: . ._ ,. dl. .

• ., $. . . .. .- . .. . n . > . . . . :.7,j t.C i. '.. ; N. .., ~. a.;...

. + -' . M ;i ' Implement the,:. agency.'.s .N. . excellence. ~2.t.

~ r".v.w:S(Goi. l,rVIH.A)"~rS:" .. m .: e ::6r. ~pl m'* m2  ! an;for-

' - E K. - r,egul.atory!'~.w.y

+C-S~.:.~.

"~

' ' ' ?. . .' ? +:

.- :, . .: :. : p. ." v v. . > - . + .:. . . :. . . -

~ .. . .

. , ,  ;  ?-  : .- : .- .

> - / W.M: ~e p

% Ger6.'.Evahate sandiim' 1'emsnt:nesded improvements..for..five'.

proc 6sse51by'.f001911M.1999';;:..(Go61:VII.'B)O ' E.c.. ic. -t.r.

major' NRC 3 J: 'c Strategy EX 7.1: -- . JWe will make regulatory excellence...the cornerstone e.dg.;.A J/;Wf?T.7/qfof.:all' of 7 0F:st'ratsgles 0 :and activities? . *J .

Substrategy..EX 7.1.1: z.. . We will.proa~c.tively. examine opr.. programs iand . . -

(StMudPN:7MMMpdr:formance:fnsrder:to:improveithe way we:do ourf ' ~

W J gi g lj.e c = sgwor.kcthrou~ghicomp}eh~ensive,' systematic,; agency wide

.<: n . -

.z- ' approach:to: program assessmentend improvement.

Planned Accomplishments:

EX 7.1.1.1 Conduct quarterly self-assessments of performance on the a basis of specific criteria with performance measures to ensure programs meet management expectations for on site, on time, and on target.

Measure: Coqq1etion of seif-assessment each quarter (Target: One per quarter)

EX 7.1.1.2 Conduct periodic reviews of the cuality of inspection reports.

,leasure: Number of inspection reports reviewed for quality (Target: Each site will receive a peer review reports twice a year)

EX 7.1.1.3 Conduct inspector objectivity visits in accordance with MC 0102.

Measure: Number of objectivity visits by each resident inspector (Target: The SRIs wi11 spend at least one week per year at the other site) 1 38

Substrategy'7.1.4i.lJ.j-Werwiltprovide'. train'ing:and development to our

. 5..WA$1'Dtiffeto;enatile?us:'.to'.

~; achieve 'eicellence in our organizational.and individual performance. -

Planned Accomplishments:

EX 7.1.4.1 Provide training to managers in accordance w'ith'NRC' program and Region 11 supervisory addendum.

-Measure: Individual. training requirements in procedures met. (Target: Requirements met in 90 percent of cases within 24 months of assignment as supervisor) -- .

~ ' ' * " ' ~ ~ ~

~

EX 7.1.4.2 Ensure that inspectors and license reviewers are adequately trained and fully qualified to perform licensi_ng casework actions and inspections. '

Measure:  ;'imeliness of staff qualification and maintenance of staff quali.fication. (Target:

Staff qualification completed and maintained in -

accordance with IMC 1246 (or IMC 1245.for previously qualified staff). For staff in qualification completion of courses in accordance with the Training Plan. 80 percent of new staff will be qualified within two years

' of beginning assignment. Staff continuing qualification maintained.)

9 39 1

NUCLEAR MATERIALS USERS

LICENSING AND INSPECTION PROGRAM A. Resources jai,s{tgAlr fiP$ M @,996 ], 2 M H #999 5 5R REYy.120Rby.Ks nf885$(*$,@ .PS~$(k)k EE..g .PS.$(k) FTE.. a PS.$(k)? FTE c ateni p b.. c... , 9 1355W, _. . Qi .,

Nucr'- _ - . 12.2 1 S_a_ . . _ .hy-q

&;.cu M c.2:

r

-~ _ . . _d-:

LTnI60bisisFeW E# .* ' 8 F" .

.3

~

1' B. Goals / Planned Ac,complishments/ Output Measures By Strategic Arena

1. Strategic Arena: , Nuclear Materials Safety GensraTeGobT:T.5EP~~eVedt?.radiationVr.dlat'e'd.

r deaths or,-illnesses due .to '

~~WNMiif#diV.i]ia~n.i,', lie;6fisourc6,?;biproduct,.and

~

u . special . nuclear

- f de; w W m .gmate ga,1s 4 gGo II .

Performance .ie ch.nsr c+@. :}a],,5 )j :...p_

m n .itr .Goais:fYrsM ! YCb/ W~i As ~ir.r,p:n. -

~

....;.... . .ecc .. , i . .,. ,u-a . e.:.,.

~

"~Zero' nadiatrofi-related 'dda'ths'ifdelto civilian use of source.

byprodudt, .and speciaT nuclear' ciaterials. (Goal II.A)

No increase in the number of significant radiation exposures due to loss or use of source, byproduct, and special nuclear materials.

(Goal II.A.1) .

No increase .in the number of losses of licensed material as reported to Congress annually. (Goal II.A.1.a)

'NA .accidentil.' criticality inv51hing , licensed mateiial'. (Gdal III. A.1.b)

J

• . No . increase-in the-number..of.niisadniinistration events which cause

~ significant . radiation exposures. -- (Goal II . A.2)

Strategy NMS 2.1 We will' assure -that licensees discharge.their primary

. responsibility for using materials safety-Substrategy NHS 2.1.4 We will make licensee performance and compliance with requirements consequential by decreasing the inspection frequency for good compliers and assessing penalties to non compliers.

40

Planned Accomplishments:

NMS 2.1.4.1 Review the performance of each materials licensee after each inspection and adjust inspection frequencies based on this performance.

Measure: Inspection frequency revision (Target:

Inspection frequencies adjusted in accordance with criteria in IMC 2800)

NMS 2.1.4.2 Identify and take enforcement against licensees who fail to

, comply with regulatory requirements in accordance with NUREG-1600 and the Enforcement Manual.

Measure: Conduct enforcement panels to coordinate potentfal escalated enforcement. -(Target: As needed on a weekly basis with appropriate panel

. material provided to participants 48 hours5.555556e-4 days <br />0.0133 hours <br />7.936508e-5 weeks <br />1.8264e-5 months <br /> in advance)

Measure: Timeliness of Non-exempt escalated enforcement (Target: Process 90 percent of cases within the timeliness goals established in Section 5.6 of the Enforcement Manual with all non-exerrpt cases issued within 90 days except those case types with a goal of 105 days.)

a Measure: Review 01 investigative findings for appropriate enforcement action. (Target: Review OI report within 45 days of 01 Report issuance for potential enforcement)

Measure: Issue Confirmatory Action letters as needed to confirm licensee corimitments regarding emergent safety issues. (Target: CALs issued within two days of receiving corimitments frorn licensees 90 percent of the time.)

Measure: Review non-escalated enforcement for consistency and cortpliance. (Target: Participation in one Peer Review and completion of one audit of a representative sa:iple of inspection reports)

Substr.ategy"NMSl2 1.5: We will licen'se 'and inspect . facilities and material' l

~

' ' ' ~; c users'to.. help; ens ~ure .that'they~ operate and ~

~

.. decommission '. safely"and develop safe products. .

P1anned Accomplishments:

NMS 2.1.5.1 Complete materials licensing casework reviews, document the bases for licensing decisions, consider enforcement history i

on renewals, and maintain licensing files in orderly fashion I

and retain appropriate documents. e.g.. license review

! checklists, and supporting data.

41

r Heasure: Quality and timeliness of reviews of applications for new materials licenses, amendrnents. and renewals. (Target: Evaluate app 11 cations in accordance with established criteria (Standard Review Plans.-Policy and Guidance Directives, and Technical Assistance Request decisions). Complete 80 percent of reviews for new applications and amendnents within 90 days. Cmplete 80 percent of reviews 1 for renewals within 180 days. Eliminate the.

number of " backlogged" cases (as defined in U.S.

Nuclear Regulatory Cwmission Accountabi11ty Report Fiscal Year 1996. NUREG 1542. Vol. 2) especially with respect to core cases. i.e.. new and amendnents. We will eliminate all cases older than one year. For cases older than one year, w will develop and coordinate an action plan with hM55.)

NMS 2.1.5.2 Implement new materials licensing guidance as developed and finalized. ensuring consistency in licensing within and between regions and NHSS.

Measure: Timeliness of implementation of new guidance and review of actions to assure consistency. *

(Target: New guidance implemented within 45 days of receipt and review of all licensing n actions by supervisor)

NMS 2.1.5.3 Schedule and complete materials inspections in a timely manner and issue timely inspection reports.

Measure: Quality and timeliness of inspection of materials licensees and reports of inspections.

(Target: Cortplete inspections in accordance with IMC 2800 (materials). and 2605 (decommissioning) 1220 (reciprocity). with less than 10 percent overdue as defined in the IMC.

Cxpletion of inspectton reports in accordance with the quality standards and timeliness of MC 0610 (21 days for routine and 30 days for, team) with less than 10 percent overdue.)

NMS 2.1.5.4 Perform timely evaluation of events (including medical misadministration) including on-site inspections as needed to identify causes and root causes of events, risk precursors, evaluate licensee compensatory measures and  ;

corrective actions.. determine if there are generic '

implications, document findings, review NRC processes, procedures and performance to determine if actions are necessary to improve NRC performance, and develop recommendations.

Measure: Quality and timeliness of licensee event report reviews and NRC process evaluation. (Target:

42

( Preliminary Notifications. Horning Reports and

\

Input to NMED system in accordance with the quality and timeliness requirements of IMCs and Directives. Responses will be corimensurate with the risk significance and site specific / generic l implications of the event. Review 95 percent of

~

• l licensee events reported to NRC within five working days. For events classified as A0s or other events of interest considered as A0s, a

. lessons learned evaluation wi11 be performed.)

NMS 2.1.5.5 Conduct Augmented Inspection Team (AIT) inspections to review each event that meets the thresholds established in MD 8.3.

Measure: AIT inspections conducted to review significant events. (Target: AITs conducted in accordance with ho 8.3 and IMC 0325 and 90 percent of AIT reports-issued within 30 days of the end of the inspection)

NMS 2.1.5.6 Expeditiously determine the safety significance and validity of allegations received.

Measure: Prornptly assess and acknowledge allegations receive). (Target: 90 percent of all cases will be reviewed by the Allegation Review Bo&rd and p acknowledged within 30 days of receipt)

Measure: Timely closure of allegations. (Target:

Closure of all assigned allegations. not involving wrongdoing or discrimination, within 180 days of receipt)

Measure: Provide periodic status to allegers. (Target:

Issue status letters at 6 month intervals)

Maintain management focuc on allegation timeliness. (Target: Weekly meetings with senior Reglonal management focusing on allegations open greater than 90 days)

NMS 2.1.5.7 Support 01 investigations.

Measure: Timeliness in corppleting investigations.

(Target: Provide technical support to 01 on the schedule requested by OI B0 percent of the time)

NMS 2.1.5.8 Ensure that supervisors accompany inspectors on a periodic basis.

Measure: Nurnber of inspection accornpaniments. (Target:

Branch Chiefs will accornpany each inspector per fiscal year. and new inspectors more frequently) 43

NMS 2.1.5.9 Ensure that inspectors and license reviewers are adequately trained and full,y qualified to perform inspections and complete licensing casework actions.

Measure: Timeliness of staff qualification and maintenance of staff qualification. (Target:

Staff qualification cornpleted and maintained in accordance with IMC 1246 (or IMC 1245 for previously qualified inspection staff and the Directives for licensing staff). For staff in qualification. cortpletion af courses in

. accordance with the Training Plan. 80 percent of new staff will be qualified within two years of beginning assignment. Staff continuing qualification maintained.)

~

NMS 2.1.5.10 Perform Project Management for the U.S. Navy Master

.Materjals License (NHL).

Measure: Quality af oversight and timeliness of actions.

(Target: Implement inspection and license review in accordance with IMC 2810 and Policy and Guidance Directives)

NMS 2.1.5.11 Identify safety issues that have generic significance.

Measure: Timeliness of draft Information Notices a forwarded to Headquarters (Target: 60 days frcm identificat10.1)

NMS 2.1.5.12 Support IMPEP review of another NRC Region for adequacy to .

ensure public health and safety and conformance with NRC policies and procedures.

Measure: Quality and number of IMPEPs supported.

(Target: Participation in one IMPEP using the criteria of MD 5.6.)

NMS 2.1.5.13 Control and monitor employee's radiation dose and implement controls for use of radioactive materials by staff.

Measure: Implementation of MD 10.131. (Target:

Implementation of ROI 2130. Radiation Protection Manual and ROI 2132. Region II Personnel Monitoring Program)

Strategy NHS 2.2 _We_will regulate,uses. consistent withtthe level of risk:w involved by ' decreasing oversight of..those materials' that-pose the lowest radiological risk to'the public and

. .. continuing emphasis on high risk activities.

44

1 i

Substrategy NHS2:2.2

• We will assess'our. reg 01ations and'3rocesses'to

.....w.e. . ....#.4.wmidenti fy,those that-are,now. ore can ae .nisk . informed.

2?. - performan'ce! based or. r.isk informed. -less e : .. :.=.. -

.: /.JS -Je -i prescriptive" "I -

+'- - .

~ ~ ~ ~

Planned- Accomplishments:

NMS 2.2.2.1 Support the revision of materials regulatory requirements.

including the revision of 10 CFR Part 35 by reviewing and commenting on the draft proposed rule changes Measure: Quality and timeliness of reviews. (Target:

Reviews completed /cwments provided in accordance with schedule established by NMSS 80 percent of the time.) .

Substfategy NHS '2 2!3 MWe-Will reengineer.8ourJ1icen'sihg p'rocsssss',W . f.

. .jis . . .

. ' f ;.; :tStailoring.them~toYrdflect the relative. hazards of

MEsiill5, :_..2%2iEN'd:41icen' sed mater,i61s.'. - h. ..; .mai9d.#W!Si- ' i Planned Accomplishments:

NMS 2.2.3.1. Support the materials BPR Project implementation. including the Guidance Consolidation Project. to support simplified and streamlined licensing processes.

n , Measure: Quality and timeliness of Consolidation products. (Target: Support provided to Consolidation teams in accordance with schedules developed by NMSS 80 percent of the time.)

l I

l 45 l

1 l

2. Strategic Arena: Protecting the Environment 1

Genera 1 -Goalpyf. . . , , .

ply.lt -Q w n' pr.:nQtM:~~=.r

, . - n. , : e .

a N'"-"ProtNt'tbienVivoRment ~iiikohn5EiIfiith'civiliin"Oss~6f-$6tirc~et" byproduct', and>special nuclear materials through .the implementation-of

_cfthe. Atomic / Energy Act and the. National Environmental.. Policy Act- .

M?-k(, GOB  ? 1NiNW.W2W.L's'r v ? ! M ri k : X i G '!* : + - -

i10 1. * -

c. p -h a N.: U n :. . . .;. g .:2 Performance.=MGMW3%:th.%M&;. .9:-Goals:,3ggjtggnich-Mb4gg_jsf g3 -

.::; m e 5 . u :a. .

%.- . . h . ; y. . .--. u :. .

• .sa:h' gero.ibf.fsite . releases from, operating ~.faciljties .of ~ radioactive ..

~

.L i.. n~ n U.Olp.. -F.ema.t..e.r..:i.al;th.a.ts..ha'v..eithei .,t.en.t.iala.t. o -cause adve lp.denv.1 ronment;s.(.Goa].3V.'A .p52: .:;; . - -

. , ...-..7..

c . r...;.-n

, . y;3 3;.

. -. .a.-

.t. a, ; . _. .. 4 . .g ; . ,- -

s.

• i..' . ' No . increase .in.the' number.sof $?53te releases from:6pe,_ rating

' MW:-facilities of? radioactive material 4 hat exceed 210'.CFR:Part'?20:1:::

..-fi 7.d-WimitYd'#(Go31EV:A}1).%9/~#C  ; -' "i' ~ i--W??Sd E M.b-

. ~'

.:tr.w

-X-?'.*?F.'C'# Fi t 1.~.0.0C '

NJ~i.J.'T

^~-e

= ' ; ,. '".T-Y.&  : N .~. . - ~ ~ 9~ 1 -  :

yys; : - -

e..t:;c;;m.En..re.v W:

y]ronmentaEImpaEts,Oriwi~hav.eibeen :. life'ntif.ied.th.

r.ougO '~

h:iNEP&.

- " .pr;o:'. .e.c A ss.;

1 -

. . .y .

~

. -before Op.; regdlatory:.

action

. . .; ; ,tisitaken.

..(Goal'V.B)'.

-re.r m i-fr.r.ri.R.ca l Mid('cC:Jila~chofdancefwith:' NRC~Vele'aie'!cr.iteria:

.- NoJit s'will .'be rslease~diiintil (Goal:V.C) ~ a'5-satisfactorily fen Strategy.PE 5.~1 3:We~will . improve ths process by which licensees w - -y- , xsuccessfullyccomplete decommissioning.of non re~a ctor

.tsites. -- -

Planned Accomplishments:

PE 5.1.1 Coc.,7ete reviews of ORNL terminated sites list facilities and document the bases for decisions.

Measure: Quality and timeliness of reviews. (Target:

Complete reviews of all facilities on the list 4<

by 9/30/98. and for those not released. define l actions to be taken to release.) )1 PE 5.1.2 Schedule and complete decommissioning inspections in a timely manner and issue timely inspection reports, i

i i

I 1

46 l

l

]

?

i Measure: Quality and timeliness of inspection of licensees undergoing decommissioning and reports of inspections. (Target: Complete inspections in accordance with IMC 2605 with less than 10 percent overdue as defined in the IMC.

~

Capletion of inspection reports in accordance with the quality standards and timeliness of MC 0610 (21 days for routine and 30 days for team) with less than 10 percent overdue.)

PE 5.1.3 Maintain an adequate supply of operable and calibrated portable survey instruments to support independent surveys during inspections and to support incident response.

Measure: Number of operable and calibrated instraents.

(Target: The complement of instraents necessary for incident response will be

. maintained at all times. The supply of other instruments will be in accordance with the docmented minima inventory requirements 80 percent of the time.) -

PE 5.1.4 . Maintain capability to do screening analyses.of samples for beta / gamma activity. low energy beta activity. and alpha activity. We will coordinate with Region I for other '

radiological analytical services. We will develop and implement counting equipment QA/0C procedures.

n Measure: Operability of instruments and timeliness of transmittal of samples to Region 1. (Target:

Betalgatma.10w energy beta. and alpha counting instruments will be operable and calibrated or will be sent for repair within ten working days of identification of inoperability. Samples will be sent to Region I within ten working days of receipt in Region.)

PE 5.1.5 Expeditiously determine the safety significance and validity of allegations received. .

Measure: Pro 7ptly assess and acknowledge allegations received. (Target: 90 percent of all cases will be reviewed by the Allegation Review Board and acknowledged within 30 days of receipt)

Measure: Timely closure of allegations. (Target:

Closure of all assigned allegations, not involving wrongdoing or discrimination. within 180 days of receipt)

Measure: Provide periodic status to allegers. (Drget:

Issue status letters at 6 month intervals)

Maintain management focus on allegation timeliness. (Target: Weekly meetings with i

47

I senior Regional management focusing on allegations open greater than 90 days)

PE 5.1.6 Ensure that decommissioning inspectors and license reviewers are adequately trained and fully-qualified to perform and complete inspections and licer. sing casework actions.

Measure: Timeliness of staff qualification and maintenance of staff qualification. (Target:

. Staff qualification completed and maintained in accordance with IMC 1246 (or IMC 1245 for previously qualified staff). For sta.ff in qualification. coqq1etion of courses in accordance with the Training Plan. 80 percent of new staff will be qualified within two years of beginning assignment. Staff continuing qualification maintained)

~

Substrat~egyLPE'5.'1.2 '-TWeiwill .assurg:.th'at . licensees.have adequate. funds L

.. 1. -

9 cavai.lable 'for:. decommission".g and maintaining-

. .. d n . c_: . J. . . '. f.inanciaUrequireme'nts. -

4% -

Planned Accomplishments:

PE 5.1.2.1 Complete timely financial assurance reviews and document the bases for decisions.

a.

Measure: Quality and timeliness of reviews. (Target:

Initiate reviews within 30 days of receipt of financial assurance information and transmit RAls or acceptances to licensees within 30 days of receipt of contractor evaluations}

Strategy PE 5.2 We.will assure that licensees protect the. environment

. during operations.

• Substrategy.PE 5.2.1 During-initial-licensing and any other major. NRC m.m w graz,Tws 5:c#,,::factionithat-couldsignificantly r 7.: ef:. :c,.1df.the' environment;7we will consider affect the quality the. ,

_ ,., fa 2 2 . .w. , .c.. environmental, effects and alternatives associated c:a Y ~ ~ 2 'ith's'uch' major':NRC actions.

w Planned Accomplishments:

PE 5.2.1.1 Complete timely materials licensing casework reviews for cases that could have significant environmental impact.

document the bases for licensing decisions, and retain appropriate documents, e.g.. license review checklists, and supporting data.

Measure: Quality and timeliness of reviews of 48

applications. (Target: Evaluate applications in accordance with established criteria (IMC 2605. Standard Review Plan for Well Logging. Policy and Guidance Directive 84-20.

NMSS Policy and Procedures Letter 1-48. and

. Technical Assistance Request decisions.)

Substrategy",

"' PEE 5.5.21, Me~wilU inspect.totensure that li.censee's -identify.

74M:.f" J<and .mitigatehiote'ntial; adverse -impacts'-onMhe C . I, Planned Accomplishments:

PE 5.5.2.1 Complete inspections of materials licensees ef. fluent control and environmental monitoring programs where applicable and issue, timely inspection reports.

Measure: Quality and timeliness of inspection of materfals licensees and reports of inspections.

(Target: Complete inspections in accordance with IMC 2800 (materials). 2605 (decarimissioning).1220 (reciprocity). and 2690 (ISFSis) with less than 10 percent overdue as defined in the IMC. Cmpletion of inspection reports in accordance with the quality standards

' and timeliness of MC 0610 (21 days for routine and 30 days for team) with less then 10 percent overdue.)

PE 5.5.2.2 Ensure that inspectors and license reviewers are adequately trained and fully-qualified to perform inspections and complete licensing casework actions.

Measure: Timeliness of staff qualification and maintenance of staff qualification. (Target:

Staff qualification completed and maintained in accordance with IMC 1246 (on IMC 12a5 for previously qualified inspection staff and Directives for licensing staff). For staff in qualification, completion of courses in accordance with the Training Plan. 80 percent of new staff will be qualified within two years of beginning assignment. Staff continuing qualification maintained.)

PE 5.5.2.3 Perform timely evaluation of environmental events including on-site ins)ections to identify causes and root causes of events: rist precu sors: evaluate licensee compensatory measures and corre:tive actions: determine if there are generic implications: document findings: review NRC processes, procedur?s and performance to determine if actions are necessai y to improve NRC performance; and develop recommendations.

49

Measure: Quality and timeliness of licensee event reports revfews. (Target: Preliminary Notifications.

Morning Reports. and Input to NMED system in accordance with the quality and timeliness requirements of IMCs and Directives. Responses wi11 be cwmensurate with the risk significance and site specific / generic implications of the event. Review 95 percent of licensee events reported to NRC within five working days. For events classified as A0s or other events of interest considered as A0s. a lessons learned evaluation wi11 be performed.)

PE 5.5.2.4 Conduct Augmented Inspection Team (AIT) inspections to review each event that meets the thresholds established in MD 8.8. .

Measure: AIT inspections conducted to review significant events. (Target: AITs conducted in accordance with ho 8.3 and IMC 0325 and 90 percent of AIT reports issued within 30 days of the end of the inspection.)

PE 5.5.2.5 Support 01 investigation of effluent control, environmental or decommissioning issues.

Measure: Timeliness in cornpleting investigations of 9

effluent control, environmental. or decommissioning issues. (Target: Provide technical support to 01 on the schedule requested by OI 80 percent of the time.)

PE 5.5.2.6 Expeditiously determine the safety significance and validity of allegations received.

Measure: Prornptly assess and acknowledge allegations received. (Target: 90 percent of all cases will be reviewed by the Allegation Review Board and acknowledged within 30 days of receipt)

Measure: Timely closure of allegations. (Target:

Closure of all assigned allegations. not involving wrongdoing or discrimination, within 180 days of receipt)

Measure: Provide periodic status to allegers. (Tar Issue status letters at 6 month intervals)get:

Maintain management focus on allegation timeliness. (Target: Weekly meetings with senior Regional management focusing on allegations open greater than 90 days) 50

E 5.5.2.7 Identify and take enforcement against licensees who fail to comply with regulatory requirements in accordance with NUREG-1600 and the Enforcement Manual.

Measure: Conduct enforcement panels to coordinate potenttal escalated enforcement. (Target: As needed on a weekly basis with appropriate panel material provided to participants 48 hours5.555556e-4 days <br />0.0133 hours <br />7.936508e-5 weeks <br />1.8264e-5 months <br /> in advance) f Meas &re: Timeliness of Non-exemt escalated enforcement (Target: Process 90 percent of cases within the timeliness goals established in Section 5.6 of

. the Enforcement Manual with all non-exempt cases issued within 90 days. except those case types with a goal of 105 days.) .

^

Measure: ' Review Ol' Investigative findings for appropriate enforcement action. (Target: Review OI report within 45 days of 01 Report issuance for potential enforcement)

Measure: ' Issue confirmatory ction Letters as needed to \

confirm licensee cortmitments regarding emergent \

safety issues. (Target: CALs issued within two days of receiving cmmitments frorn licensees 90 percent of the time.)

^

Measure: Review non-escalated enforcement for consistency and corpliance. (Target: Participation in one Peer Review and completion of one audit of a representative sample of inspection reports) 1 I

l 4

51 i  !

1

3. Strategic Arena: Public Confidence General Gogl: . g ,_,,, ,g.. ,3. g ;,_g . .

...v.. .. , ,.. ~ .. . . . .

i-Th:e:.publierthose we regulate.c i' . and 3theri stakeholder. in the . national

1. Wand;in~teFnational communitidwill have. clear and. accurate.information.

NRC'.s

.'T YYab'o~ut';3Mme'aningfulfrole'9n.4and;

^

f . resp'ect

~

?_.for and: confiden

- degulatory :: program. 2 (Goal iVI) ??;~". '.'.. ' .

g a: u +%g +( .-:,.. i- x ~ 7 g n.

= at&W.w .~ . m.mW -. :b. . :. s. .l?.

. +.-~->+ a-%.

- .lf~?'."..'.$. m 1-1.Wggp>.2.y+.m.wurc.d ...

.n .r.+,s.: s , . . .. _ . , .,m -h. - u .- - l '. .

-  : ~. a: 5. ;'- .- i: .

f

• d,.m o % il-- eme.z.-;

. nt ,thetAg~slW$kllm3=

encycs ul=UP36' .

nvo P[fh'3m ihnic$th~6se e regdla; plan"to;imarovelowait informs.anda... lvescthe M.E. p'r~oinim:di(G6'*w"VI'.'A)ME:te,Tand:.otiel.istakeh'o1ders-Jin al "'! *.tR* T :P -

~ NRC'.sjregdlato Strategf PC r6mW ' .F.We' Willf objhetMeTy ' demonstrate 'that NRC 's ' efforts .

-%:.r .r;q. zen

5.vs;;;.s:iL%ix .pyr",are e~niblingMthFnat'

safetf:W W C-&~;-ion to use nuclear *-

.- - ' materials"-

SubstrategyiPO:6?.li2: m We:will.smeasurerand; report.the performance of both "W.4Sn;iw,rt -s .ocr:NRC rand.d ts r.li censees vand isha re 'this . performance

/ T.:J..J;;cn % _. . inform'ation.iri..a". fair;and focused way with '

d er;U@-/Gr cr5.intereste& stakeholder. -

P1anned Accomplishments:

PC 6.1.2.1 Disseminate information to public on significant actions.

Measure: Time iness and quality of press releases.

(Tar ;'ec: Press releases issued within two days of issuance of civil penalty or order)

(Target: Press releases issued for each open pre-decisional enforcement conference)

PC 6.1.2.2 Conduct public stakeholder meetings for significant decommissioning activities.

Measure: Number and timeliness of meetings. (Target:

Meetings held as specified in IMC 2605.)

PC 6.1.2.3 Conduct periodic press conferences in location where there is anticipated interest.

Measure: Number of conferences. (Target: Quarterly)

PC 6.1.2.4 Conduct public exit meetings for significant inspections.

Measure: Percentage of public exit meetings conducted for each AIT. (Target: 80 percent)

PC 6.1.2.5 Respond to inqJiries frOm the public.

Measure: Timeliness and quality of re5ponse (Target:

Respond within 45 days of receipt of a written

• request 80 percent of the time and prornptly (within two working days) to verbal requests 80 percent of the time)

PC 6.1.2.6 . Provide notice of meetings held with licensees.

~ ~

Measure: Timeliness and type of notice. (Target:

Notices issued in accordance with Mana

.- Directive on meetings with licensees) gement 53

4. Strategic Arena: Excellence General " Goal: ;;jJhe.NRC regulatory: program will be efficient. and will

~~ aT10' w =the Nation to s'afely use nuclear materials..for

- . civilian;purpo.ses.

.;.;(Goal. VII).- .. , .. . . .

Performance ~ Goals k ,... v, . n. ,.,

.j,..,,.. -. .; _

. r. . .-

.. .m .

....c-u-

. . m-g e w p. 45. .~.s . . o . :n... . .

.m1 emeift -

?.92@9/E$ si .stheiagencyls plan SNII "h- for;v.-regulatory excellence; E". .'n" rc.ce:cnsr.(waa

%e 1

..c .

n

.%..~t:.t.

r - -. Wsp?A)NN:6?'.M5-!W" M.-:+c n

. iEValifat . land fimplem.~.,-e ~ .-:.. :a .ent 'needed improvemen

' +,.e-ts for~- five,:....

.:J

.n -

F: - _.*

major..NRC2.c

.O . :l processes ;by' July".1l 1999._ :(Goal. VIL B) .7... J

_ . : ._1. -

i Strategy 7EXG.1GrU;WeWillsmake. regulstory excellence'.the. cornerstone

..a:eeW=;44 :.mfor nr.6f t6ur'<strat' gies and activities. r l

Substrategy.EX J.:1.1: . We will-proactively examine our programs,and.

. . , ,,~..' ' 7, -+ b, . performanc'e jn. order.to. improve.the-way.we do our,

' .. .., _-work throughtcomprehensive, systematic.-ragency wide

" ?? ~ 2 approach toiprogram assessment and improvement.

Planned Acco'mplishments:

EX 7.1.1.1 Conduct quarterly self-assessments of performance on the a basis of specific criteria with performance measures to ensure programs meet management expectations for on site on time, and on target.

Measure: Cornpletion of self-assessment each quarter (Target: One per quarter)

EX 7.1.1.2 Conduct periodic reviews of the quality of inspection reports.

Measure: Number of inspection reports reviewed for quality (Target: Peer review at least twice per year)

Substrategy 7.1.4: We will provide training and development to our staff to. enable us to achieve excellence in our organizational and -individual performance.

Planned Accomplishments:

EX 7.1.'4.1 Provide training to managers in accordance with NRC program and Region II supervisory addendum.

Measure: Individual training requirements in procedures met. (Target: Requirements met in 90 percent 54 g _ _ _ - _ _ _ _ _ _ _ _ _ _ _ _ - - __.

i' .

l 0f cases within 24 months of assignment as supervisor)

I EX 7.1.4.2 Ensure that inspectors and license reviewers are adequately trained and fully qualified to perform licensing casework actions and inspections.

Measure: Timeliness of staff qualification and i

i maintenance of staff qual.ification. (Target:

• ' Staff qualification ctmpleted and maintained in accordance with IMC 1246 (or IMC 1245 for previously qualified staff). For staff in qualification, completion of courses in accordance with the Training Plan. 80 percent

\ of new staff will be qualified within two years of beginning assignment. Staff continuing qualification maintained.) -

i i

l Q

8 i

i t

I i

55

4

)

. , I STATE PROGRAMS l

l A. Resources Ja,rggd i, . ;d.;;;F,YQ9981f??^. _f.s g, EY.1999.c.. ..L ::i ._:g,FN2000j;;. 3

@ M N;.!Ar.ej. M[d iPMM6$ g ; g (fiTE M IRS]N@?fFT[T.@ g[$(6 nhy~5 S'tiWTREoif$iii~c9. 3@ .eT'O 22.;0VV '4M .

V.a w 3.'.

B. Goals / Planned Accomplishments / Output Measures By Strategic Arena

1. Strategic Arena: Nuclear Materials Safety General Goal:~ ' Prevent 3ridi'a tion 2related deaths or illnesses due' to ..

. civilian:.use of. source. ' byproduct ~, and special nuclear

( _ .

. materials. ~ (Goal II)~

~' ..

~.? - . . . ..

2 Performance ' Goals: 1 -

a .. : .u. .... ...

• 4Zero. radiation-related deathsLdue to1 civilian use of' source, bypro. duct', cand.special nuclear materials. (Goal' II. A)

~

No increase-in the number of significant radiation expos'ures due to loss or use'of source, byproduct, and special nuclear materials.

(Goal:EI.A.1) -

No increase in the number of losses of licensed material as reported to Congress annually. (Goal II. A.1.a)

No accidental criticality involving licensed material. (Goal II.A.I.b)

> ~

No increase in.the number of misadministration events which cause significant radiation exposures. (Goal II.A.2)

Strategy.2.3:~

We will work.with the Agreement States to assure

~ consistent ~ protection of public health and safety nationwide.' --

Substrategy 2.3.1: We will provide for early and substantive involvement of.the Agreement States in rulemaking and regulatory processes, including the transition to risk-informed, performance-based regulation or a risk informed. less prescriptive approach.

Planned' Accomplishments:

SP 2.3.1.1 Review Region II Agreement State regulation changes.

Measure: Quality and timeliness of reviews. (Target:

56

Reviews will be cmpleted in accordance.with SP D.7 . Documentation of these reviews will be provided to OGC within 30 days 80 percent of the time. )

SP 2.3.1.2 Review and comment on OSP draft documents and participate on task forces and in training courses.

. Measure: Quality and timeliness of reviews and

' participation in task forces and training courses. (Target: Reviews will be c.ornpleted in accordance with schedules established by SP

' 80. percent of the time.)

Substrategy'2.3.2:~iW ;Weisillir'eWew the adequacy >and compati.b'ility. ofpC..

A =cea~ch Agreement?.Stateits N

~cm.gp =INDG~gijjMh65FesDl 7 ts ?ohth_?. Radiation:C6nt'r;61.EPF6gf a

,. $$MMk!/$s@M.I M =.T . W isVperfirusnEe".' review-tbitfish Agre5me6tiSta'fEsME49*MW&MM#

Planned Accomplishments: .

SP 2.3.2.1 Support IMPEP reviews for adequacy to ensure public health

,and safety and compatibility.of programs with NRC programs.

Measure: Quality and nurnber of IMPEPs supported.

(Target: Participation in two IMPEPs using the criteria of h0 5.6.)

Substrategy. 2.3.3:u i L:- We:wil.12 continue (to frespond.to . re(uestse fromi- '-

- ". Eindividual. states that. express an interesbins f

' -'-"puFsding'Agrdhment'St5tbistatu~s' ahdTorkiith" bach'~

...._+.,

~.3. ~.. .~ state-to achieve 3his goal::we'will also. encourage 5 9 4-i: ~ T N i i: *retentiorir 'f;eki5tiiig'.fgreementiStates' o

. s.m:W'Mthrdtigh"noritiibnstary incentiv sF. ._. . _primir'ily _ . ' ' _ ".

~

Planned Accomplishments:

l SP 2.3.3.1 Support the Agreement State assistance request in Region II and support any State desiring to become an Agreement State.

Measure: Timeliness and quality of support to Agreement l States or States desiring to become Agreement 1 States. (Target: Support provided in accordance with States' needed schedules 80 percent of the time.)

• l SP 2.3.3.2 Conduct annual meetings with Agreement States not undergoing an IMPEP.

Measure: Quality and number of annual meetings. (Target: '

Annual reviews completed in accordance with SP Procedure D.24 for each State not receiving an IMPEP in FY98.)

57

REACTOR / MATERIALS ENFORCEMENT ACTIONS PROGRAM A. Resources

-@ ..U. _ii@. e_t_Y.A. 'r's..a. n_d..!.

M. _E... '._F%. '_'199.8. MEEY.C1999;s.d

5. Z:s C ~v

. . ~ .

W5E.Y. i:2.._0_00>4.'.M. ..

M.Ec$oEIS.IiEfiM.Ej .v. ._C2.0s.1 J >;. . 3 . 0 ., ... e.. . .

.'3. 0 ;

SEbMMS p.W;-p nGQt4 p 2.1 ..- .~ = . ~ g. & ,. ;. .

B. Goals / Planned Accomplishments / Output Heasures by Strategic Arena

1. Strategic Arena: Nuclear Reactor Safety Genei 51fG6&lu..~~~TPFeVe~ntfradiHtio~nM lite'di' deaths'.'or'.illnessesYdeb~.itor : -:.

V..Safdd.M

..:. :N'i

q:g;;GM: civilian.i.noclearir.da~ctors'.~s:s(=GosT;I)

~ ,. 3 +9_T!.J :

- ~ ~-~.e m.'D.';"'

c

:[ ' ~;'=;iX.=.:

~wy

-]~ , ..{

PerformanceiGoals

.+=.- .. .w . S.

.a. . f.. ,- ,

. j- . g,. ,,g.gg.jlfg.g

• .' _ . sc . .= d J - -

u:<.1%n.2erorcivilian

. guw a.u-s .:e. .s.:m;a,n.: nuclear-m.w;: 2 reactor

-g . c. accidents.%-(.

.'..-..e.. Goal 3+. A):.- :~.. =

• r;t g.1:.-Ha1ntainlo;h, p . ' W events

. m; .c ;. w ..

w frequency:of

.f

?J 6 w r:'hich:,cou . .ld lead to a: severe raccident M(Gobl ?I A.1) :hw.:.ny  :..- .c.~.<v e. .;

n :m. .:n_.

...y..... :w c c. ...-::. . -n

."=:s;::::x. .;'dueMo' radiation.'or.~ra . .u bioactivity releases .from civilian s .. Zero"disths nuclear reactors. :(Goal'I.8) o N " ' -

..u.-...~.u.._-~.v-~,.-..---~-w-.-.~~--v.,~.

> Zero .signif.icant radiation exposures'. dub cto: civilian'n'uclear'. reactors. '

(Goal .I .B.1) -:. :uh : :r ""

. -=  :

Str~a ~'tbH'NRS .1:0:'.Ws/willl;as~suredhatRibensee's: discharge their.: primary

~

~ ~ " responsibility..for.iconductin6 safe operations. - -

Substrategy NRS 1.1.4: . We will. make'. licensee performanEeTand' c~ om~prian'ce'

g. r: v-e with.our requirements consequential:by decreasing .

,;:.4..

.mth '-inspection'frbquency'for good i performers and -

J-U:gr. .::m 3+m massessing~ penalties to poor performers;  :--

Planned Accomplishments:

NRS 1.1.4.I' Identify and take enforcement against licensees who fail to comply with regulatory requirements in accordance with NUREG-1600 and the Enforcement Manual.

Measures: A. Conduct enforcement panels to evaluate and coordinate potential escalated enforcement. (Target: As needed on a weekly basis with appropriate panel material provided to participants 48 hours5.555556e-4 days <br />0.0133 hours <br />7.936508e-5 weeks <br />1.8264e-5 months <br /> 58

in advance.)

8. Timeliness of non-exempt escalated enforcernent will be conducted in t

accordance with the timeliness goals specifled in the Enforcement Manual.

(Target: On average. 90 percent of cases will be issued within 90 days of inspection cornpletion, and. on average.

l 100 percent within 120 days.)

. C. Monitor DOL actions for potential enforcement. (Target: Issue Chilling l

Effect Letters within 30 days of receipt

' of a DOL District Director's decision of

\ discrimination).

D. Review OI investigative findings for

, appropriate enforcement action. (Target:

) Review OI report within 45 days of 01

. Report issuance for potential enforcement).,

i E. Issue Confirmatory Action Letters as needed to confirm . licensee coranitments

regarding emergent safety issues. (Target:

l as needed) . . - . . .

F. Review non-escalated enforcement for

{ consistency. timeliness, and cornpliance.

l (Target: Participation in 2 Peer Reviews and cornpletion of 1 audit of a n representative sample of reactor inspection reports).

G. Timeliness of non-escalated enforcement (Target: 90 percent of cases within the report issuance timeliness goals of MC 0610) e 59

2. Strategic Arena: Nuclear Haterials Safety General' Goat.M"P.revent .radiatiori related deaths or. illnesses-due to ~

r - .O"$;civilianlyse of,Jource;- byproduct. and special nuclear

" "' T'W-W

~

rrrm=ncerv. .

ymat'er:ials'.

..s==

• (Goal:II) .

Performance ~ Goal.. .y..s:j;lllafj; 7

..-.J.O... .

c; .;. 7 7, : .

~ . m :: : .. ,

n.~ w..s-:y w.n.n -

.es,.;,  :--

~

• o 9.~$'fe~r$faifi'ati~'r@'pecialunucleidssteF1als'.i.s(Goal 6. 2II.;A)E-bM

. ~

--c.MLyprodolit1%ndi..s. "b .,m.r.m w.. ~ w -----

c.;.;m2 .e u

. . w. .

. -- m  :. .n.c;: M.-wa

• ;wNoiin.creaseJ An.wuc-he.;,:,m.cznin ~ - 1. number..of.significant ~ c.

iadiat'lon expo

~

T.-?-';los' 36&use o.n s

NM-

.tv fssotfree',;by* product.tandespecial ~~ '

a

^

. nuc

;*'us

. . .a,w_ w.musW

.ra:e.2(Goal:IIEBF4

.ac m:-:.o. -

"Ma'.r ' * * ". '

w- -y W w@; :a ' "

. ':- G 'Q^ . -

c:6.No;increasednathelnumber. ofDosses.of licensed material :as:m. :areported* .

. w.

2.E. td'CorigrdsUanntial195(GoallII C) ... -

. - s .v , - m. ~ . a . _. .- .

. = w........_...m

w. .

• . .:.-;-w;No.acc'idental.cr_iticality;invo.l.ving licensed material. (Goal II.'D) .

. u ..w . . mnm .o. .. - .,. . . . .. .-

xwA .

• A Nod.n.-n.-q u-++:.v~ ++. -wncr.easean th'e2 number.~of;misidministrat' ion events

. w. ..~-

~

E which.caus C...?Wsi glii fi ca rit4ra di ati on"expostfrss'.O (Goal ..II . E ) - i -

+ -E St'rategy4NHS ~

211TrWe^.Will ' ass'ur~e thst lice ~nse'es discharge their primary

a. e responsibiTityifor Using materials safety.

Substrategy NHS 201.4: We will mskeilicensee performance and compliance

'?.with our requirements consequential by decreasing

. the-inspection frequency for good performers and assessing penalties to poor performers.

Planned Accomplishments:

NMS 2.1.4.1 Identify and take enforcement against licensee's who fail to comply with regulatory requirements in accordance with NUREG-1600 and the Enforcement Manual.

Measures: A. Conduct enforcement panels to coordinate potential escalated enforcement. (Target:

As needed on a weekly basis with appropriate panel material provided to participants 48 hours5.555556e-4 days <br />0.0133 hours <br />7.936508e-5 weeks <br />1.8264e-5 months <br /> in advance.)

8. Timeliness of non-exempt escalated enforcement will be conducted in accordance with the timeliness goals-specified in the Enforcement Manual.

1 (Target: On average. 90 percent of cases will be issued within 90 days of inspection completion, and. on average.

100 percent within 120 days.)

60

I l

C. Review OI investigative findings for appropriate enforcement action. (Target:

Review OI report within 45 days of 01 Report issuance for potential enforcement).

• * * * *

• E. Issue Confirmatory Action Letters as needed to confirm licensee cannitments regarding emergent safety issues. (Target:

As needed) .

l

• F. Review non-escalated enforcement for consistency. timeliness. and cmpliance.

. . (Target: . Participation in 1 Peer Review and cmpletion of 1 audit of a representative sanp).le of materials inspection reports . .

G. Timeliness of non-escalated enforcement actions (Target: 90 percent of-cases

, within report issuance timeliness goals of MC 0610. ) .

W as e S

1 i

4 61

O f

3. Strategic Arena: Public Confidence l General' Goal:'"0".The'.publjc, O'M those=ye'. regulate, and other. stakeholder in l

the:natibnal:' and;; international community. will have clear

. .. .._ .. ,Jand. accurate".information :about, a meaningful .roletin, and

. _::.?fif. t respect .for and confidence.in, NRC's regulatory program.

.: . .. u',l.".w..  ;'%

:'r uwt &;;.'.iw(Goa1.+VI)- .w: . . . = 'cn"

- '&.m:~.

~c~- . , :.

~ . . .-

Performance Gobl:$,J ai L .cs ;a,Q.5fy lm'_V 7w

1. ~j.- . - ---

y m- ~w- . .: . . .

~ . :,

-8 . . . . .

,.;; m m e. . w -n.m p ;.a w ., m.. gency.s

. . e. c . .. ..

plan-to;1.marove how it informs.:: ~the p 31 e..w ,,

ment,

.and involves.

E'?$.pu..ili Im c;Fth'o~se weWegul ate. ; and :ot 1er:stakehol dres .in' NRC's 2 regulatory Giprogram?.Ef(G6sl.'VIfA)MEFtJf:'O ~ .

.< %.M

~

StratdgyfPC:6.'1WWeiwill2bbjectivelf":. demonstrate that NRC!s efforts are- .

nss:.:m.m.nT# Enabling:-the:n' at' ion to'use nuclear materials : safety;

'~

SubstrategyJPC:6cl.2:p-'.We.will measure'and. report the performance.ot both

.a. 3-( ,7 er. - - ~.NRC and.its; licensees and. share this performance v.-

[.~~ ,c

"~~ . . . .;. - ..-g ;information in~;a.' fair and focused way with':

. interested ~stakeholdersi .

~

Planned Accomplishments:

PC 6.1.2.1 Disseminate information to public on significant actions.

a Measure: Timeliness and quality of press releases.

(Target: Press releases issued within two days of issuance of civil penalty or order)

(Target: Press releases issued for each open pre-decisional enforcement conference) 62

4. Strategic Arena: Excellence General'.Goali

~ 3'The NRC.regdlatoVy pr'ogram will be. efficient and .will

. . - += .1 h'llo#,thEN5 tion-toisafdTy;use ' nuclear materials .for.

ci vili air puFpo'sss . T(G_6;al ;VII) '

I

"'~

Perfobm'aniscGoals: -; ~ .

r;;=:. a.  ; . T. - '.';Y f . .. .  ; f' .

e- ' S ~ sImpleriierit'.the :agenci.'s d-i b.9&FMfM?tM,. plan :forfregulatory MCM~l.i'%.MM 'excellened:

G-4

' (Goal.'.VII. A)~ .

M;j@Ev51uate-and-implement.:needed!.

.I

' ' < . ' -: - P . .. . 5for?five improvements '

" m{

l rhprocesse's byQuliT;3999;".'(Goal VII.B), . '"W- ~

StratsgfiEXR11iEWessil.lsmake:regblatorysexcslience.the: cornerstone =for all

~

- m-: < : . e.. .of-oure strategiestand 'acti vities. " ' : .=".N ~'-c -

Sbbstrategy EX;71.m f:'We will proa.ctively examine' our. programs'and ~

g i-c.v y 'c. o - Ty. performance in orderato improve the way we:-do our r..'",

..q.: xTc:9 f..3.1,;;+., work -throug ,co.mprehensive.

h .systemati c. :3 agency wi de

= approach.to. program assessment and improvement.

1 Planned Accomplishments:

EX 7.1.1.1 Conduct quarterly self-assessments of performance on the basis of specific criteria with performance measures to a ensure programs meet management expectations for on site, on time. and on target.

Measure: Cortpletion of self-assessment each quarter (Target: One per quarter)

Substrategy EX 7.1.4: We will provide training and development to our staff to enable'us to achieve excellence in our organizational and individual . performance.

Planned Accomplishments:

EX 7.1.4.1 Conduct training to the Regional Staff on allegation management and enforcement.

63

5 Heasure: Cctrpletion of Training by Regional and Resident Inspectors (Target: 100 percent of Regional /

Resident staff for allegation training and 75 percent af Regfonal/ Resident staff for enforcement training) e 9

• e 9 e 0

9 p C e n l

64 l

l-

INDEPENDENT PERFORMANCE EVALUATIONS PROGRAM A. Resources gpaFfsd7A'~ai@ M K5Yg 9p,8 @ }&.y E G1999 74 # yppt;g,20,00 h $ (

. ,saeq L. - . ,j PSis(k) .

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~

IEdfdiithiEpYnse@ir$ P ~+ 9 ?;1.-259 2 W 1. 25":' - '-' ^

41?251 B. Goals / Planned Accomplishments / Output Measures By Strategic Arena Strategic Arena:

1. . Nuclear Reactor Safety GeneraFGoal LSiPreventiradiatio.n relatedideath's or= v illnesses due .to7=;< ' ~ -

-c.g w 4 civil-lan'nucleartreactors- Goal..I) - '

~a . ~ ^' ~

Pe%.$5d?ng$l2O $@#

rf&inance 'GoalsM4 Elfidili".34@Tp ?fd@n5(R.

' T- M"li m -?-

6; ' TW ' *-%Gm 940.0/699PAMWTWW -

W:

• ~g;:(WiW}

'":: Zero civilian

. : . .: r .; i '/* s.

, nuclear . reactor: accidents-(Goal

~ , , :b >:

• g -

W*W ,

I) .

-l- q. :.

l N 25Ha' irita' int 5Mb40e'nE94of J~'Jn esvsnfifwtiifhicotild 'Te'ad 6a sever'e la'ccid5 fit

~. ..t

~

~

- W.:i.-:(G6al:lsA.1)dwwp

7. ay.f.W- . .l-5,.tvcv;Wf a.b - -

n~' a'

> ' .2Zsrdideaths;due'to'! radiation'or radioa5tivity rel5ases from civilian a ' nuclear > reactors c(Goal'I;A) ' ' ' '

.: q :; .... ,c.

Zero significant radiation exposures'due to civilian nuclear reactors

-(Goal I.B:1)

. g . w. . .y -n , . . . , .~ , .. . .s . y . u-, -- - -

1201 CAsiurFithatslicilise's discharge.their: e prima ~ry Stratedijj.NRS.1:%C-if

~~ .2. 4 o.,;.G.:!."-=~ bresp6ns'ibilityJo6 conducting safe operatio

..- 1

..-..m...

~.,: .4. %. . .<

n.

-. r. . .: _ . .

Substrategy.NRS ' ~; 1.1.B: .We-will maintain'and exercise an incident response

-capability'to. ensure that licensees and the NRC are prepared to respond to radiological emergencies.

Planned Accomplishments:

NRS 1.1.8.1 Support each incident response exercise by providing technical managers and staff personnel qualified to function in the incident response center.

65

Measure: Number of exercises performed (Target: four exercises per year)

NRS 1.1.8.2 Respond to incidents with qualified individuals to assess radiological emergencies and provide accurate assessments to response managers.

Measure: Membership and training qualifications of all reactor safety team and protective measures

. .. . team. (Target:. ccmoletion of semi-annual training)

NRS 1.1.8.:5 Maintain sufficient number of qualified individuals for emergency response in the Region.

Measure: Number of personnel designated for each position.

(Target: Maintain depth of three people in each position)

NRS 1.1.8.4 Re' view changes to licensee *s Emergency Plan.

Measure: Quality and timeliness of all Emergency Plan .

changes. (Target: 80 percent of licensee's Emergency Plans reviewed within 60 days of receipt)

NRS 1.1.8.5 Maintain the incident investigation qualifications of staff.

u Measure: Qualifications of individuals on the IIT roster.

(Target: Provide individuals to be placed on the IIT roster as regrested by AE00. Assure individuals on roster trained in accordance with requirements)

NRS 1.1.8.6 Maintain regional response procedures, equipment, and facilities in state of readiness.

Measure: Adequacy of readiness for exercises and events.

(Target: The ERC perform surveillance of ,

equipment as defined in regional procedures.

ERC update procedures one time per year) 1 66

2. Strategic Arena: Nuclear Materials Safety General

_u Goal:U/,4. Prevent >. radiation-related deaths:or-illnesses:due to...

7"ps.n];e.._>

myu.

'i-p pt,civilihn.ussT6f,30use,9bip'roduct " -;indispeciaT. nuclear

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Strategy NMS.'23:' We Will assurs th'at?li~censees-discharge their;pr.imar.y

' responsibility.for using materials safety. '

o Substrategy'NMS 2.1.5: We will license and inspect facilities and material i users to. help ensure that they operate and I decommission safely and develop safe products.

Planned Accomplishments:

NMS 2.1.5.1 Sup> ort each incident response exercise by providing tec1nical managers and staff personnel qualified to function in the incident response center.

Measure: Number of exercises performed (Target: one  !

, exercise per year)

NMS 2.1.5.2 Respond to incidents with qualified individuals to assess radiological emergencies and provide accurate assessments to response managers.

l Measure: Membership and training qualifications of all  ;

\ fuel facility and materials safety and i protective measures teams. (Target: completion of semi-annual training) 67 l

L______._______--__-------------- -

NMS 2.1.5.3 Maintain sufficient number of qualified individuals for emergency response in the Region.

Measure: Number of personnel designated for each position.

(Target: Maintain depth of three people in each position)

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NMS 2.2.1.1 Support AE00 nuclear materials event data base (NMED).

Measure: Provide input to NMED for materials events in

'NRC and Agreement States. (Target: Provide input via the HQ Operations Centur within two days of receipt of event) n l

68

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69

(

. a Significant Reaulatory Effectiveness / Excellence Initiatives Region II's plans for self-assessing our performance during Fiscal Year 1998 are provided below. Foremost in our assessment plan has been the use of quarterly self-assessments by each Regional Division.

Our assessment plan includes audits of specific areas. We plan to invite participation in these by other Regional and Program Offices. Our plan also includes continued participation in Agency performance reviews such as the IMPEP of Agreement States in other Regions IMPEP of other Regional materials and fuel facility programs, operator licensing, and allegations.

Reaion II Performance Assessment Plan For FY 98

. Obiective The objective of the assessment plan is to (1) provide a systematic approach to. evaluate strengths and weaknesses in the implementation of programs assigned.to the Region and (2) provide input into decisions where the performance should be modified.

Process / Goal.s The process in FY 98 will consist of the following planned assessments:

1. Quarterly self-assessments of performance by each Regional Division.

The assessments will include tie establishment of performance indicators and measures based on the Operating Plan agreed u Office and based on the Agency's Strategic Plan.The ponassessment with the ED0'sresults will be reported to the Regional Administrator and discussed during the Region II management retreats.

2. Targeted evaluations in areas where there is potential for performance problems. These areas are selected to aid in the early detection and 3revention of problems. The group assigned to perform these audits will Je proactive in seeking the participation from other Regional and Program Offices. The evaluations for FY 98 will include:

a. Review of the security and handling of financial assurance documents (Reference MD 8.12).

b. Review of the Radiation Safety Officer function in the Region.

70

c. Review of the allegation process and the quality and timeliness of allegation closures (Reference MD 8.8).

d. Review the progress toward implementing the results of the NRR sponsored job task analysis for DRP functions in the Regions.

e' Review of" the quality of the issued inspection reports from perspective of whether focused on performance, appropriate message. and enforcement actions supported (Reference Manual Chapter 0610 and the Enforcement Manual).

f. Followup review of the implementation of the Regional Security Plan.

g. Followup review of the issuance of exemptions.

4

.0 8

4 71

.  ? A R~~ 3 R _3..u, \.A _

MA\'AG V E\~~/ ORGAN::ZA~~::0\

AC~~::V::~~:: ES .

8 72

i PART B: REGIONAL' MANAGEMENT /0 ORGANIZATION ACTIVITIES l

The following provide the targets for the activities indicated:

a. Supervisor to Employee Ratio

~

'The current Reg' ion il supervisor to employee ratio is 1 to 8 and thus meets NRC's goal. Region II plans to continue maintaining this ratio.

Twice each year. Region II management will evaluate the effectiveness of the organizational structure to determine if further reductions can be made in the future without negatively impacting mission accomplishment.

b. Positions'at" Grades GG 14 and Above .

The Region plans to pa'rtner the Staffing Plan that will meet the in this area by the end of FY99. Region II Agency's makes every42 percent effort to re goal, duce its number of GG-14s and above

.. each vacated position by senior managers to determine if the backfill needs to be 'a GG-14. Since the Regional reorganization in FY 1996 resulted in eliminating section chief positions. Region II has had six GG-15s that are not in supervisory positions and that significantly skew our "GG-14 and above' num]ers. As discussed during the recent Region 11 Management Retreat. thirty-six staff will be eligible for optional retirement between now and the end of FY 1998. 22 of whom are at the GG-14'and above. Consequently. Region II will be able to reduce the total number'of "GG-14s and above" positions by backfilling only the most crucial GG-14 mission-related positions. Once the Staffing Plan for FY99 is approved. Region II will replace the GG-14 positions with GG-13s in' cases where not indicated as a permanent GG-14.

c. IT Initiatives The Region does not plan initiatives other than implementation of those promulgated by the Chief Information Officer.

d. FTE Staffvear Manaaement Throughout the Fiscal Year 1997. the Region took initiatives to reduce the FTE from a ceiling of 223 for FY 1997 to a ceiling of 219 for FY98.

The Region maintained a steady yet conservative staffing approach to ensure that mission needs and staffing goals were met without exceeding the FY 1998 FTE ceiling. At the beginning of FY 1998, the Region had 221 employees on board. Given the attrition rate of approximately 3 percent, this level of staff will prepare the Region to meet operational needs without exceeding the FTE allocation of 219 for FY98.

e. Prooosed Contractual Projects

.The Region plans none of these during the Operating Plan period.

f. Guidelines for EE0 and Affirmative Action in Operatina Plans The Region, in conjunction with the Office of Small Business and Civil Rights, proposes the following planned activities or areas of emphasis 73

1 in this area during the Operating Plan period.

Support employee development and career enhancement through rotations, details, reassignments, and formal training.

Specifically, assure that minorities and women are provided a fair opportunity to participate.

Actively supporting the activities of the various Agency EE0 advisory committees, and support employee participation in these activities.

Be proactive in providing candid feedback to employees through the

' performance appraisal process: in providing monetary and non-monetary recognition to deserving employees: in monitoring awards and training activities to ensure fair and eauitable participation of women and minorities:. and in encouraging qualified women and minorities to participate in executive ieadership programs.

Ensure that'all hiring activities include specific affirmative action efforts to include minorities and women in the pool of candidates. -

Support the' Agency's Management Diversity initiative and attend required and refresher EE0 training.

When filing vacancies. utilize broad rating factors, when possible, to facilitate a more diverse pool of candidates.

d'ctively seek to promptly resolve issues that could lead to formal EE0 complaints.

Discuss EE0 initiatives for the office with supervisors and employees to facilitate understanding, demonstrate support. and encourage open communications.

74

i 1 PART B. REGION II - SUPPORT ACTIVITIES General 2Goa'l:Vn "F:2 ~ ^ ~ 'I C ' ? .).'

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)

Planned .High quality, culturally diverse applicant pool Accomplishment Measure: Applicant pool provided consists of highly qualified candidates from agency identified underrepresented groups. (Target: Consistent with the Agency EE0 Plan)

Planned Replacement Hiring Accomplishment l Measure: The number of vacancies for which staffing support is provided. (Target: . Provide staffing support for fi11ing vacant pasitions consistent i with Staffing Plan targets)

Planned Human resources advisory products and services Accomplishment to managers and employees Measure: Benefits forms, training requests and personnel actions are processed within established time frames. (Target: 95 percent of above requests are processcd by the effective date of action)

Planned Develop Region II's Annual Budget Accomplishment Measure: Timeliness and Quality of Budget (Target: FY 2000 Budget information submitted to DC in appropriate time frame to support 2/99 budget submission to Congress: FY 2001 Budget information submitted to OC in appropriate time frame to support Budget Request to W1B 9/99)

Planned Collect amounts due NRC l Accomplishment

\ Measure: Timeliness of license fee data submissions to OC

\

(Target

Provide license fee billing data to the DC within ten calendar days from the end of 75

. e the Quarterly Fee Period) i Planned - Processing Travel Authorizations and Travel Accomplishment Vouchers Measure: Timeliness of travel authorization and travel voucher processing (Target: Travel authorizations are prepared by the date required by the traveler (when authorizations are submitted in cmpliance with NRC directives).

Travel vouchers are to be audited and reimbursement checks processed within five work days after date of receipt of the voucher.)

Planned .. ..P.rocurement of supplies and services necessary Accomplishment to the functioning of the Region II Office. .

Measure: Timeliness of processing of requisitions and purchase orders as determined by random sample of 30 each quarter. (Target: 90 percent requisitions to be processed within 14 work days after date of receipt. 90 percent Purchase Orders to be processed within 14 work days after date of receipt.)

Planned Provide standin Accomplishment timely manner. g information reports to management in a Measure: Eighty-five percent of reports to be issued in accordance with scheduled time frame. (Target:

Onsite and Back Shift Reports - five work days after end of Pay Period Inspector Utilization - five workdays after end of month Management Information Report - 15 work days after end of month Inspector Followup - five work days after date of receipt

• RITS Audit - five work days after week ending

• Plant Status and Morning Reports

- Plant Status: Daily by 7:30 a.m.

- Morning Report - Daily by 1:30 p.m. '

76 -

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APPENDIX D: INSPECTOR ACCOMPANIMENTS & INSPECTION FILE REVIEWS

1. INSPECTOR ACCOMPANIMENTS Licensee: Virginia Equine imaging Location: Middleburg, VA License Type: Veterinary Diagnostic inspection Date: February 2,1998 License No. 45-25405-01 Inspection Type: Initial, announced Priority: 5 Inspector: O. Bailey Licensee: Mc Donough Bolyard Peck, Inc.

Location: Fairfax, VA License Type: Portable Gauge inspection Date: February 5,1998 License No: 45-25409-01 Inspection Type: Initial, announced Priority: 5 Inspector: O. Bailey Licensee: Best Industries, Inc.

Location: Springfield VA License Type: Brachytherapy, Mfg. & Dist.

Inspection Date: February 3,1998 License No: 45-19757-01 Inspection Type: routine, unannounced Priority: 3 Inspector: O. Bailey Licensee: Mount Vernon Hospital Location: Alexandra , VA License Type: Hospital Inspection Date: February 3-4,1998 License No: 45-17187-01 Inspection type: routine, announced Priority: 5 Inspector: O. Bailey Licensee: Prince William Hospital Location: Manassas VA.

License Type: Hospital Inspection Date: February 5,1998 License No: 45-19485-01 Inspection Type: routine, unannounced Priority: 3 Inspector: O. Bailey i

---_--___.______________w

Licensee: University of Florida Location: Gainesville FL License Type: SNM Inspection Date: February 24,1998 License No: SNM-1050 Inspection Type: unannounced Priority: 5 Inspector: B. Parker Licensee: Great Lakes Dredge and Dock Location: Green Cove Springs FL License Type: Underwater density gauge inspection Date: February 25,1998 License No: 09-24891-01 Inspection Type: unannounced ~

Priority: 5 Inspector: B. Parker Licensee: Veterans' Affairs Medical Center ,

Location: Lake City FL License Type: Medical Inspection Date: February 25,1998 License No: 09-25129-01 j

inspection Type: unannounced -

Priority: 3  ;

Inspector: B. Parker Licensee: Computer Sciences-Raytheon

' Location: Patrick Air Force Base License Type: Calibration facility inspection Date: February 26,1998 License No: 09-25013-01 Inspection Type: unannounced l

i Priority: 3 Inspector: B. Parker Licensee: Veterans' Affairs Medical Center  !

Location: Gainesville FL License Type: Type A Broad- Medical inspection Date: February 23-24,1998 i License No: 09-12467-02 Inspection Type: unannounced Priority: 1 Inspector: J. Pelchat and B. Parker l

L 1

f l 2. INSPECTION FILE REVIEWS File No: 98-01 Licensee: Dr. Jose L. Fernandez License No: 52-25114-01 License Type: Therapy - Strontium -90 Eye Applicator Inspection Date: June 9,1997 l Priority: 3 Type of inspection: Compliance Action Follow up inspector J. Diaz Velez Date of report: June 9,1997 Supervisor's Review: John Potter Comments: This was a special follow up inspection to an enforcement action taken against the licensee. During a previous inspection in March 1995, the inspector noted that the source calibration certificate was incorrect and also the doctor had neglected to account for decay of the source when treating patients. As the result, the doctor was required to notify all patients of their misadministration. The inspector confirmed that patients had been notified during the June 1997 follow up. 4 File No: 98-02 Licensee: United Hospital Center License No: 47-01458-01 License Type: Medical Inspection Date: March 26,1996 Priority: 1 Type of Inspection: Nuclear Medicine & HDR Inspector: L. Franklin Date of report: March,1996 Supervisor's Review: John Potter Comments: There were no violations uncovered during this inspection or during the previous inspection in January 1995. Therefore the supervisors agreed with the inspector's recommendation to reduce the inspection frequency to 2 years. Region ll followed the guidance in Inspection Manual Chapter (IMC) 2800-05 to arrive at this conclusion.

File No: 98-03 Licensee: Cardiovascular Radiology institute License No: 52-25016-01 License Type: Private Practice Nuclear Medicine Inspection Date: September 28,1997, and September 29,1997 Priority: 3 Type of Inspection: Unannounced Special(Change of Ownership)

Inspector: H. Bermudez Date of report:

Supervisors Review: Charles Hosey l

Comments: The scope of the new owner's operations was not described very well other than to indicate an increase in the patient workload since the last inspection. The previous owner died in May 1995, and the practice was sold to the new owner shortly thereafter. The inspection was made specifically to review the new owner's operations and compliance with regulations.

File No: 98-04 Licensee: Hospital interamericano 1 License No: 52-25019-01 License Type: Nuclear Medicine and Intemal Therapy inspection Date: September 25,1997 Priority: 3 Type of inspection: Routine Unannounced Inspection inspector: L. Franklin Data of report: j SW- 'isor's Review: John Potter Comments: The inspector used the pilot Nuclear Medicine inspection form draft #87115A.

However, inspection notes were limited in their description of the operations. No independent me > ements were made by the inspector although he did say a reading at the hot lab was  ;

<0. ;,iR/hr. The type of instrument used and calibration date were not given in the report. i File No: 98-05 Licensee: Puerto Rico Ind. Development License No: 52-19377-02 License Type: Portable Gauge d inspection Date: November 20,1996 Priority: 5 Type of Inspection: Unannounced Routine inspection ]

Inspector: J. Diaz Date of report: December 3,1996 {

Supervisor's Review:

John Potter Commenti Notice of Violation issued on December 3,1996. Licensee's response December 31,1996. File closed February 19,1997. Very complete report and compliance action.

{

I File No: 98-06 Licensee: NASA (Langley Research Center)

License No: 45-01052-21 l

License Type: Research and Development inspection Date: January 17,1997 Priority: 3 Type of Inspection: Unannounced inspector: A. Jones Date of report: January 17,1997

Supervisor's Review

T. Decker Comments: Complete report and inspection.

I

' File No: 98-07 Licensee:: Department of interior -

License No: 39-25372-01 License Type: Research and Development inspection Date: July 31,1997 Priority: 5 I Type of inspection: Unannou,1ced and Initial -

Inspector: B. Parker-Date of report: July 31,1997-

~ Supervisor's Review:

Comments: Initial inspection described the scope of the licensee's operations'well. No i violations noted.

1

~

File No: 98-08

~ Licensee: . - Columbia Pentagon City Hospital License No: 45-17123-01 License Type: Nuclear Medicine inspection Date: March 18,1997 Priority: 3 Type of Inspection: Announced Reactive inspection.

. Inspector: J.Henson Date of report: March 1997 Supervisor's Review:

Comments: Reactive inspection made after notification that a contaminated package was received from Syncor Nuclear Pharmacy.' No violations against this licensee were uncovered.

File No: 98-09 Licensee: Dr. Santiago Garcia License No: 52-25245-01 License Type: Therapy, Strontium-90 Eye Applicator inspection.Date: _ May 1996 Priority: 3 Type of Inspection: Unannounced Routine Inspector: - H. Bermudez Date of report: May 1996 i Supervisor's Review: John Potter ll Comments: The Module 4, Sr" Eye Applicator quality management program review needs to

!- be expanded to identify a requirement to review the instrument's calibration certificate. - The original output and decay-corrected output for the day of treatment.

( '

[

l l

File No: .98-10 Licensee: Department of the Navy

- License No: 45-23645-01NA License Type: Master License Inspection Date: June 19,1997 Priority: .1 Type ofInspection: Annual Review Inspector. J.Henson l Date of report: June 1997 Supervisor's Review; a Comments: This was the annual review of the Navy's master license. During the review period, there were permit reviews performed on June 13,1997, by A. Garcia, Region IV, a reactive )

inspection on February 28,1997, and four permit reviews on March 14,1997. Findings: The Navy is exercising management oversight for adequate control.

File No: 98-11

. Licensee: Applied Radiant Energy Corp.

l License No: 45-11496-02 -

License Type: PoolIrradiator Inspection Date: September 15,1997, and December 3,4,8, and 9,1997 Priority: 1 Type of inspection: Pre-Licensing inspector: W. Loo Date of report: December 1997 Supervisor's Review:

Comments: Repeated visits to the site to evaluate construction of the facility for pool irradiators operation. The licensee was having difficulty with the construction of a storage pool, because of leaks.

File No: 98-12 Licensee: Virginia Polytechnic Institute License No: 45-09475-30 License Type: Veterinary Research inspection Date: May 21-22,1997 Priority: 1 Type of Inspection: Routine Unannounced Inspector: A. Jones and B. Parker Date of report: May 1997 Supervisor's Review: T. Decker Comments: Very good description of the licensee's operations. Report discussed with A.

Jones, inspector, during review.

l

t l

File No: 98-13 Licensee: Alexandra Hospital License No: 45-09358-02 License Type: Nuclear Medicine and Brachytherapy (HDR)

Inspection Date: April 23-24,1997 Pnody: 1 Type of Inspection: Routine Unannounced inspector: A. Jones l Date of report: May 1997 Supervisor's Review: C. Hosey Comments: Used HDR inspection checklist 024 and 025, also used QMP forms for all other modalities. Report discussed with A. Jones during review.

l-File No: 98-14 Licensee: . United Hospital Center License No: 47-01458-01 ,

License Type: Nuclear Medicine with HDR Inspection Date: April 3,1996 ,

Priority: 1 T pe ofInspection: Routine Unannounced Inspector: L. Franklin Date of report: April 1996 Supervisor's Review: J, Potter Comments: Supervisor concurred with the inspector's recommendation to extend the inspection frequency based on no violations found on this inspection or previous one.

File No: 98-15 Licensee: Wetzel County Sanitary Landfill License No: 47-25146-01 License Type: Portable Gauge inspection Date: April 3,1996 Priority: 5 Type of Inspection: Routine Unannounced Inspector: O. M. Bailey Date of report: May 1996 Supervisor's Review: J. Potter Comments: Notice of Violation issued on April 17,1996; response received on April 26,1996; file closed May 28,1996. Complete report and inspection notes, inspection discussed with O.

Bailey during the review.

1 File No: 98-16 Licensee: McCallum Testing Labs License No: 45-15325-01 License Type:' Portable Gauge inspection Date: September 12,1996 Priority: 4 Type of Inspection: Routine Unannounced l Inspector B. Parker and J. Potter

! Date of report: September 1996 Supervisor's Review: J. Potter Comments: Inspection included a field site audit while the portable gauge was in use at a Navy base.

File No: 98-17 Licensee: Nondestructive inspection Service IJcense No: 47-11883-01 License Type: Radiography inspection Date: December 17,1996 Priority: 1 Type of inspection: Routine Unannounced Inspector: L. Franklin Date of report: December 1996 Supervisor's Review: J. Potter Comments: Very limited description of the licensee's operations. Three violations noted during the previous inspection were reviewed and closed. There were no violations noted during this inspection. The inspector did not include a field site-audit of radiography operations. The inspector used Xetex 3058, serial #25714, calibrated in February 1996, to make measurements of the storage area. The meter should have been calibrated no earlier than September 1996, the licensee's 3 month meter calibration interval. The next inspection date was extended to December 1998, by the supervisor.

File No: 98-18 Licensee: Roanoke College License No: 45-10085-04 License Type: Small Research and Development inspection Date: October 21-22,1996 Priority: 5 Type of Inspection: Routine Unannounced Inspector: A. Jones Date of report: November 1996 Supervisor's Review: C. Hosey Comments: Three violations cited; Notice of Violation issued November 7,1996; response received December 3,1996; inspection closed December 19,1996.

File No: 98 19-Licensee: Isomedix Operations, Inc.

License No: 52-24994-01 License Type: PoolIrradiator Inspection Date: October 22,1997 Priority: 1 Type of Inspection: Routine Unannounced

-Inspector: J. Diaz and J. Henson Date of report: November 1997 Supervisor's Review: C. Hosey Comments: Team inspection to follow up on the previous inspection of March 31,1997, where serious violations were found and an enforcement conference was held. Complete report with good description of the scope of operations. No violations noted.

File No: 98-20 Licensee: EG & G License No: F1806-1 License Type: Radiography (Reciprocity at Kennedy Space Center)

Inspection Date: March 20,1997 Priority:~ 1 Type of Inspection: Reciprocity Unannounced Inspector: J. Pelchat Date of report: March 199'7 Supervisor's Review: T. Decker Comments: Radiography inspection of office files only. No field site audit during this or the previous inspection in May 1996.

File No: 98-21 Licensee: Pensacola Testing License No: F1117-2 License Type: Reciprocity inspection Date: April 21,1997 Priority: 1

. Type of Inspection:

Unannounced Reciprocity Field Site inspector: - O. Bailey .

Date of report:

Supervisor's Review: J. Potter Comments: Good description of a field-site inspection of this State of Florida licensee operation under reciprocity at a Federaljurisdiction site. The inspector listed Xetex model 3058 survey

. meter that was last calibrated on February 21,1996,14 months ago. The inspector said she may have used another meter and recorded the wrong one on the report. During the review, i the meter that she used was located and the meter's sticker indicated February 21,1996, as

the last date of calibration.

l File No: 98-22

, Licensee: West Virginia University l License No: 47-23035-01 l License Type: Broad-Scope - No Medica!

l Inspection Date: March 20-21,1996 Priority: 1 L Type of Inspection: Routine Unannounced inspector. L. Franklin Date of report: April 1996 Supervisor's Review: J. Potter Comments: Limited description of this University Broad-Scope license. No mention of the use of hazard guides to assign oversight for project authorizations. Laboratory inspection field-note form used to record observations during inspection of selected labs.

a0

4 9

APPENDIX E

' ~ GOOD PRACTICES 9

l f

NEEDED STAFF CAPABILITIES FOR NUCLEAR MATERIALS INSPECTION / LICENSING A. License Reviewer h 1. Degree in health physics. medical physics, biology, environmental sicences and/or exten;ive experience in radiation safety associated with programs licensed by the region

2. Demonstrated capability to work independently

3. Knowledge of NRC licensing guidance (SRPs. TARS)

4. Detailed knowledge of NRC regulatory requirements applicalbe to each type of license application reviewed by the region (10 CFR

19. 20, 30. 31. 32. 33, 34, 35, 36, 70. 71)

5. Strong verbal and written communication skills

6. Knowledge of health physics practices associated with each type of license application reviewed -

i 7. Ability to review applications for licenses and assess impact on safety and compliance with NRC requirements Also desirable attributes

8. Ability to effectively communicate. verbally and in writing, with spanish speaking applicants / licensees, if assigned to review an application or amendment request from Puerto Rico.

9. Formerly a qualified materials inspector B. Soecialist Insoector

1. General Capabilities

a. Ability to conduct performance-based inspections for each type of license assigned to be inspected by the region

b. Ability to identify safety significant issues at each type of licensee inspected

c. Ability to prepare concise and accurate assessments of licensee performance

d. Strong verbal and written communication skills

e. Detailed knowledge of NRC requirements related to each type of license inspected (10 CFR 19. 20, 30. 31, 32, 33. 34, 35, 36, 70, 71)

f. Detailed knowledge of DDT regualtions related to the transportation of radioactive material

g. Detailed knowledge of radiation safety at licensee facilities including, where appropriate, contamination

1 .

1 Needed Staff Capabilities A. Project inspectors Ability to perform specialized pe formance-based inspections in assigned area Ability to recognize safety issues in all regulatory areas Ability to plan inspection program for assigned facilities Ability to organize work assignments and projects Ability to consolidate large quantities of information into concise terms.

Ability to coordinate with other inspectors and the program office Ability to track and trend information and data to provide a basis for decision making.

Ability to prepare concise and accurate briefing papers to serve as a basis for management decisions.

Understanding of activities and processes at assigned facilities.

. Strong verbal and written communication skill .

Understanding of regulatory programs at assigned facilities. ,

. Ability to access licensee performance.

O. Rosent!aspsetor Degree in engineering, chemistry, or health physics is preferred Demonstrated capability to analyze systems and processes Demonstrated capabb.ty in performance-based inspections Demonstrated capability to work independently Capehility to promptly respond to events during non-regular hours Ability to classify issues based on safety significance Ability to supervise site secretary

. Strong verbal and written communications skills Ability to gain trust and cooperation of licensee Ability to satisfy NRC mobility requirements Familiarity with types of systems and processes found at fuel facilities Working knowledge of methods used in analyzing nuclear criticality safety of fuel facility process systems Working knowledge of nuclear criticality safety contml methods used at fuel facilities Inspection experience at a fuel facility

. Knowledge of fuel facility operations i Knowledge of NRC regulations applicable to fuel facilities Knowledge of uranium health physics practices Flexibility to deal with frequent priority shifts C. Specialist inspectors

)

1. General Capabilities

=

j Ability to perform specialized performance-based inspections in assigned area.

Ability to recognize safety issues in assigned area and determine safety l significance.

l .

Ability to organize work assignments.

Ability to coordinate with other inspectors and the program office on identified issues.

Ability to track and trend information and data to provide a basis for decision making.

Ability to prepare concise and accurate assessments of licensee performance.

Understanding of activities and processes at assigned facilities.

. Strt.ng verbal and written communication skill.

Understanding of assigned regulatory programs at assigned facilities.

2

2. Specific Capabilities (detailed knowledge in specific areas)

a. Health Physics inspectors

. 10 CFR Part 20 requirements

. contamination control -

. intemal dosimetry

. air sampling

. -ALARA

. bioassay

. extemal dosimetry

b. Physical Security inspectors .

. 10 CFR Part 73 requirements

. Access Control

. Detection Systems

• Response Tactics

. ' Alarm Assessment

c. Erregency Preparedness inspectors

. Emergency Response

. Conduct of Emergency Drills

. Training of personnel

=- Handling ofinjured personnel

. State / Local coordination methods and requirements

d. Fire Protection inspectors

. National Fire Code

. Flammable material control and storage

. Fire fighting tactics

. Pre-fire planning

. Fire load calculations

.- NRC Technical positions

e. Operational Safety inspectors

. Detailed knowledge of chemical processes and risks enherent in such processes

. Factors which influence neutron multiplication factors

. Specrfic methods of controlling moderation, geometry, concentration, and mass and their respective limitations

. Double Contingency Principle

. Criticality Alarm System operation and their limitations

. Buckling calculations and their use in converting between geometries

. Configuration management

. Performance testing of active engineered controls

f. Transportation Inspectors

. DOT regulations and 10 CFR Part 71

. Certificates of Compliance

. Quality Assurance Programs

. Testing requirements for containers

g. Environmental Protection inspectors Measurement capabilities ,

. Environmentalsampling techniques i . NRC technical positions PAWP51\CAPABILI.TY Attachment 4

l

- 1 I

GOOD PRACTICE: TARGETING INFORMATION 1

1 TARGETING INFORMATION A. . Management Controls (88005)

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 No particular emphasis was identified. '

Westinghouse No particular emphasis was identified.

B. Operations Review (88020)

B&W NNFO 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 l projects in a manner similar to the normal routine work.

l 1

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 nitr' ate, and the design, construction, and testing of facilities for the new naval fuel manufacturing proc 8sS., " '

- 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.

Framatome Cogema Fuels No particular area of emphasis other than to assure that the SERF facilities receive significant attention. The presence of byproduct material with its significance as a source term causes those areas to be of importance.

General Electric ,

No particular area of emphasis has 'been idenGfied. Entire program area should be addressed. Of note is that the fire loading in solvent extraction is lower than at other facilities because of the organic.used.

Nuclear Fuel Services ,

Emphasis should be on the control of fire loading and cr, the conversion of the sprinkler system in the High Enriched Uranium Recovery Facility from a manual to an automatic system. Emphasis should also be on issues developed during 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 bumed back to U 30, due to the presence of oxygen in the collection system.

. D. HEU Access Controls (S1912,81914,81915,81918,81917,81922,810 5,81929, 81932,81933, and 81934)

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 naval fuel process becomes ready for operation.

E. HEU Alarms and Barriers (81910,81911,81913,81918,81919,81920,81921,81923, 81924, 81928, 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

I l

i naval fuel proces. becomes ready for operation.

F. HEU Other Security Areas (81930, 81935, 81020, ?1022, 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 ...:.. .he program continues to be managed in an effective manner.

- Nuclear Fuel Serv'ces ,

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 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 l

No particular area of emphasis has been identified.

Spent Fuel Shipments No particular ccea of emphasis has been identified.

4 l

i l

____-_______-_-________a

I )

(

1.

Radiation Protection (83822) '

B&W NNFD 1

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 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 i

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 L 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 halflife may be increase.

Nuclear Fuel Services l -

Emphasis should be on controls over worker dese. 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 find 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.

l General Electric Emphasis on proper waste characterization and program assessment.

Nuclear Fuel Services Emphasis on proper waste characterization and program assessment.

Westinghouse Emphasis on proper waste characterization and program assessment.

K. Low-Level Waste Storage (84900)

B&W NNFD '

No partic'ular area of emphasis was identified. '

Framatome Cogema Feels 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 of emphasis was identified.

L Transportation (86740)

B&W NNFD Shipment to Envirocare. Compliance with CoC requirements.

Framatome Cogema Fuels Compliance with CoC requirements.

General Electric Compliance with CoC requirements.

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.

~ ' ' ~ " ' ' '

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 of emphasis was identified.

N. Environmental Protection (88045)

B&W NNFD 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 identifed.

I L

- Westinghouse No particular area of emphasis was identified.

O. Decommissioning (88104)

Nuclear Fuel Services Work associated with North Site and Pond 4.

P. Operator Training (88010)

- B&W NNFD Emphasis on adherence to procedures and controls associated with calculations of H/X ratios.

9 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.

Nuclear Fuel Services 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 l which is performed by operators. -

Framatome Cogema Fuels Emphasl on maintenance of safety related controls.

General Ele'ctric Emphasis on maintenance of new controls established for the DCF.

, J l

1

l Nuclear Fuel Services t Emphasis on maintenance of safety related controls associated with HEURF.

- Westinghouse l

l Emphasis on maintenance of safety related controls.

R. Emergency Preparedness (88050)

- B&W NNFD No particular emphasis was identified.

J l

Framatome Cogema' Fuels No particular emphasis was identified.

General Electric No particular emphasis was identified.

Nuclear Fuel Services No particular emphasis was identified.

Westinghouse No particular emphasis was identified.

S. ISFSI inspection North Anna 4 Emphasis on dry run of case loading. l T. NNFD Resident Emphasis in accordance with LPR .

i- U. NFS Resident

- Emphasis in accordance with LPR G:\ SCHEDULE \98 TARGET.

i _ _ _ _ _ _ _ . _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

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APPENDIX F LICENSE FILE REVlEWS (NOTE: The reviewer codes lirted below do not always match the reviewer code of the Ril staff l member who signed the license, because of signature authority. The reviewer code of the staff

, member who actually completed the review is listed as the ' Reviewer.")

l File No.: 1 Licensee: Department of the Navy License No.: 45-23645-01NA Location: N/A Amendment No.: 6 License Type: Master Material License Type of Action: Amendment Date issued: 6/4/97 License Reviewer G3 File No.: 2 '

Licensee: Appalachian Regional Consultants, Iric. License No.: 16-25373-01 Location: Kentucky Amendment No.: N/A j License Type: Portable Gauge '

Type of Action: New Date issued: 11/28/96  ;

License Reviewer: G5 Comments:

l a) incorrect checklist used during review.

b) Minor deficiencies in application not identified.

c) Obsolete license condition (LC 166).

d) Incorrect Milestone 22 date.

File No.: 3 '

Licensee: American Geotech,Inc.

License No.: 47-25354-01 Location: WestVirginia Amendment No.: N/A License Type: Portable Gauge Type of Action: New  ;

Date issued: 3/8/96 License Reviewer. G4 Comments:

a) Minor deficiencies in application not identified.

b) Obsolete license condition (LC 166).

c) - Cover letter not in file; thus check of Milestone 22 date could not be performed.

File No.: 4 Licensee: American Geotech,Inc. License No.: 47-25354-01 i Location: West Virginia Amendment No.: 1 License Type: Pertable Gauge Type of Action: Amendment Date issued: 8/28/96 License Reviewer: G4 Comments:

a) . Non-applicable license conditions (LCs 245, 246).

b) Cover letter not in file; thus check of Milestone 22 date could not be performed. i i

i l

1 File No.: 5 ~

Licensee: McDonough Bolyard Peck, Inc. License No.: 45-25409-01 Location: Virginia Amendment No.: N/A 1 License Type: Portable Gauge Type of Action: New Date Amendment Issued: 10/31/97- License Reviewer: G1 Comments:

a) Applications based on DG-0008 and NUREG 1556 both tied-down.

b) Reviewer's checklist not in file.

c) Obsolete license condition (LC 166). ,

d) Incorrect Milestone 22 date.

File No.: 6

' Licensee: Executive Supervisors, Inc. License No.: 47-24859-01 Location: West Virginia Amdndment No.: 2 License Type: Portab!e Gauge Type of Action: Amendment Date issued: 11/13/97 License Reviewer. G8

~~ "'~

Comments:

a) Obsolete license condition (LC 166).

b) incorrect Milestone 22 date.

File No.: 7 Licensee: Eastern Associated Coal Corp. License No.: 47-24809-01 Location: West Virginia Amendment No.: 6 License Type: Fixed Gauge Type of Action: Amendment Date issued: 2/27/97 License Reviewer: G3 Comments:

a) Obsolete license condition (LC 166).

b) Printing error on license.

File No.: 8 Licensee: Eastern Associated Coal Corp. License No.: 47-25103-01 Location: West Virginia - Amendment No.: 3 License Type: Fixed Gauge Type of Action: Termination Date issued: 2/21/97 License Reviewer: G7 File No.: 9 Licensee: Cor Scan Plus License No.: 47-25351-01 Location: West Virginia Amendment No.: 4 License Type: Medical Type of Action: Amendment Date issued: 10/9/97 License Reviewer. G8 Comments:

a) Obsolete license condition (LC 166).

b) Grammatically incorrect sentence in cover letter.

File No.: 10 Licensee: Hospital Oncologico Andres Grillasca License No.: 52-11832-02 Location: Puerto Rico Amendment No.: N/A License Type: Medical Type of Action: New Date issued: 1/9/97 License Reviewer: G8 Comments:

a) Obsoleto license condition (LC 166).

b) License issued with known deficiencies and QMP weaknesses, as noted in cover letter.

File No.: 11 Licensee: Lewis-Gale Hospital,Inc. License No.: 45-09207-01

- Location: Virginia Amendment No.: 40 License Type: HDR Typeof Action: New Date issued: 3/22/96 License Reviewer G9 Comments:

a) Minor deficiencies in application not identified.

b) Reviewer's checklist not in file, c) Obsolete license condition (LC 166).

d) Incorrect Milestone 22 date.

File No.: 12 Licensee: Bernardo A. Puebla, M.D. License No.: 52-23097-02 Location: Puerto Rico Amendment No.: N/A-License Type: Sr-90 Eye Applicator Type of Action: New Date issued: 3/28/97 License Reviewer: G6  ;

Comments:

a) Obsolete license condition (LC 166).

b) Cover letter not in file; thus check of Milestone 22 date could not be performed.

File No.: 13 Licensee: Henrico Doctors' Hospital License No.: 45-16231-02  ;

Location: Virginia Amendment No.: 1 License Type: Teletherapy (storage only) Type of Action: Amendment Date issued: 11/8/96 License Reviewer: G2 Comments:

a) Obsolete license condition (LC 166).

b) Typographical error in license.

c) Incorrect Milestone 22 date.

File No.: 14 Licensee: Weirton Medical Center License No.: 47-17567-01 l Location: West Virginia Amendment No.: N/A  !

l LicenseType: Medical Type of Action: Notification t (

Date issued: N/A License Reviewer: G5 j I

1 4

File No.: 15 Licensee: Columbia Montgomery Regional Hospital License No.: 45-19057-01 Location: Virginia Amendment No.: N/A License Type: Medical Type of Action: Notification Date issued: N/A License Reviewer. G5 File No.: 16 Licensee: Georgetown Equine Hospital License No.: 45-25359-01 i Location: Virginia Amendment No.:' N/A License Type: Veterinary Type of Action: New Date issued: 4/17/97 License Reviewer: G1 Comments:

a) Obsolete license condition (LC 166).

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L APPENDIX G INCIDENT FILE REVIEWS File No.1

~ Licensee: Northern Virginia Isotopes, Inc.

l License No.: 45-25221-01MD l . Incident ID No.: 970738 .

l Location: Sterling, VA

! Date of Event: 7/28/97 L - Type of Event: High Film Badge Reading l Investigation Date: 7/29-30/97 L Investigation Type: Site .

[ Summary of incident and Final Disposition: Potential overexposure identified by NRC during i annual repo't review. Investigation completed to make the determination that exposure was erroneom:.

l. Comment:

! a) No documentation on event found in inspection file. '

File No. 2 Licensee: N/A License No.: N/A Incident ID No.: 960594 l Location: Herman Strauss Industries, Wheeling, WV L Date of Event: 10/4/96 l

Type of Event: Contaminated Metal Found

l. Investigation Date: 10/7-8/96 Investigation Type: Site Summary of Incident and Final Disposition: Radioactive material found at scrap metal yard, r

Regionalinspector worked in conjunction with lead EPA inspectors. Ra-226 sources found to be properly secured.

. File No. 3 ~

Licensee: Longview Inspection, Inc.

License No.: 45-25279-01 Incident ID No.: 960274 l Location: Camden County, GA L Date of Event: 4/10/96 L Type of Event: Lost Radiography Camera ,

investigation Date: None i investigation Type: None Summary of incident ar,J Final Disposition: Stolen radiography device recovered in Georgia.

Licensee retrieved.

Comment:

a) No NRC documentation on event in file, only reports from State of Georgia and letter from licensee, even though phone discussions with licensee and State of Georgia took place.

i File No. 4 Licensee: Jose N. DeLeon, MD License No.: 52-19206-01 1 incident ID No.: 980005 {'

Location: Puerto Rico -

Date of Event: 12/11/97 Type of Event: Misadministration investigation Date: 12!11/97 -

Investigation Type: Routine ,

Summary of incident and Final Disposition: Inspector on routine inspection discovered that nine misadministration involving strontium-90 eye applicators occurred between July 1994 and June 1996. Enforcement conference scheduled for March 1998.

File No. 5 Licensee: Hospital Ramon De Betances -

License No.: 52-13598-03 Incident ID No.: 970914 .. , . . . . . .,", ;

Location: Mayaguez, Puerto Rico

~

Date of Event: 9/17/97-Type of Event: 1-131 spill Investigation Date: 12/8/97 investigation Type: Routine Inv.estigation Summary of incident and Final Disposition: 1-131 spill occurred while patient receiving therapy dose. Licensee sent documentation that response to spill was appropriate. Inspector looked at event at next routine investigation and determined correct steps were taken in cleanup.

Comments:

a) inconsistent amounts of I-131 involved in spill noted in documentation.

b) Follow up on event unclear / difficult to understand from inspector field notes.

c) Documentation / follow up on additional vomiting problem unclear in field notes.

File No. 6 Licensee: Marshal Miller and Associates License No.: 45-17195-01 Incident ID No.: 970858 Location: Bluefield, VA Date of Event: 8/18/97 Type of Event: Possible Overexposure investigation Date: 9/2-3/97 .

Investigation Type: Site Summary of incident and Final Disposition: Potential overexposure to the extremities of two individuals performing well-logging. Apparent violations discovered at inspection a,nd case was referred to 01.

Comment:

a) inconsistent dates in file documents.

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File No. 7

Licensee: Professional Services Industries, Inc.

License No.: 45-25088-01 Incident ID No.: 960699

. Location: Bristol, VA Date of Event: 11/8/96 Type of Event: Apparent Overexposure Investigation Date: 11/13-21/96,12/4/96 Investigation Type: AIT . ,

Summary of incident and Final Disposition: Apparent overexposure resulted from technician routinely touching a source. AIT investigation concluded that overexposure did not occur, but did identify less than adequate management oversight.

Comment:

a) Original PN not found in file. .

File No. 8 Licensee: Femancez, Jose, MD License No.: 52-25114-01 incident ID No.: 960060 Location: San Juan, Puerto Rico Date of Event: 8/7/96 (1/94-10/95)

Type of Event: Misadministration investigation Date: 4/8-10/97 investigation Type: Site Summary of incident and Final Disposition: Inspections on 11/18/95 and 4/8-10/97 identified numerous instances of medical misadministration as well as eight apparent violations related to the licensees' use of strontium-90 eye applicators. License modified to allow only storage and not use of eye applicators.

File No. 9 Licensee: S. teel of West Virginia License No.: N/A .'

Incident ID No.: 970510 Location: Huntington, WV -

Date of Event: 6/4/97 I Type of Event: Contaminated Metal Found Investigation Date: None fi investigation Type: None Summary of incident and Final Disposition: Scrap metal from Sherrinton, Inc., Oak Hill, OH set off radiation alarm. Gauge was originally sold to Soil Enrichment Corp, Chicago, IL. Region 11 staff referred the case to Region Ill.

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File No. '10 Licensee: National Hospital Medical Center License No.: 47-17123 l ' Incident ID No.: 970152 Location: Arlington, VA Date of Event: 2/27/97 Type of Event: Contaminated Package Investigation Date: 3/18/97 investigat;on Type: Site, .

Summary of incident and Final Disposition: Received contaminated package from Syncor Radiopharmaceuticals. Special inspection proved that no violations were noenu.. d.

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APPENDIX F LICENSE FILE REVIEWS (NOTE: The reviewer codes listed below do not always match the reviewer code of the Ril staff member who signed the license, because of signature authority. The reviewer code of tha staff member who actually completed the review is listed as the " Reviewer.")

File No.: 1 Licensee: Department of the Navy License No.: 45-23645-01NA Location: N/A Amendment No.: 6

' License Type: Master Material License Type of Action: Amendment 3

Date issued: 6/4/97 License Reviewer: G3 File No.: 2 '

Licensee: Appalachian RegionalConsultants,Inc. License No.: 16-25373-01 Location: Kentucky Amendment No.: N/A' License Type: Portable Gauge . Type of Action: New Date issued: 11/28/96 License Reviewer: G5 Comments:

a) Incorrect checklist used dunng review.

b) Minor _ deficiencies in application not identified. i c) Obsolete license condition (LC 166).

d) incorrect Milestone 22 date.

File No.: 3 Licensee: A'mencan Geotech, Inc. License No.: 47-25354-01 Location: WestVirginia Amendment No.: N/A License Type: Portable Gauge Type of Action: New Date issued: 3/8/96 License Reviewer: G4 I Comments:

a) Minor deficiencies in application not identified.

b) Obsolete license condition (LC 166).

c) Cover letter not in file; thus check of Milestone 22 date could not be performed. 1 File No.: 4 Licensee: American Geotech, Inc. License No.: 47-25354-01 Location: WestVirginia Amendment No.: 1 License Type: Portable Gauge Type of Action: Amendment Date issued: 8/28/96 License Reviewer: G4 i Comments:  !

l a) Non-applicable license conditions (LCs 245, 246).

b) Cover letter not in file; thus check of Milestone 22 date could not be performed.

1 I

File No.: 5 Licensee: McDonough Bolyard Peck, Inc. License No.: 45-25409-01 Location: Virginia Amendment No.: N/A License Type: Portable Gauge Type of Action: New Date Amendment issued: 10/31/97 License Reviewer: G1 Comments:

.a) Applications based on DG-0008 and NUREG 1556 both tied-down.

b) Reviewer's checklist not in file.

c) Obsolete license condition (LC 166).

d) Incorrect Milestone 22 date.

File No.: 6 Licensee: Executive Supervisors, Inc. License No.: 47-24859-01 Location: West Virginia Am'endment No.: 2 License Type: Portable Gauge Type of Action: Amendment Date issued: 11/13/97 License Reviewer G8 Comments:

a) Obsolete license condition (LC 166).

b) incorrect Milestone 22 date.

File No.: 7 Licensee: Eastern Associated Coal Corp. License No.: 47-24809-01 Location: West Virginia Amendment No.: 6 License Type: Fixed Gauge Type of Action: Amendment Date issued: 2/27/97 License Reviewer: G3 Comments:

a) Obsolete license condition (LC 166).

b) Printing error on license.

File No.: 8 Licensee: Eastern Associated Coal Corp. License No.: 47-25103-01 Location: West Virginia Amendment No.: 3 f

' License Type: Fixed Gauge Type of Action: Termina+ ion j Date issued: 2/21/97 License Reviewer G7  !

File No.: 9 Licensee: Cor Scan Plus License No.: 47-25351-01 Location: West Virginia Amendment No.: 4 License Type: Medical Type of Action: Amendment Date issued: 10/9/97 License Reviewer: G8 Comments:

a) Obsolete license condition (LC 166).

! b) Grammatically incorrect sentence in cover letter.

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File No.: 10 Licensee: Hospital Oncologico Andres Grillasca License No.: 52-11832-02 Location: Puerto Rico Amendment No.: N/A License Type: Medical Type of Action: New-Date issued: 1/9/97 License Reviewer: G8 Comments:

a) Obsolete licens'e condition (LC 166).

b) License issued with known deficiencies and QMP weaknesses, as noted in cover letter.

File No.: 11-Licensee: Lewis-Gale Hospital, Inc. License No.: 45-09207-01 Location: Virginia Amendment No.: 40 License Type: HDR Type of Action: New Date issued: 3/22/96 License Reviewer: G9 Comments:

a) Minor deficiencies in application not identified.

b) Reviewer's checklist not in file.

c) Obsolete license condition (LC 166). -

d) Incorrect Milestone 22 date.

File No.: 12 Licensee: Bemardo A. Puebla, M.D. License No.: 52-23097-02 Location: Puerto Rico Amendment No.: N/A License Type: Sr-90 Eye Applicator Type of Action: New Date issued: 3/28/97 License Reviewer: G6 Comments:

a) Obsolete license condition (LC 166).

b) Cover letter not in file; thus check of Milestone 22 date could not be performed.

File No.: 13 Licensee: Henrico Doctors' Hospital License No.: 45-16231-02 Location: Virginia Amendment No.: 1 License Type: Teletherapy (storage only) Type of Action: Amendment Date issued: 11/8/96 - License Reviewer: G2 Comments:

a) Obsolete license condition (LC 166).

b) Typographical error in license.

c) Incorrect Milestone 22 date.

File No.: 14 Licensee: Weirton Medical Center License No.: 47-17567-01 ,

Location: West Virginia Amendment No.: N/A License Type: Medical Type of Action: Notification  !

Date issued: N/A License Reviewer: G5 l l

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J File No.: 15 Licensee: Columbia Montgomery Regional Hospital License No.: 45-19057-01 Location: Virginia Amendment No.: N/A License Type: Medical Type of Action: Notification Date issued: N/A License Reviewer: G5 File No.: 16

' Licensee: Georgetown Equine Hospital License No.: 45-25359-01

' Location: Virginia Amendment No.: N/A License Type: Veterinary Type of Action: New Date issued: 4/17/97 License Reviewer: G1 Comments:

a) Obsolete license condition (LC 166).

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4 L_______.____ . _ _ _ _ _ _ . _ _

APPENDIX G INCIDENT FILE REVIEWS File No.1 -

. Licensee: Northern Virginia isotopes, Inc.

License No.: 45-25221-01MD

- Incident ID No.: 970738-Location: Sterling, VA : '

" Date of Event: 7/28/97 -

Type of Event: High Film Badge Reading investigation Date: 7/29_-30/97

.I investigation Type: Site Summary of incident and Final Disposition: Potential overexposure identified by'NRC during annual report review. Investigation completed to make the determination that exposure was erroneous.

Comment:

a) No documentation on event found in inspection file. ,

File No. 2 Licensee: N/A License No.: N/A Incident ID No.: 960594 Location: Herman Strauss Industries, Wheeling, WV

^ Date of Event: 10/4/96

-Type of Event: Contaminated Metal Found Investigation Date: 10/7-8/96  !

Investigation Type: Site Summary of incident and Final Disposition: Radioactive material found at scrap metal yard.

Regional inspector worked in conjunction with lead EPA inspectors. Ra-226 sources found to be properly secured.

L File No. Licensee: Longview inspection, Inc.

License No.: 45-25279-01 Incident ID No.: 960274 Location: Camden County, GA Date of Event: 4/10/96 Type of Event: Lost Radiography Camera

' Investigation Date: None

. Investigation Type: None

' Summary of incident and Final Disposition: Stolen radiography device recovered in Georgia.

Licensee retrieved.

Comment:

a) No NRC documentation on event in file, only reports from State of Georgia and letter from licensee, even though phone discussions with licensee and State of Georgia took place.

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. File No. 4

~ Licensee: Jose N. DeLeon, MD License No.: 52-19206-01 l . Incident ID No.: 980005 Location: Puerto Rico Date of Event: 12/11/97 Type of Eventi Misadministration

! Investigation Date: 12/11/97

- Investigation Type: Routine Summary of incident and Final Disposition: Inspector on routine inspection discovered that nine misadministration involving strontium-90 eye applicators occurred between July 1994 and June 1996. Enforcement conference scheduled for March 1998.

.1 File No. 5 i Licensee: Hospital Ramon De Betances ~

License No.: 52-13598-03 Incident ID No.: 970914 Locatior:: Mayaguez, Puerto Rico Date of Event: 9/17/97 Type of Event: J-131 spill '

investigation Date: 12/8/97 Investigation Type: Routine Investigation Summary of incident and Final Disposition: 1-131 spill occurred while patient receiving therapy dose. Licensee sent documentation that response to spill was appropriate. Inspector looked at -

event at next routine investigation and determined correct steps were taken in cleanup.

Comments:

a) _- Inconsistent amounts of l-131 involved in spill noted in documentation.

b) Follow up on event unclear / difficult to. understand from inspector field notes. _

c)' ~ Documentation / follow up on additional vomiting problem unclear in field notes.

File No. 6 Licensee: Marshal Miller and Associates License No.: 45-17195-01 incident ID No.: 970858.

Location: Bluefield,' VA Date of Event: 8/18/97. -

Type of Event: Possible Overexposure investigation Date: 9/2-3/97 Investigation Type: Site Summary of incident and Final Disposition: Potential overexposure to the extremities of two individuals performing well-logging. Apparent vlotations discovered at inspection and case was referred to Oi.

Comment:

a) Inconsistent dates in file documents.

File No. 7 Licensee: Professional Services Industries, Inc.

License No.: 45-25088-01 incident ID No.: 960699 Location: Bristol, VA Date of Event: 11/8/96 Type of Event: Apparent Overexposure Investigation Date: 11/13-21/96,12/4/96 Investigation Type: AIT Summary of incident and Final Disposition: Apparent overexposure resulted from technician routinely touching a source. AIT investigation concluded that overexposure did not occur, but did identify less than adequate management oversignt.

Comment:

a) Original PN not found in file.

File No. 8 Licensee: Fernandez, Jose, MD License No.: 52-25114-01 incident ID No.: 960060 l.ocation: San Juan, Puerto Rico Date of Event: 8/7/96t'/94-1G/95)

Type of Event: Misadmruistrations investigation Date: 4/8-10/97 investigation Type: Site Summary of incident and Final Disposition: Inspections on 11/18/95 and 4/8-10/97 identified numerous instances of medical misadmiriistrations as well as eight apparent violations related to the licensees' use of strontium-90 eye applicators. License modified to allow only storage and not use of eye applicators.

File No. 9 Licensee: Steel of West Virginia License No.: N/A Incident ID No.: 970510 Location: Huntington, WV Date of Event 6/4/97 Type of Event: Contamhated Metal Found Investigation Date: None Investigation Type: None Summary of incident and Final Disposition: Scrap metal from Sherrinton, Inc., Oak Hill, OH set off radiation alarm. Gauge was originally sold to Soil Enrichment Corp, Chicago, (L. Region 11 staff referred the case to Region Ill.

File No.10 Licensee: National Hospital Medical Center Ucense No.: 47-17123 incident ID No.: 970152 Location: Arlington, VA Date of Event: 2/27/97 Type cf Event: Contaminated Package investigation Date: 3/18/97 investigation Type: Site Summary of incident and Final Disposition: Received contaminated packaga from Syncor Radiopharmaceuticals. Special inspection proved that no violations were identified.

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p uroq'o UNITED STATES I-/Y6//

n'

,, NUCLEAR REGULATORY COMMISSION U 1.))

[ n REGION 11 g- y ATLANTA FEDERAL CENTER S 61 FORSYTH STREET. SW, SUITE 23T85

• $, / ATLANTA, GEORGIA 30303-3415 March 16, 1998 MEMORANDUM T0: Carl J. Pa]er' o, ector Off e of 9 1 r rial Safety and Safeguards FROM: 1s A. es. Regi A ministrator 7

SUBJECT:

ACTIONS TAKEN IN R PONSE T0 FINDINGS OF THE INTEGRATED MATERIALS PERFOR CE EVALUATION PROGRAM REVIEW OF. REGION II During the week of February 9-13. 1998, the Integrated Materials Performance Evaluation Program Review of Region II was conducted. Attached are the Region's actions in response to the recommendations and suggestions provided by the review team during the exit meeting on February 13. 1998.

The team was very professional and conducted an excellent exit meeting.

Please pass on my thanks.to George Deegan. team leader.

Should you have any questions please give me a call.

Attachment:

As stated cc w/att:

H. Thompson. DEDR D. Cool NMSS E. Ten Eyck. NMSS G. Deegan NMSS i

ACTIONS TAKEN BY REGION II IN RESPONSE TO IMPEP FINDINGS REPORTED DURING EXIT MEETING Recommendation 1: Region II will assure its inspectors make use of survey instruments calibrated at proper frequencies.

Region II has reminded Division of Nuclear Materials Safety (DNMS) staff of

.the requirement to use survey instruments calibrated at the frequency required for the type of licensee being inspected (e.g., instruments calibrated within six months for radiography licensees). In addition. Region II has developed an instrument calibration and inventory program using Microsoft Access to assist in the management of the survey instrument program. This program will be implemented by Aaril 30, 1998. This program will provide a report which lists instruments tlat are due for calibration in the next three months so they can be retrieved from inspectors and removed from service for calibration

'before the calibration due date. The Region will also post, by March 31. a notice in the instrument storage area reminding inspectors to check the

' calibration date on the instrument to ensure that it will remain in calibration during the inspection. ,

Recommendation 2: Region II will develop and implement an effective, periodic in-depth peer review type of quality assurance program for licensing actions.

Region II will issue a Regional Office Instruction (ROI) by April 15. 1998.

which will establish a peer review for completed licensing actions. This ROI will require semi-annual reviews of completed licensing actions by license reviewers and DNMS managers. The review will focus on appropriateness of license conditions used and documents referenced, grammatical / clerical errors, deficiencies in the application for licensing action, appropriate checklist and completeness of licensing file and quality of the review (i.e., did the licensing action accurately reflect what the licensee / applicant requested).

The first licensing Peer Review will be conducted by April 30, 1998.

Recommendation 3: Region II will ensure that the fuel cycle inspection program is not adversely affected when the current IFS program for tracking inspection results is terminated.

Region II will begin using the NMSS Fuel Cycle Inspection Management System to track inspection results on or before May 1. 1998. If this system cannot handle the volume.- the Region will consider incorporating the information contained in the IFS system in the Site Integration Matrix System or will develop a Microsoft Access-based program to replace the IFS systen Succestion 1: Region II will use the inspection field notes pilot format developed for nuclear medicine license inspections for other categories of inspections in order to provide a greater description of licensee operations.

As directed in previous correspondence from NMSS. Region II will continue to use the Field Notes contained in approved inspection procedures. However, until the new procedures are issued. Region II will stress to inspectors the need to provide greater description of the licensee *s operations in the field l

notes using the nuclear medicine pilot format as an example.

2 Succestion 2: .The former stand'ard licensee condition No. 166 (maintenance'of decommissioning records) will no-longer be applied to new Region II licensees, and be removed from current licenses.

The Region has discontinued using license condition No. 166 in new licenses  ;

issued. In addition, the license condition.will be removed from licenses as amendments'or renewals of existing licenses are issued.

Spaaestion 3: NMSS will clarify the " Milestone 22" issued by memorandum to the

' Regions.

The issue relates to the appropriate date to enter in the Licensing Management '

System (LMS) for the issuance of the licensing action. Since the IMPEP.

Region II has begun entering in LMS the date of the management r'eview as the date when the' licensing action was completed.

Succestion 4: Region II will consider altering the language of ROI 1030 to allow more flexibility in handling phone calls from allegers.

Region II has determined that ROI 1030 provides the appropriate instructions

'for- members of the staff in the handling of allegations. DNMS management will reemphasize to DNMS staff that. where possible, incoming calls from allegers .

should be referred to the Senior Allegations Coordinator or other technical members of the Enforcement and Investigations Coordination Staff.

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