ML20248J256
| ML20248J256 | |
| Person / Time | |
|---|---|
| Site: | 07001100 |
| Issue date: | 10/02/1989 |
| From: | Austin M, Bidinger G, Costello F, Craig Gordon, Joyner J, Oconnell V NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I) |
| To: | |
| Shared Package | |
| ML20248J250 | List: |
| References | |
| 70-1100-89-80, NUDOCS 8910130174 | |
| Download: ML20248J256 (26) | |
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t U.S. NUCLEAR REGULATORY COMMISSION REGION I
. Report No. 70-1100/89-80 Docket No. 70-1100 License No.' SNM-1067 Priority 1 Category ULFF Licensee: Combustion Engineering, Incorporated 1000 Prospect Hill Road Windsor, Connecticut 06095 Facility Name: Nuclear Fuel Manufacturing and Nuclear Laboratories Inspection At: Windsor, Connecticut i
Inspection Conducted: August 28-29 and September 5-8, 1989 Inspectors:
Mi el A. Austin adiation Specialist, RI /dat( '
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/dat6 Geo .'Bidingpicensing Project Manager, dnun1hdzd Francij M. Costello Senior Health Physicist, iower
/da'te RI [)
tbb)Rb, 10 l M Craig Z. G4ryon, Emergency Preparedness bat'e SpecialisY, RI 0 V (L//
Peter V. O'Connell,' Radiation Specialist, RI uh/nd(te Approved by:
Ja es W
. Joyner, Te(nA.eade'r701 vision
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P ect Manager, RI
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Inspection' Summary: Inspection on August 28-29 and September 5-8,'1989' (Report No. 70-1100/89-80)
Areas Inspected: Special, announced inspection to review status of progress made by the licensee in correcting programmatic deficiencies in the licensed program, including reviews of facility operations, nuclear criticality safety, f equipment maintenance, licensing,-management controls, radiological controls
- l. and emergency preparedness.
Results: The licensee has made progress in implementing its Nuclear Fuel Integrated Improvement Program, although the schedule has slipped in several areas. Significant improvements were noted in the handling and control of radioactive material. Two Severity Level IV violations were identified:
failure to establish and post all required criticality safety controls for the l
'Sinterability Test Hood (Section 4.4); failure to assure that production and salaried personnel who enter the restricted areas receive formal annual L radiation worker training (Section 6.3). 1 i
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DETAILS 1.0 . Individuals Contacted
- S. T.. Brewer, President, Nuclear Power Businesses Division
- P. L. McGill, Vice President, Nuclear Fuel
- C. R. Waterman, Vice President and General Manager, Nuclear Fuel
-Manufacturing W. D. Mawhinney, Vice President, Nuclear Quality Systems, and Chairman, i Nuclear Safety Committee
' *P. R. Rosenthal, Program Manager, Radiological Protection and Industrial Safety l A. E. Scherer, Director, Nuclear Licensing I G. Kersteen, Manager, Production P. Hubert, Manager, Manufacturing Engineering D. G. Stump, Manager, Radiological and Industrial Safety
- R. E. Vaughn, Manager, Operations R. E. Sheeran, Manager, Accountability and Security
- J. F. Conant, Manager, Nuclear Material Licensing R. Klotz, Nuclear Criticality Specialist J. Vollaro, Health Physics and Safety Supervisor
- denotes those present at the exit interview. The inspectors also interviewed other licensee employees during the inspection.
2.0 Purpose of Inspection The Systematic Assessment of Licensee Performance (SALP) is an integrated NRC staff effort to evaluate licensee performance based on a collection of relevant observations and data. The SALP supplements the normal regulatory process, which is used to ensure compliance with NRC rules, regulations, and license conditions. The SALP is intended to be sufficiently diagnostic to provide meaningful guidance to licensee management to prorr.ote quality and safety of facility operations.
SALP evaluations are not typically performed for non-reactor nuclear facilities. However, a SALP evaluation of Combustion Engineering, Incorporated, was conducted in 1988, for the period July 1,1986 through June 30, 1988, in light of the licensee's sustained poor level of performance and the licensee's apparent inability to identify and correct deficiencies in radiation safety, criticality safety, nuclear material accountability, transportation, and other areas.
An NRC SALP Board met on August 30, 1988, to assess the licensee's performance in accordance with generic guidance in NRC Manual Chapter 0516, " Systematic Assessment of Licensee Performance". Subsequently, the SALP report was discussed with the licensee at a meeting on October 26, 1988.
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2.1 Assessment Criteria During the SALP process, licensee performance is assessed in selected functional areas that have the potential to significantly affect nuclear safety and the environment. The following evaluation criteria, where appropriate, were used to assess each functional area:
- 1. Management involvement and control in assuring quality
- 2. Approach to resolution of technical issues from a safety standpoint
- 3. Audits and feedback mechanisms
- 4. Enforcement history
- 5. Reporting and analysis of reportable events
- 6. Staffing (including management)
- 7. Training and qualification effectiveness
- 8. Quality of Procedures and Operations Based on the SALP Board assessment, each functional area evaluated was classified into one of three performance categories. Licensee performance rated below the lowest category would have already resulted in escalated enforcement actions, which could include modification, suspension, or revocation of the license. The definitions of the performance categories are:
Category 1 - Reduced NRC attention may be appropriate. Licensee management attention and involvement are aggresive and oriented toward promoting radiation safety. Licensee resources are ample and effectively used, resulting in a high level uf performance with respect to operational safety. None of the functional areas evaluated at Combustion Engineering during the 1988 SALP were classified as Category 1. '
Category 2 - NRC attention should be maintained at normal levels that are appropriate for the licensee. Licensee management attention and involvement are evident and reflect concern for radiation safety. Licensee resources are adequate and used effectively so that the licensee achieves satisfactory performance with respect to operational safety. As shown in Section 2.2, five of ten functional areas evaluated in 1988 were classified as Category 2.
Category 3 - NRC and licensee attention should be increased. Licensee management attention and involvement are acceptable and promote radiation safety, but weaknesses are evident. Licensee resources appear to be !'
strained or not used effectively so that performance with respect to operational safety is only minimally satisfactory. As shown in Section 2.2, five of ten functional areas evaluated in 1988 were classified as Category 3. i l
4 The SALP Board has also assessed each functional area to compare the licensee's performance near the end of the assessment period with that during the entire period to identify any trends in performance. The trend categories used by the SALP Board in 1988 were as follows:
Improving - Licensee performance was determined to be improving near the close of the assessment period.
Declining - Licensee performance was determined to be declining near the close of the assessment period.
2.2 Results of 1988 SALP The overall assessment of licensee performance for the 1986-1988 period was that, at the start of the assessment period, the licensee generally did not maintain adequate control over licensed activities to assure ef fective and responsible performance. In addition, at the beginning of the assessment period, the licensee was not responsive to NRC initiatives.
Actions were initiated by the licensee to correct specific, idantified, violations but investigations into the root causes of violations, i.e.,
programmatic deficiencies, were not conducted. Toward the end of the assessment period, the licensee initiated actions to strengthen management, investigate root causes of violations, improve staffing and correct deficiencies in process equipment. However, these actions, which were expected to take about two years to complete, were initiated too late to be adequately addressed or evaluated during this assessment period.
The SALP ratings and trends for each functional area are as follows:
Rating for Functional Area Assessment Period Trend Facility Operations 3 Improving Nuclear Criticality Safety 2 --
Safeguards 2 --
Equipment Maintenance 2 --
Radiological Controls 3 --
Vendor Quality Assurance 2 --
Management Controls 3 --
Fire Protection 2 --
Licensing Issues 3 --
2.3 Post-SALP Activities While routine inspections during the latter part of 1988 and throughout 1989 indicated that the licensee had taken numerous actions to address the programmatic deficiencies identified in the SAlp report, NRC conducted a team inspection at CE on August 28-29 and September 5-8, 1989, to evaluate l
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L l the progress made by CE on the NRC recommendations in the SALP report.
The.following report addresses the status of CE responses to recommendations in all of the functional areas in which the licensee was rated as SALP Category 3, as well as in two areas in which the licensee was rated as SALP Category 2.
The areas addressed in this report include:
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- Facility Operations-L
- Nuclear Criticality Safety
- Equipment Maintenance
- Radiological Controls
- Management Controls
- Licensing Issues 3.0 Facility Operations The 'SALP. Board recommended that the licensee (1) conduct periodic self-assessments and independent audits of facility operations, and (2) establish and maintain a performance improvement program. The SALP report noted that licensee management recognizes the need for improvement in facilities, procedures, training and management of the nuclear fuel manufacturing operation.
The inspectors toured the plant and held discussions with licensee representatives to evaluate the overall status of facility operations.
The inspector's findings from these tours and discussions in each of the program areas are discussed in the representative sections of this report.
3.1 Implementation of program Improvements The licensee established a task force in the latter part of 1988 and performed an assessment of its activities relative to NRC and other regulatory requirements in order to address the SALP Board recommendations.
The task force made a number of findings and recominendations, which are being tracked to closure by the licensee. The actions described in this report resulted from either task force recommendations, from the Nuclear Fuel Integrated Improvement Program (NFIIP), or from the results of audits performed by the licensee.
The licensee has adopted and incorporated a number of improvements to the nuclear fuel manufacturing facilities, safety procedures, safety training and management of the nuclear fuel operations. The managerial changes ,
have been documented previously in correspondence from the licensee and '
in inspection reports. The inspectors confirmed that the organizational structure is as previously described. The other corrective actions relative to the SALP Board recommendations, and to the specific areas for improvement cited above, are contained in the sections of the report that q follow.
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l 3.2 Conclusions y
The licensee's actions to upgrade equipment and establish a preventive maintenance program have resulted in much improved radiological safety working conditions. Audits of program implementation are being conducted and findings are being tracked to closure but repeat instances of worker noncompliance with safety requirements suggest that :ontinued management-attention is required.
4.0 Nuclear Criticality Safety The SALP Board recommended that the licensee establish a formal change control system to assure that each process and equipment change is properly reviewed, evaluated, fabricated, installed and operated in accordance with the criteria established as a result of the nuclear criticality safety evaluation. The inspectors ccaducted interviews with licensee representatives, reviewed procedures, and examined areas within the Pellet Shop to evaluate the licensee's nuclear criticality safety (NCS) progr4m.
4.1 System of Controls The license 2 has a written " Criticality Safety Program", PR-3, Revision 1, dated 8-1-89, which describes a new change control system. The PR-3 document contains a CE policy statement which addresses the double contingency principle, reliance on favorable geometry, where practicable, and a requirement for a determination that a new or changed process would be subcritical. The policy statement is signed by the Vice President / General Manager, the Director - Product Development, and the Vice President -
Nuclear Fuel. The policy is silent on employee responsibilities to follow procedures and on employee obligations to halt an operation if it is not covered by procedure.or if safety is in doubt. This deficiency was discussed with the Program Manager, Radiological and Industrial Safety (RIS).
The PR-3 document has other sections on Design Bases, Changes / Modifications, Operating Instructions / Posting, Configuration Management, Product Development Laboratory, and Alarm Systems. The Design Bases section reproduces criteria in the license.
The formal change / modification program in PR-3 requires that all requests for changes / modifications be submitted to Manufacturing Engineering, who initiates the Change / Modification Review (CMR). The CMR must be approved by the Manager, Manufacturing Engineering and the Vice President /Gereral Manager. The CMR is then forwarded to the Program Manager, Radiological and Industrial Safety, for review for health and safety considerations.
If reviews of criticality safety, radiological safety, or industrial safety are required, the Program Manager also determines whether licensing action is required to initiate the charge. The program document allows either the Criticality Safety Specialist (CSS) or the Senior Criticality
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. Safety Specialist (SCSS)M ot approve the CMR. In addition, the licensee allows for analysis done by an analyst followed by review and approval by either the CSS or the SCSS. The Program Manager, NIS, was informed that, in order to provide separation of responsibilities, the Criticality Safety Specialist should perform the evaluation and establish the limits and controls; the Senior Criticality Safety Specialist should review and approve the CMR.
1 No instruction has been issued to implement the program; however, such a document was being circulated for management approval. The instruction requires that the Criticality Safety Specialist, rather than the Senior Criticality Safety Specialist, approve the CMR. In discussions with the Specialist and the Senior Specialist, it was apparent that the Specialist obtains the Senior Specialist's review and approval before the Specialist approves the CMR. This does not, however, satisfy requirements of the proposed license amendment being reviewed by NMSS. The Program Manager, NIS, was informed of.this discrepancy.
For any CMR which requires the use of computer analysis, the Criticality Safety Specialist defines the problems to be analysed and submits the problems to the Reactor Physics Department. The Reactor Physics Department utilizes the codes and quality assurance procedures which were developed for reactor design and for compliance with Part 50 requirements. The analytical results are returned to the Criticality Safety Specialist who, if satisfied with the results, forwards the analytical results and the operating limits to the Senior Criticality Safety Specialist for review.
The Senior Criticality Safety Specialist can, and sometime does, request further analysis as part of the review before concurring in the CMR. The Criticality Safety Specialist then forwards the approved CMR to the Program Manager, RIS.
The reactor phys +cs department has issued two memoranda to explain how the analysis will be performed. The memos were issued before the latest proposed reorganization. One memo requires the Criticality Safety Specialist to verify actual equipment installation as described in the CMR before final approval is given for the change. This " verification before final approval" requirement has not been carried forward into the Criticality Safety Program document, PR-3. This significant omission was discussed with the Program Manager, NIS.
4.2 Nuclear Criticality Safety Training 4 The inspectors held discussions with the Supervisor of Nuclear Training to evaluate the status of the Nuclear Criticality Safety training program.
The licensee established a routine General Employee Training (GET) program in November, 1988 that included NCS training. The NCS training curriculum was reviewed by the Program Manager, RIS and by the Radiation Protection Supervisor to ensure the instruction would effectively communicate with 1/ This portion is currently filled by the former incumbent, who has come out of retirement on a part-time, consulting basis to fulfill the position requirements.
8 the operators in the shop; however, the curriculum was not reviewed by a Criticality Safety Specialist for technical adequacy. An inspector took the GET. and the associated Radiation Worker (Radworker) Training programs on August 28-29, 1989. He noted that the policies, practices and procedural controls related to NCS were reviewed during the training, and that strict procedural compliance was stressed. (Also see Section 6.3).
4.3 NCS Audits Audits of the NCS program have been increased significantly, according to the Chairman of the Nuclear Safety Committee. The Criticality Safety Specialist performs monthly audits; the Senior Criticality Safety Specialist - ,
performs quarterly audits; and the Nuclear Safety Committee performs annual audits. Significant improvement is noted in that the audits are-now more ef fective in disclosing problems which exist in the plant. The closeout of findings and recommendations is done in the next audit report.
The weaknesses in the program, however, are that, frequently, corrective actions have not been effective in preventing repeat items, and there is no review of the program by an independent, technically qualified individual.
The Operations Manager impacts on the nuclear criticality safety and the CMR process by scheduling some reviews, and coordinating the interaction between licensing, safety, and production ~ when significant issues, such as the need for a new shipping container, develop. The Operations Manager is not responsible for safe:y, but rather serves to coordinate and assure that safety services are provided in a timely manner.
The licensee made additional commitments for the Nuclear Criticality Safety Program which were not directly addressed in the SALP recommendations.
These included (a) upgrading procedures and retraining, (b) " applying systematic, stepwise audit sequences," and (c) use of the Configuration Management System for insuring compliance. CE's action to implement item (a) was to prepare the program document discussed above. Training has l been done through General Employee Training and radworker training as described above. With respect to item (b), after several days of inspector inquiry, the CE Nuclear Licensing Department decided that the word " audit" should have been " inspection" and this referred to the review steps in the CMR process described above. For item (c), each CMR approval is given a number and, hence, is traceable through the records in the Configuration Management System.
4.4 Implementation of NCS Controls The inspectors conducted a tour of the Pellet Shop to examine the implementation of NCS controls within the workplace. The inspectors observed that the NCS posting for the Sinterability Test Hood permitted the storage of four 35 kg mass units of SNM within the hood, but it did
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not specify a limit for the volume of each mass unit, nor did it require a one-foot separation between each mass' unit. No physical barriers were-installed and no storage zones were visibly marked to provide this one-foot separation. The licensee had not' performed an NCS evaluation to demonstrate that neither a container. volume limit nor a minimum separation distance between mass units were needed. Section 2.2.2, " Administrative Responsibilities and Controls - Nuclear Fuel Manufacturing," of .Part I (Specifications) of License No. SNM-1067, requires analysis to establish the required safety limits and controls. Section 4.1.4, " Posting Limits,"
of Part I requires that all work stations and storage areas be posted with a nuclear safety limit. Section 4.2.5, " Limits for Safe Individual Units", of Part I requires that mass units of 35 kg of U02 in the form of powder or pellets be kept in steel containers with-a maximum volume of 5 gallons. Section 4.2.6, " Interaction Criteria", of Part I requires that all mass units have a separation of at least one foot, edge to edge.
Failure to establish volume and spacing limits and controls for~this hood is a violation of the nr. clear criticality safety specifications of the license. (70-1100/89-80-01)
The section of PR-3 on Operating Instructions / Posting does not re' quire posting of all significant limits and controls. The above violation may be attributable, in part, to the lack of precise wording in the picgram chapter.
4.5 Conclusions The licensee has taken steps to implement the SALP Board recommendations and the NCS program, overall, was being effectively implemented. Some deficiencies exist in the program control document, the program implementing instruction was- still in the approval process, corrective actions to identified problems are not always effective in preventing repeat items, and one violation was identified.
5.0 Equipment Maintenance l The SALP Board recommended that the licensee continue emphasis on the implementation of uporaded programs in this functional area.
1 5.1 Monitoring and Control of Equipment The licensee has established a more formalized system to ensure that the !
equipment that supports facility operations is monitored and repaired when needed. The Operations Manager, a position established in 1988 to coordinate the interaction between licensing, safety and production, with the ascistance of two Operations Shift Supervisors (which are also new positions), 1 monitors the repair and maintenance of facility equipment. The status of equipment repair is reported and controlled daily by the use of an Equipment
. Status Report (ESR) that is updated and published at the end of the third l
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e 10 shift. The ESR provides the status of a wide variety of equipment, and is used to help assure that the repair of safety-related equipment is given an appropriate priority, compared to product-related equipment, and to confirm that repairs have been completed. An administrative procedure that describes the ESR system was drafted and was in the process of being formally approved. However, the ESR was already being used by the licensee on a daily basis. The inspector observed this new ESR system to be an improvement in the licensee's monitoring and control of facility equipment and operations.
During previous NRC inspections, it was identified that the licensee did not perform adequate maintenance of ventilation systems in the Pellet Shop, thus the licensee failed to minimize the spread of contamination and decrease levels of airborne radioactivity. Holes were found in glove boxes and flexible hoses were repaired inadequately with tape. During tours of the Pellet Shop, the inspector noted that many improvements have been made in this area. Generally, the processing equipment appeared to be properly repaired and well maintained.
5.2 Equipment Operation and Maintenance An exception to this was noted regarding the Furnace Hydrogen Burnoff Ventilation. The exhaust flow meter for the Furnace Hydrogen Burnoff System indicated that the exhaust filters were blocked (zero flow) while the differential pressure gauge (stack filter differential pressure) indicated that the exhaust ventilation appeared to be operating properly.
Subsequent licensee evaluation determined that the filters were blocked.
The licensee was continuing to investigate the problem and, prior to the end of the inspection period, had not determined the cause of the discrepancy between the readings.
The licensee's Procedure RPI-211, " Ventilation System Monitoring", requires a Radiation Protection Technician to monitor, on a daily basis, the stack filter pressure differential and to notify supervision if a high pressure differential is noted. However, there is no guidance in the procedure regarding an acceptable minimal stack flow, as measured by the exhaust flow meter; therefore supervision was not aware of the loss of ventilation.
Licensee evaluation of this area will be reviewed during a future inspection.
The licensee recently implemented a preventive maintenance program. Under l this program, the licensee generates a monthly list of the required preventive maintenance for equipment in the Pellet Shop. The inspector reviewed Procedure RP-17, " Preventative Maintenance Program" and records of completed and scheduled periodic maintenance. With the exception of a 1 to 2 month backlog of periodic maintenance, the program appears to be functioning satisfactorily. The licensee stated that the backlog observed was primarily due to the extra work which was completed during the recent shutdown.
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- 5.3 Conclusions Based on the review performed, it was concluded that the licensee has {
continued emphasis on implementation of its equipment maintenance upgraded programs. As documented above, even though some deficiencies in program ,
implementation exist, Pellet Shop process equipment was being adequately maintained.
6.0 Radiological Controls The SALP Board recommended that the licensee:
- Expand and maintain a technically qualified, professional radiation protection staff;
- Review and revise, as necessary, the facility Radiation Protection Program; l
- Place high priority on the establishment, completion and implementation of written radiation protection procedures; and,
- Promote an improved workplace relationship " culture" between management and operators.
L The inspectors reviewed the licensee's radiological controls program with emphasis on the areas identified as deficient in the 1988 SALP report.
The deficient areas included: the lack of. independent audits of sufficient technical depth; the lack of professional technical personnel; inadequate radiation protection staffing; inadequate training of radiation workers I and the health physics staff; the lack of policies and procedures for l
radiation protection activities; inadequate bicassay and respiratory protection programs; excessive radioactive contamination levels in restricted areas; non-representative sampling of gaseous releases; and, l
inappropriate characterization of radioactive waste.
In addition, the SALP noted that a work environment in which both management and employees showed a genuinely positive attitude toward safety was lacking. The inspector noted that this safety attitude still has not been fully integrated into the licensee's facility as demonstrated by:
The number of instances of worker noncompliance with requirements and the lack of appropriate corrective actions by management. (See Section 6.1)
The lack of management commitment to the required radiation safety retraining. (See Section 6.3)
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l Discussions with production workers and radiation protection f personnel, including supervisory personnel, regarding instances which l demonstrated weaknesses in the work relationship between production and radiation protection personnel.
6.1 Management Oversight and Staffing The licensee has assigned responsibility for the radiation protection program development to the Program Manager, Radiological and Industrial i Safety (RIS). This individual also performs monthly audits of the
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implementation of the radiation protection program, although the procedure (Administrative Procedure-7) which will describe the scope of these audits is still in the developmental stage. Implementation of the radiation protection program has been assigned to the Manager, Radiological and Ir.dustrial Safety. Both he and the Program Manager report directly to the Vice President / General Manager, Nuclear Fuel Manufacturing. Currently, one supervisor, nine in-house technicians, and five contractor technicians work for the Manager, Radiological and Industrial Safety, to provide implementation of the radiation protection program. The staffing at the technician level appears adequate to cover the manufacturing activities.
However, there have been no improvements in the technical qualification of the professional staff since the end of the SALP period. Furthermore, there have been no independent audits of the radiation protection program.
The audits which were conducted lacked any required followup to assure ,
correction of identified deficiencies.
The licensee also utilizes a Radiation Deficiency Reporting System for documenting deficiencies in criticality, radiological, industrial, fire, and environmental safety compliance.
The inspector reviewed several Radiation Deficiency Reports and discussed the implementation of this program with several supervisors, technicians and workers. The following weaknesses were identified in this program.
The licensee's responses to the deficiencies did not address their root causes. This is illustrated by frequent examples of repeat deficiencies.
There were no established criteria for what type of deficiencies should be reported on the Radiation Deficiency Report. Radiation protection personnel interviewed did not agree as to when a Radiation Deficiency Report should be completed.
Training of workers on the use of Radiation Deficiency Reports needs '
to be improved. The inspector spoke with a production supervisor who said he was not aware of these reports, although several deficiency reports had been written regarding his work and the work of the individuals he supervised, l l
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13 The licensee is attempting to strengthen this program and supplied the inspector with a draft copy of a Deficiency Radiation Protection Instruction which was written to improve the licensee's performance in this area.
6.2 Radiation Protection Program and Procedures The licensee's radiation protection activities are defined by several radiation protection programs which are implemented in radiation protection instructions.
In late 1987, the licensee hired a consultant to write radiation protection procedures. These were re-written by the licensee and were issued in early 1989 as Radiation Protection Instructions. The Radiation Protection Instructions, as written, incorporated programmatic elements as well as implementation of the program. Subsequently, the Program Manager, RIS, initiated a re-writing of the Instructions and has been issuing elements of the radiation protection program. Those issued to date include the licensee's programs for bioassay, internal exposure control, respiratory protection, transportation of radioactive materials, and radioactive waste management. The licensee is planning to prepare programs for instrument calibration, dosimetry, environmental monitoring, external exposure control and ALARA. The Radiation Protection Instructions are being revised concurrently to ensure consistency with the Radiation Protection Program as the elements of the Program are issued.
In summary, the licensee has reviewed and revised the facility radiation protection program and has established and implemented its Radiation Protection Instructions. However, the program and instructions are continually being revised as the licensee acquires experience with their use.
6.3 Training of Radiation Protection Staff and Radiation Workers The licensee has developed a three-part formal training program for its health physics staff. The program was developed by the Manager, Radiological and Industrial Safety and reflects a job-and-task analysis of the radiation protection technician position by the licensee's Nuclear Training Group.
The job-and-task analysis was used to determine the specific training l needs for the licensee's radiation protection technicians. The first part is a self-study course which provides information on required basic mathematics and physics. The second part is formal classroom training on the fundamentals of radiation protection, modified to reflect the problems )
of an operating fuel facility. The final part is on-the-job training 3 which focuses on the licensee's Radiation Protection Instructions. l Currently, the radiation protection technicians have initiated work on the l first part, the second part is complete and awaiting completion of the l first part by the technicians, while the third part is still under development. !
In addit 1on, two members of the staff have received formal training in I l
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respiratory protection from a consultant and have been providing instructions to-the other technicians. Technicians interviewed by the inspectors j appeared to be familiar with the Radiation Protection Instructions and the !
requirements of their positions. However, these interviews also revealed J that work on the self-study part of the training program is going slowly, and licensae attention to this deficiency appears warranted.
The licensee has established a program, consisting of General Employee ]
Training and Radworker Training, to provide formal radiation safety j training to each of its radiation workers. ihe initial training takes '
approximately twelve hours to complete. This formal training is required annually for radiation workers. The licensee's training staff sends notices to management identifying individuals who have missed the required retraining.
This radiation worker training is required by Combustion Engineering's License to be given to salaried personnel who enter restricted areas, production personnel who handle radioactive material, and all maintenance workers on an annual basis, with no more than 13 months between training sessions in accordance with Section 2.6.2 of the NRC-approved license application. The inspector reviewed training records and log entries of personnel who entered the restricted areas and noted that several salaried and production personnel had entered and worked in restricted areas without satisfying the required annual retraining requirement. The inspector noted that among those who were most overdue for training were a radiation protection technician and the Manager, Production. This is a violation of the facility license. (70-1100/89-80-02)
The inspector noted that, for six months, the Manager, Radiological and Industrial Safety and the Manager, Production had been sent the lists of personnel in their departments who needed retraining, but the listed personnel were not retrained. This represents another example where compliance with licen:,e and procedure requirements was not sufficiently stressed or implemented.
6.4 Bioassay, Respiratory Protection, and Contamination Control Programs The licensee has made significant progress in enclosing its work stations in the Pellet Shop, resulting in reduced radioactive contamination levels and reduced airborne radioactivity levels. The licensee has established, through its Radiation Protection Instructions, a program for identifying and correcting instances of excessive contamination in the restricted area. Review of records and discussions with radiation protection and productfon personnel indicated that work areas were shut down when excessive contamination was identified, and operations did not resume until decontamination was complete.
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.The licensee has established and implemented its ' bioassay and respiratory protection programs. Licensee personnel are continuing to develop procedures
' to relate bioassay results to regulatory limits, but these efforts were not complete at the time of the inspection. However, the. licensee has implemented a breathing . zone air sampling program and a review of these records indicated that there had been'no apparent exposures to airborne radioactivity in excess of regulatory limits.
6.5 Sampling of Gaseous Releases The licensee employed a consultant to review its stack sampling to determine how to' ensure isokinetic, representative sampling of the effluent. The licensee implemented the consultant's recommendations and issued sampling flow-rate curves to its staff to indicate the required sampling flow required to ensure . isokinetic sampling. Discussions with licensee personnel indicated that this has resulted in the isokinetic sampling of the licensee's gaseous effluents.
6.6 Radioactive Waste Characterization and Transportation In 1989, the licensee issued new radioactive waste characterization and
. transportation' instructions. Licensee personnel stated that training on these new instructions was provided to all appropriate personnel. A review of selected, records of waste characterized and transported for disposal indicated that the limits for low specific activity had been met and that compliance with transportation requirements had been achieved.
6.7 External Dosimetry In addition' to deficiencies identified in the SALP, the inspectors also reviewed the licensee's external dosimetry program. It was noted that the licensee uses a Teledyne TLD as its personnel monitor. The inspectors reviewed the records of personnel monitoring and noted that the licensee maintains records that extend back to 1971, and also maintains records of termination letters sent to former employees. The records indicated that the maximuia external doses to employees were shallow doses received by
" stack and load" workers ohn load uranium pellets into fuel rods. The i maximum shallow doses received by any individual since 1980 were as follows:
4 16 Year Shallow Dose (mrem) Deep Dose (mrem) 1989 (through June) 1815 281 1988 2298 252 1987 2741 634 1986 2723 484 1985 2419 334 1984 8137 3227 1983 5530 665 1982 10575 1430 1981 13400 1690 1980 14265 3225 The licensee accepts the dosimetry vendor's reported shallow dose without applying any correction factors for beta energy. The licensee has asked its. vendor to determine whether such a correction factor was necessary for the beta spectrum which results from the isotopic composition of uranium used at the licensee's facility. When the vendor provides the requested data, the licensee plans to have the vendor apply the correction factor to the doses reported to the licensee. The inspectors observed a licensee radiation protection technician perform a beta dose survey with an E'v erline R0-2 ion chamber using a beta correction factor in the area where the
" stack and load" workers were loading uranium pellets into fuel rods.
They observed an apparent beta dose rate of 50 millirems per hour in the area of the worker's unshielded face.
The inspector noted that the TLD was worn underneath the worker's protective clothing. No correction factor was used to account for the higher dose rate received by the skin of the face compared to that of the TLD under the protective. clothing. The licensee stated its intention to investigate the need to apply an additional correction factor to correct for the effect of the protective clothing. In addition, the licensee, operating under a Radiation Protection Instruction, has an ongoing study to determine whether extremity monitoring should be required for some workers, particularly the " stack and load" workers. The determination of the adequacy of the licensee's monitoring of skin and extremity doses will remain an unresolved item pending the conclusion of the licensee's study of extremity doses and the effects of beta energy and protective clothing on the interpretation of the personnel dosimetry results. (70-1100/89-80-03) 6.8 Conclusions The licensee has taken steps to implemant the SALP Board recommendations.
The staffinf in radiation protection is adequate; the facility Radiation Protection Program is being revised; new radiation protection procedures have been established and implemented (but are being revised); and, there is evidence that the licensee has taken steps to attempt to improve the l workplace " culture". However, the inspector noted that the improvements l
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l- in " culture" have not been fully integrated into the program. In addition, l l there have been no improvements in the technical qualifications of the I professional staff; the revision of the radiation protection program and procedures remains incomplete, and the self-study portion of the radiation protection technician training program is going slowly.
7.0 Emergency Preparedness The SALP Board recommended that the licensee conduct a site-wide demonstration of the Emergency Plan, including offsite support agencies.
Specific deficiencies identified in the SALP included: the content, control and distribution of the Radiological Contingency Plan (RCP);
interface with offsite support groups; availability of qualified personnel to coordinate emergencies and administer program hetivities; performance of independent audits; and the adequacy of the Emergency Control Center.
The inspector met with licensee staff who were cognizant in routine emergency preparedness (EP) functions and program administration in order to determine the licensee's progress in meeting documented commitments.
Discussions also were held to determine the status of upgrading other areas of the program prior to conduct of an emergoncy exercise.
7.1 Program Implementation The inspector determined that in 1987 and 1988, a great deal of the licensee's effort was devoted to addressing higher priority deficiencies such as those in the radiation protection area, while little or no actions were taken in EP. However, early in 1989, appropriate management and staff attention were provided in the area of EP so that tangible program changes were in evidence. On June 30, 1989, the licensee completed the first major step to upgrading the program by submitting, for NRC approval, a complete revision to the RCP. At the time of the inspection, the submittal was under NRC review. Despite the need to improve the RCP, the inspector noted that the licensee also will be expected to meet the i requirements of the new NRC regulation for fuel cycle licensees regarding submission of upgraded RCP's, which becomes effective in April 1990.
During an NRC inspection in July 1989 (Inspection No. 89-04) the licensee noted that procedural changes should be complete such that an upgraded emergency drill could be conducted in early October,1989, a slippage from an earlier plan to hold such a drill in early 1989. (See Section 7.4). However, as noted below, procedural development has not been completed and the early October date for a drill appears to be unachievable.
The licensee was reminded of the license requirement to conduct a drill involving off-site agencies by the end of the calendar year. The licensee representatives acknowledged this requirement.
Review of the key program areas revealed that certain other documented commitments still have not been met and remain incomplete. These are identified by the program areas discussed in the following sections.
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7.2 RCP Implementing Procedures l
After the RCP.was completed, implementing procedures to carry out emergency l response were drafted and issued for comment to key corporate and site-staff. EP staff received comments from most personnel and, at the time ~of the inspection', these were being considered for incorporation into the procedures. Although procedures were generally complete, it was not clear that a management review or authorization was necessary prior to final implementation. The inspector reviewed the format of the draft implementing procedures and nott d that functional checklists for personnel to use during emergency response were not included. Following internal approval, the licensee should submit implementing procedures to NRC for approval.
7.3 Emergency Response Organization (ERO) Assignments Discussions with EP staff revealed that ERO assignments were being made based upon an individual's background, experience, and routine job function.
A list of individuals assigned to fill the roles of backshift Emergency Directors, dose assessors, re-entry teams, decontamination teams, radiation survey teams, medical /first aid responders, security control, and other personnel necessary to implement the RCP u s almost complete. When the
. list and ERO training and qualification are complete, it appears that emergency response coverage will be adequate on a 24 hour2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> basis. It was unclear that management was involved in deciding on ERO assignments.
Also, there was no directive to show selections will be supported by management.
. 7.4 Training In its response to the NRC's Operational Safety Assessment (0SA) report, the licensee committed to conducting instruction in the use of hazardous materials by the fourth quarter of 1988, and to implementing a training-and qualification program in EP by the second q u rter of 1989. At the time of the inspection, the implementing procedures were still in draft form, and no formal training on the new RCP or hazardous material use '
procedures was being provided. The licensee's staff stated that development of lesson plans for this training had begun and would be completed soon after the implementing procedures were approved. ERO qualification criteria are expected to include classroom instruction and performance-based training in use of new procedures.
7.5 Facilities and Equipment The Emergency Control Center, located in Building 6, previously was determined by the NRC to be inadequate to allow the licensee to effectively coordinate response to emergencies. A new facility (guard house at the plant site entrance) will be designated as the initial command center and renamed the Emergency Operations Center (E0C). Inspection of the newly t
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designated E0C indicated that the facility was not ready to accommodate response personnel. The conference room inside Building 4 is now designated for management of long term responses and is adequate. Inventory lists of emergency equipment and supplies designated for emergency use are being reestablished. Locations for emergency equipment cabinets around the site were also to be changed, but the licensee had not yet designated the new locations.
7.6 Audits A concern was identified in the OSA with the method the licensee used to conduct audits. NRC identified that EP audits were being performed by individuals who had direct responsibility for implementation of the EP program, thereby precluding the-independent review process. Licensee representatives indicated during the inspection that the audit function for EP and other site program areas was transferred to a separate audit group and that an independent audit would be conducted when most EP areas were complete.
7.7 Interface with Offsite Support Groups The lack of a close working relationship between the licensee and offsite support groups was identified as one of the primary concerns in the OSA.
In a July,1989 NRC inspection, it was identified that the licensee conducted two emergency drills during 1988, neither of which included participation by offsite agencies. The licensee was issued a Notice of Violation (70-1100/89-04-01) for failure to meet the requirements of the RCP with regard to participation by offsite agencies in emergency drills.
At the time of the inspection, the licensee had not responded to this violation.
Immediately following the July 1989 inspection, however, the licensee took initiatives to promote offsite relations. A meeting was held by the licensee with Windsor Civil Preparedness officials to discuss coordination of emergency preparedness activities. The licensee described the RCP and its use, notification procedures, communication channels, and expected actions to be taken by themselves, by the town of Windsor, and by the State of Connecticut during emergencies. After this meeting, the licensee formally requested to meet with representatives of the State of Connecticut to review the new RCP. Letters of A hospitals (St. Francis, Hartford, and Mt. Sinai)greement were outwith local of date but are presently being revised.
7.8 Conclusions Implementation of SALP Board recommendations is behind schedule and incomplete, although specific program deficiencies are being addressed.
Implementing procedures were almost through the approvai process, but specific dates to finish training lesson plans, perform all response
'20 training, complete response facilities, and conclude meetings and agreements with offsite' support' groups could not be determined. A commitment to conduct a site-wide, full participation exercise has been delayed and the currently scheduled date, early October 1989, appears unachievable.
Attention by licensee management to incomplete program areas is required to assure that a full participation exercise of the current, approved emergency plan is conducted before the end of 1989.
8.0 Management Controls The SALP Board recommended that the licensee:
- Improve self-assessment. capabilities
- Develop an internal audit program
- Increase nuclear safety committee meeting frequency The 1988 SALP report noted the following specific weaknesses in these programmatic areas:
Weak policies relative to a written safety program Workplace " culture" that did not foster safety and compliance
- Inadequate use of the Nuclear Safety Committee
- Ineffective internal audit program
- No independent annual audit of radiological / criticality safety No annual audit of the material control and accountability program
. No formal mechanism to assure correction of-noncompliance items
- Inadequate attention to programmatic deficiencies Corrective actions focused only on specific noncompliance items 8.1 Oversight of Licensed Activities The inspector interviewed the Chairman of the Nuclear Safety Committee (NSC), reviewed the NSC's Annual Audit of the Nuclear Fuel Manufacturing Facility (dated February 21,1989), and reviewed the minutes of NSC meetings since mid-1988. These activities revealed a significantly increased level of involvement of the NSC with the radiological safety program than observed at the time of the SALP. -
Discussions with the NSC Chairman also revealed that the licensee had distributed approximately 50 controlled copies of the facility's NRC l license to key members of the nuclear fuel manufacturing management team .!
and staff, thus providing widespread information on the NRC requirements applicable to the facility. This represents a significant change from past practices and is indicative of the licensee's effort to emphasize its commitment to the safety program. Further, while review is not required, all members of the NSC receive copies of all proposed NRC license amendment requests for review prior to submission to the Nuclear Regulatory Commission. l The Chairman indicated that he reviews all changes and provides to the
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l, 4 amendment- originator any comments he or other committee members have. One F exception is that all amendment requests that have criticality safety.
implications must be reviewed'by the licensee's criticality safety consultant, and the NSC. The inspector, reviewed the file of NSC minutes maintained by ,
the. Secretary to the NSC Chairman. The minutes reviewed, dated between J July 8, 1988 and July-10, 1989, revealed four instances.in which a license amendment was discussed at a formal NSC meeting. According to the minutes- q of the. February 9,1989 meeting, however, Committee members agreed that i the' Committee was not set up to do licensing reviews. The licensee needs I to assure-that this issue has been resolved and that all members of the Committee understand their licensed obligation to review proposed licensing actions to assure that nuclear safety has been addressed.
8.2 Audits The licensee's internal audit program was discussed by the. inspectors with several members of the licensee's organization, including the Vice President and General Manager (VP/GM) Nuclear Fuel Manufacturing; the Vice President, Nuclear Quality Systems (who is also Chairman, NSC); and the-Operations-Manager. These discussions revealed that the following audit programs have been established and have been or are being implemented:
- ' Management Inspection Program - From mid-March 1989 through the end of May, the VP/GM and nine of his direct subordinates were _ scheduled to perform frequent inspection tours (total of about 15 per week) of
.the Nuclear Fuel Manufacturing facility. The tours were scheduled to provide management presence in the plant, to enable managers to expand their knowledge of programmatic areas, and to identify safety or operational problems. The tours included all shifts including some required to be performed between 2 and 4 a.m. According to the Operations Manager, only about ten of the scheduled tours were not done. Findings from each tour were documented on a prepared form and corrective actions were being tracked to closure. Beginning in early June, the licensee reduced the frequency of the required tours to two on each of the second and third shifts per week, and reduced the number of managers involved to seven.
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Nuclear Quality Systems - These audits focus on product quality.
Approximately 180 such inspections were done in 1988, but frequency in 1989 was reduced to about two per week. A specific fuel fabrication contract involved in 1988 required continous quality control inspections, a major factor in the reduction in frequency of these inspections.
Comments resulting from deficiencies noted during the inspections were documented, and some product quality problems were identified and are being addressed. Closure of these items was being tracked by the Operations Manager.
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l 22 The Program Manager,. Radiological and' Industrial Safety, and the Nuclear Criticality Safety Specialist routinely perform safety audits. _ The former performs monthly audits of the radiation safety
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and criticality safety programs. He documents his findings and 1
- provides them to the responsible managers for action. -The Operations Manager receives a copy of the.-findings-and tracks' closure of each-
{ recommendation. ~The Nuclear Criticality. Safety Specialist also l performs a monthly audit, similarly documents his findings and they. 1 are similarly tracked to closure. On August 31, 1989, during.such an audit, a violation of the criticality safety posting limits was identified in the screening hood. Production records indicated.that. the 35 kilogram mass limit has been exceeded by about 2% earlier in the' day, but was within limits when found by the Nuclear Criticality
. Safety Specialist. Discussions with the Operations Manager revealed that this finding apparently was not promptly referred to' production or. safety management in the~ facility. However, the shift supervisor was told of the finding later that day by a facility employee and the shift supervisor took prompt action to initiate the Abnormal Event Occurrence system. This incident suggests that additional sensitization of the facility staff to potential significance of safety-related events is required.
In an. effort to improve the coordination between the safety and production organizations, the licensee established the position.of Operations Manager and provided shift supervisors on the second and third shifts who report to him. .The Operations Manager noted that he had given these individuals specific safety-related assignments, such as review of all criticality. safety limit postings for visibility, consistency, ease of interpretation, etc., and review of shop instructions'to verify that only current approved procedures were in use.. Again, fir. dings were being tracked to closure. Despite the increased frequency and breadth of'the licensee's management audits, one outstanding weakness remains. As noted in Sections 4.3 and 6.1,'there is no independent assessment of the nuclear criticality safety and radiological protection areas by technically qualified individuals. 8.3 Implementing Program and Procedures The inspectors reviewed Program Document No. PR-22, " Audits, Inspections and Surveys," which describes the types and frequency of internal audits of safety and safeguards programs at the Nuclear Fuel Manufacturing (NFM) facility and assigns responsibility for performing the audits. Revision 0 of PR-22 was issued June 21, 1989. PR-22 references several guidelines and procedures to be used in implementing the program document. Discussions with the Operations Manager revealed that, as of the date of the inspection, several of the important implementing documents had not yet been issued, including, i i
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1 Administrative Guideline (AG)-3, Document Requirements Administrative Procedure (AP)-5, Record Retention Administrative Procedure (AP)-7, Audits and Inspections PR-22 requires the audits to be performed by personnel independent of NFM operational safety and production responsibility, that the audits be j pe'rformed'in accordance with AP-7, documented in accordance with AG-3, and i records retained in accordance with AP-5. I l AG-3 had not yet been written, but AP-5 and AP-7 were in the management review process and issuance was expected in the near future. Followup corrective action to audit findings will be the responsibility of the cognizant line manager.
.8.4 Conclusions )
l Each of the programs described above is providing improved oversight i and self-evaluation of safety in the Nuclear Fuel Manufacturing facility. The individuals interviewed by the inspectors appeared to be knowledgeable of their duties and responsibilities, and their accountability for safety. The licensee appears to have taken positive steps to correct the deficiencies in this programmatic area and to be effectively implementing the programs established. However, some procedures required to implement audit programs had not yet been completed and audits, by technically qualified individuals, of the radiological protection and criticality safety programs is a continuing concern. Further, as noted in Sections'4.5 and 6.1, examples of repeat failures to comply with licensee procedures indicates that additional attention to the corrective action program is required. 9.0 Licensing Issues The SALP Board recommended that the licensee:
- Continue the use of a dedicated licensing staff.
- Assure that the dedicated licensing staff is trained in the preparation of Part 70 license modification submittals.
Provide adequate technical support to the licensing staff. 9.1 Use of Dedicated Licensing Staff The licensee currently has a dedicated staff of four people and a temporary staff equivalent to 6-7 staff years of support. This staff provides licensing support for both the Hematite (Missouri) and Windsor facilities. The temporary staff is expected to be phased out over the next 2 years as the applications for license renewal for the two facilities are completed and the backlog of licensing issues is reduced. (The Hematite renewal application is expected by the licensee to be submitted by December 1, 1989, and the Windsor renewal will be revised on or about > December 15,1989.) L________________---____---_----__----- - - o
t > .>o , - 24 9.2 Training in License Modification Submittals The dedicated ~ staff received training in regulatory requirements for 10 CFR 19, 20, 70, and 71, and in Regulatory Guide '3.52, " Standard. Format and Content for the Health and Safety Sections of License Renewal Applications for Uranium Processing and Fuel Fabrication." Some temporary members of the Licensing Staff received some or all of the training. The temporary , members work with the permanent, trained members to assure adequate preparation of1 license amendment application documents. 9.3 Technical Support to Licensing The technical content of the license applications submitted to NRC previously was lacking in quality. The licensee's license amendment application process now calls for the CE Safety Staff to provide a safety evaluation
-with its request to the CE Nuclear Licensing Staff to initiate a licensing action. Discussions with licensee personnel indicated that the Nuclear Licensing staff then prepares the license amendment application, obtains concurrence from the Program Manager, Radiological and Industrial Safety, and forwards the application to the NRC.
9.4 Upgrading of the Windsor License The licensee, in its November 21, 1988, response to the SALP Board report, also committed to revise and upgrade the license within the next year. During the inspection, it was determined that CE expects to resubmit the license renewal application and that this is how CE intends to fulfill this commitment. This action does not affect the current license, which will remain in effect until the renewal process is completed by the NRC. j l The licensing staff has prepared an administrative practices procedure for preparing license amendment application documents. This procedure was reviewed by the inspector and minor comments were provided to the Nuclear Licensing Supervisor. The procedure whereby Radiological and Industrial Safety requests Nuclear Licensing to initiate a licensing action has not been written. This procedure is needed to smooth the interface between the two departments as well as to shorten the amendment initiation process. The SALP report also commented on the quality of the licensing amendment submittals, the administration of the license, and the use of the NRC staff in a consultant role. The primary licensing activity since the SALP report was issued has been an organizational amendment. This action has necessitated several meetings and resubmittals. The problems of consultation and poor administration, however, have been resolved by use of the CE dedicated licensing staff.
W. i :.;. y o ~ . 25 o 9.5 ' Conclusions The licensee has taken action to address-the SALP Board's recommendations. While efforts to improve the quality of license amendment submittals
'still . requires attention, the' licensee's. performance in this area appears to be improving.
10.0 Exit Interview On September 8,1989, the inspectors met with the individuals identified in Section 1.0 to discuss the inspection findings. The licensee was informed that the principal findings would be presented during the October 5, 1989 meeting in the Region I office, but the scope of the inspection was reviewed and the two violations identified were reviewed. One unresolved item (Sectior. 6.7) was identified during the inspaction. An unresolved item is an item about which additional information is required to determine if the matter is clear or a violation. i l 1 i 1 - - - - - - _ _ - _ - - - - - _ _ - _ - - _ _ _ - - _ _ _ _ _ - - - __. )}}