ML21029A080
| ML21029A080 | |
| Person / Time | |
|---|---|
| Issue date: | 01/28/2021 |
| From: | Gregory Goff, Romano M, Paul Startz NRC/RGN-II/DFFI |
| To: | Eric Michel, Ladonna Suggs, Robert Williams NRC/RGN-II/DFFI |
| References | |
| Download: ML21029A080 (9) | |
Text
January 28, 2021 MEMORANDUM TO: LaDonna Suggs, Director Division of Fuel Facility Inspection Robert Williams, Chief Projects Branch 1 Division of Fuel Facility Inspection Eric Michel, Chief Projects Branch 2 Division of Fuel Facility Inspection FROM: Paul Startz, Fuel Facility Inspector (Lead) /RA/
Projects Branch 2 Division of Fuel Facility Inspection Gregory Goff, Fuel Facility Inspector /RA/
Project Branch 2 Division of Fuel Facility Inspection Michelle Romano, Fuel Facility Inspector /RA/
Project Branch 1 Division of Fuel Facility Inspection
SUBJECT:
2020 Peer Review of the Division of Fuel Facility Inspection Reports This memorandum describes the results of the annual peer review of inspection reports that were issued by the Division of Fuel Facility Inspection (DFFI) during the calendar years 2019 and 2020. The peer review was conducted in accordance with Regional Office Instruction (ROI)
No. 2240, Peer Reviews of Inspection Report, Revision 9. This ROI instructs regional staff to:
(1) conduct a peer review, at least once a year, of inspection reports issued by the Division and (2) use an Inspection Report Review Checklist provided in the ROI to conduct the review. The ROI-2240 checklist is designed to evaluate inspection reports for operating power reactors, power reactors under construction, and fuel facilities. Therefore, it should be noted that the checklist goes beyond the scope of Inspector Manual Chapter (IMC) 0616, Fuel Cycle Safety and Safeguards Inspection Reports. A list of the 12 sample inspection reports included in this review (or audit hereafter) along with related information is presented in a data table at the end of the report.
Overall, the audit team identified significant improvement from last years audit findings and did not identify significant deviations from the inspection report guidance included in IMC-0616 and the cover letter templates contained in the NRC Enforcement Manual. The team reviewed last years findings/observations to evaluate repeat issues and relisted the most prominent previous issues along with new findings and observations.
L. Suggs, et al 2 The annual audit results are being submitted to DFFI management and staff to identify repetitive problems and to allow further improvement of the inspection report writing process.
Enclosure:
Peer Review of Inspection Report CONTACT: Paul Starz, RII/DFFI 404-997-4709
ML21029A080 SUNSI REVIEW COMPLETE FORM 665 ATTACHED OFFICE RII:DFFI/PB2 RII:DFFI/PB2 :RII:DFFI/PB1 NAME P. Starz G. Goff M. Romano DATE 1/25/2021 1/25/2021 1/25/2021 Peer Review of Inspection Reports Division of Fuel Facility Inspection 1.0 Peer Review Approach
- The team used the Reports function of the Reactor Program System (RPS) to identify the list and attributes of inspection reports that were issued in calendar years 2019 and 2020. The team tried to include inspection reports that contained as many violations as possible, but there were fewer violations relative to the last audit period.
The team evaluated a large timeframe of inspection reports to maximize both the diversity of inspection areas and the review of violations.
- The team selected a sample of 12 inspection reports samples for the audit.
- The inspection samples focused on publicly available inspection reports, non-publicly available reports, and reports documenting a variety of compliance issues.
- The inspection samples did not include performance assessment reports since this type of report receives considerable peer review during the License Performance Review process.
- The team reviewed each report using the checklist in ROI-2240; the guidance in IMC-0616; NUREG-1379, NRC Editorial Style Guide; and the templates in the NRC Enforcement Manual.
- Since none of the findings represented significant deviations from the inspection report guidance, in most cases, findings and recommendations are generally described without specifying the report, facility, branch, or staff member. Findings and Observations are also organized based on the applicable report section.
2.0 Findings
This audit defines findings as issues that are not consistent with the applicable inspection report guidance or require clarification of the existing guidance. Section 4.0 contains recommendations and corrective actions for the findings in this report.
Cover Letter Section 2.1 The previous audit identified some inspection reports did not include the event notification (EN) number in the upper left corner of the cover page as required by IMC-0616. One instance was identified during this audit.
2.2 The previous audit identified some inspection reports were not fully in compliance with the format recommended in the NRC Enforcement Manual for the cover page. One instance was identified in this audit.
2.3 The previous audit identified some variation with the standard wording in the opening paragraph. Several instances were identified during this audit.
2.4 One inspection report had the wrong ADAMS ML number while another had a missing number entered in the Inspection Report Tracking System (IRTS) function of RPS; and in ADAMS.
Enclosure
Executive Summary Section 2.5 The previous audit identified some inspection reports that included open items in the Executive Summary such as open violations that were reviewed and remained open.
Inspection Manual Chapter 0616 states that open items should not be listed in the Executive Summary, but it does not elaborate if it is acceptable to discuss open items in certain cases. No repeat statements were identified in this years audit.
2.6 Some reports Executive Summary sections stated no violations of more than minor significance were identified while others did not mention such.
2.7 One report titled the Executive Summary as just the Summary.
Report Details Section 2.8 One report did not include the Summary of Plant Status.
2.9 One report was missing issue dates of report and NOV dates.
2.10 Two reports were missing the Enterprise Identifiers.
2.11 Last years audit identified that acronyms were often defined but not used again. In other cases, acronyms were not defined. This was not consistent with the NRC Editorial Style Guide in NUREG-1379. This years audit noted a higher level of compliance, but this issue still requires attention during final reviews.
2.12 Last years audit identified that some titles of procedures and documents referenced in the inspection scope were not in quotation marks as suggested by the NRC Editorial Style Guide in NUREG-1379. This years audit noted a high level of compliance.
2.13 This years audit identified that an incorrect screening question from IMC 0616 Appendix B was used while detailing a violation in Radiation Protection. Extra effort should be used to perform final report accuracy checks regarding specific references.
2.14 Last years audit identified a report closing a previously cited violation (VIO), did not clearly describe the corrective actions performed by the licensee to restore compliance nor the basis to close the violation. This years audit did not identify this issue.
2.15 Last years audit identified a report discussing a previously cited violation (VIO), did not describe what actions were still pending to close the violation. This years audit did not identify this issue.
2.16 Last years audit identified an inspection report section that did not contain a 'Scope and Conclusions' section as required by IMC-0616. This years audit did not identify this issue.
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2.17 The audit team reidentified one report that was inconsistent with the use of Chapter, Section and Paragraph with respect to the Code of Federal Regulations (CFR) and the license application. The CFR is organized by title, part, section, paragraphs in multiple levels like (a)(1)(i)(A)(1)(i). The organization of license applications varies per licensee, but it generally consists of chapters, sections, and paragraphs. When citing or referencing the CFR or a licensing basis document, inspectors should continue improving the use of the appropriate terminology consistent with the structure of the document. This years audit noted a higher level of compliance, but this issue still requires attention during final report reviews.
2.18 The previous audit identified some reports where the SLIVs were treated as NCVs because the violations were entered into their corrective action program. The statement should have read their credited corrective action program. No repeat statements were identified in this years audit.
Exit Meeting Section 2.19 Last years audit identified several inspection reports included the statement No dissenting comments were received from the licensee in the Exit Meeting section.
Although this statement is in some of the templates, IMC-0616 Section 14.01(f)(4) states that Licensee responses should not be included in the summary except in cases where the licensee disagrees with the violation. In that case, the summary should state that the licensee took exception to the violation. Inspection reports should not include a statement that no dissenting comments were received and should only be documenting when the licensee dissents. This years audit noted a report with the same issue.
Inspectors should review this section for compliance during final report reviews.
Documents Reviewed Section The audit team did not identify significant issues with this section this year.
General Comments 2.20 The format for referencing Title 10, Chapter # - Nuclear Regulatory Commission - of the Code of Federal Regulations should use the formats listed at:
https://www.nrc.gov/reading-rm/basic-ref/enf-man/app-b.html, which is Enforcement Manual Appendix B. The audit team is including this comment again this year as a reminder to carefully review reports for this previously common error.
3.0 Observations For the purpose of this audit, observations are remarks for consideration to improve the overall quality of inspection reports. Section 4.0 contains recommendations for the observations in this report, but their implementation will be at the discretion of DFFI management.
Cover Letter 3.1 In the previous audit, the concurrence blocks contained inconsistent terminology to represent staff approvals such as Via FIT and RA (feeder) which may not be clearly understood by a reader. This years audit recognizes that DFFI has migrated away from FITS which has largely solved this concern.
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3.2 Concurrence blocks varied somewhat in size, font, and presentation. In the previous audit, some concurrence blocks included a document path. These variations were identified again this year.
3.3 The audit team is recommending that the management team consider adding information to the cover letter on how the public can participate in the LISTSERV automated distribution.
3.4 In the previous audit, URENCO quarterly reports had a concurrence block for Derivative Classifier (DC) review while Category I resident reports do not. This DC concurrence block was not observed in the URENCO samples this year.
3.5 In the previous audit, some inspection reports had a misaligned event notification (EN) number in the left corner of the cover page. The current audit did not identify this issue.
Executive Summary 3.6 There were inconsistencies between reports concerning the use of page/section/paragraph references in the Executive Summary/Notice of Violation that refers to the sections of the report. This is a repeat finding from the previous audit.
3.7 One Radiation Protection inspection report failed to state which Appendix was being inspected.
3.8 One report included the zip code in the intro before the Executive Summary; the other three did not.
Report Details 3.9 The previous audit identified some cases where inspection scopes contained observations and statements that were not directly associated with the items inspected to determine if the licensee was in regulatory compliance with a requirement. The current audit identified an additional example this year. While IMC-0616 is neutral on these types of statements in the scope, the audit team is recommending their use should be limited to avoid confusion.
3.10 Last years audit identified a Nuclear Criticality Safety (NCS) section contained extensive inspection scope and potentially redundant or convoluted statements that could be confusing to a reader. Some inspection reports also contained extremely long and complex sentences. This years audit found that the sample NCS section had demonstrated significant improvement.
3.11 In the Report Details section of a few reports, some awkward sentence structures were noted again this year. This could cause confusion for members of the general public.
3.12 In one report, it was observed that references were made to three or more specific documents in succession. A simple statement that refers readers to the Documents Reviewed section could be a better option.
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Exit Meeting Summary None Documents Reviewed Section 3.13 Some inspection reports documented only the number of Corrective Action Program documents and work orders reviewed while others listed document number, titles and/or dates.
3.14 The audit team identified a report that had the licensee personnel in the Key Points of Contact out of alphabetical order by last name.
4.0 Conclusions and Recommendations Overall, the peer audit team identified significant improvement from last years audit. As a result, the team only noted minor deviations from the inspection report guidance included in IMC-0616 and the cover letter templates contained in the NRC Enforcement Manual. The team identified the following recommendations for consideration of DFFI management and staff.
Associated Recommendation Lead Finding or (Target Date)
Observation All Findings Discuss peer audit findings with DFFI management. PS (Completed)
All Findings Discuss peer audit findings with DFFI staff. PS (February 2021)
Finding 2.4 Contact the Region II owner of IRTS to correct wrong ML PS number and assign the missing ML number in the system. (February Re-issue IR with wrong VIO reference. 2021)
Corrective Action Upon management approval, implement an overcheck QC GG for Finding 2.4 of all inspection report ML number assignment to ensure (February accuracy. 2021)
Observation 3.3 Consider adding instructions to the cover letter on how the public can participate in LISTSERV automated (NA) distribution. If approved, pursue revising cover letter templates.
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5.0 List of Inspection Reports Selected for Annual Peer Review 2019-2020 PEER REVIEW OF INSPECTION REPORTS (ROI-2240)
Docket Type / Inspection ML Number on Report Report Report Peer Docket Name Number Number document Type Availability Items Issue Date Org Auditor Notes BWX Technologies, Inc. 07000027 2019-004 ML19298A117 I Public None 10/24/2019 PB2 PS BWX Technologies, Inc. 07000027 2020-001 ML20121A219 I Public 2 VIO 04/30/2020 PB2 GG Framatome, Inc. 07001257 2019-004 ML19301A076 I Public None 10/25/2019 PB2 PS Global Nuclear Fuels -
07001113 2019-005 ML20031D503 I Public None 01/31/2020 PB1 GG Americas Global Nuclear Fuels -
07001113 2020-001 ML20121A038 I Public None 04/30/2020 PB1 MR Americas Nuclear Fuel Services, Non-07000143 2019-402 ML20003E144 1 None 01/03/2020 PB1 MR Inc. public Nuclear Fuel Services, 07000143 2019-005 ML20029E884 I Public None 01/28/2020 PB1 GG Inc.
Non-Urenco USA, (LES) 07003103 2019-402 ML19361A167 I None 12/17/2019 PB1 MR public Urenco USA, (LES) 07003103 2019-004 ML19304B933 Public 2 NCV 10/31/2020 PB1 GG Incorrect Correct Urenco USA, (LES) 07003103 2019-005 I Public None 01/24/2020 PB1 PS ML2002G064 ML20024G064 Westinghouse Electric 07001151 2019-004 ML19326C453 I Public 1 VIO 11/22/2019 PB2 PS Co., LLC Westinghouse Electric Missing Non- Add date & ML 07001151 2019-401 2 VIO 12/xx/2019 PB2 MR Co., LLC date/ML# public number Legend I = Integrated Inspection Report NCV = Non-Cited Violation URI = Unresolved Item ANI = Area Needing T =Team Inspection Report VIO = Cited Violation Improvement CO = Confirmatory A =Assessment Report WER = Written Event Report Order 6