ML20203N970

Forwards Response to 860113 SALP 5 Board Rept for Apr 1984 - Sept 1985.NRR & Region III Attendance at Quarterly Senior Mgt Meetings Requested.Consolidated Trend Program Under Development

ML20203N970
Person / Time
Site:	Cook
Issue date:	03/04/1986
From:	Alexich M INDIANA MICHIGAN POWER CO. (FORMERLY INDIANA & MICHIG
To:	Keppler, James Keppler NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
Shared Package
ML20203N949	List: IR 05000315/1985001 ML20203N947 ML20203N970 ML20203N977
References
AEP:NRC:0973, AEP:NRC:973, NUDOCS 8605060244
Download: ML20203N970 (14)

Text

INDIANA & MICHIGAN ELECTRIC COMPANY P.O. BOX 16631 COLUMBUS, OHIO 43216 March 4, 1986 AEP:NRC:0973 Donald C. Cook Nuclear Plant Unit Nos. 1 and 2 Docket Nos. 50-315 and 50-316 License Nos. DPR-58 and DPR-74 RESPONSE TO SYSTEMATIC ASSESSMENT OF LICENSEE PERFORMANCE (SALP) 5 BOARD REPORT Mr. James G. Keppler, Regional Administrator U.S. Nuclear Regulatory Commission Region III 799 Roosevelt Road Glen Ellyn, IL 60137

Dear Mr. Keppler:

Attached to this letter is our response to the SALP 5 Board Report for the D. C. Cock Nuclear Plant Unit Nos. 1 and 2 dated January 13, 1986.

This report covers the period April 1, 1984 through September 30, 1985.

The concerns identified in the December 13, 1985 Special D. C. Cook Operational History Evaluation have also been considered in this response.

Because the items discussed in the Operational History Evaluation and the SALP report are very similar we have addressed both in one response. In addition to the actions described in the attachments to this letter, we have instituted the specific actions described below to provido a more active involvement between our management and the NRC. Firs.t, we are requesting the attendance of the NRR and Region III at quarterly senior management meetings with D. C. Cook and AEPSC staff. The def. ails of these meetings are being developed by our licensing personnel. Second, our licensing personnel will confer, by teleconference, with the NRR and Region III on a weekly basis, or as often as may be necessary and appropriate. It is anticipated that these weekly telephone conferences between the NRR, Region III, and our licensing personnel will provide topics for discussion and resolution at our quarterly top management meetings.

We are also developing a Consolidated Trend Program (CTP). We plan to use CTP to focus our management on programmatic weaknesses and to direct management's attention to prompt resolution of identified adverse conditions. More details on this program are provided in the attachment to this letter.

We believe the corrective actions and enhancements that have been initiated as described in this report indicate that prompt management attention has been focused on the NRC's concerns. A strong foundation has been established to improve regulatory performance at the D. C. Cook Plant.

We firmly believe that the NRC will see improved operational and regulatory performance throughout the next SALP evaluation period.

8605060244 860502 PDR ADOCK 05000315 MAR a 1986 G PDR

Mr. James G. K*ppler AEP:NRC:0973 This document has been prepared following Corporate procedures which incorporate a reasonable set of controls to insure its accuracy and completeness prior to signature by the undersigned.

Very truly yours, M. P. A-exich q (,

Vice President 3d Cm Attachments cc: John E. Dolan W. G. Smith, Jr. - Bridgman R. C. Callen G. Bruchmann G. Charnoff NRC Resident Inspector - Bridgman

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ATTACHMENT TO AEP:NRC:0973 FADICLOGICAL CCNTROLS, REFUELING, QUALITY PROGRAMS AND ADMINISTRATIVE CONTROLS, SURVEILLANCE AND SECURITY RESPCNSES TO THE SALP 5 BOARD REPORT

Mr. James G. Kappler Attachment Page 1 of 11 RADIOLOGICAL CONTROLS During this SALP evaluation period, it was of concern to management that the overall perfcrmance in the Radiological Control area was evaluated as declining. As a result, we have initiated a performance enhancement program, previously presented to the NRC with the exception of item No. 7, on October 3, 1985, that will improve our performance in the areas of radiation protection, radioactive waste management, radiochemistry and radiological work practices. This performance enhancement program and the initial results, where possible, are discussed below.

1. Beginning November 1, 1985, all radiation protection supervisors were required to oversee daily radiation protection activities for at least 40% of their time. One measure of the success of this activity is the confirmation of correct boundary posting.

Independent radiation surveys performed by management have indicated that radiation areas are being correctly posted.

2. Concurrently with increasing supervisory field time, a program of Radiation Deficiency Reporting (RDR) was begun. This reporting system, intended to identify weaknesses and, whenever possible, correct ieproperly performed activities on-the-spot, has produced approximately four hundred reports. This number gives two observations: First, plant personnel are becoming increasingly aware of the types of problems encountered in daily work activities, and second, upper management, who reviews the RDRs, are also being made aware of those problems. The RDR system provides a formal mechanism for trending deficiencies, correcting deficiencies as they occur, and reporting them to upper level management. A measure of the success of this activity is that an increasing amount of RDRs are being labeled "no further action," ie., the workers response indicated an understanding of his error and correct practice in the future.

3. Joint Corpc tce and Plant teams continue reviewing radiation procedures .ad plant practices. In additien, the Corporate Radiation Support Section reviews and assesses the operational performance of the plant Radiation Protection practices and reports their findings to management. We believe direct Corporate-Plant interface will improve the quality of procedures and lessen the potential for programmatic breakdown. Our reviews have resulted in the reassessment of radiation monitoring system setpoints calculations thus reducing spurious ESF actuations.

4. Training is another vital part of our enhancement program.

Personnel who had not received the accredited practical training and/or demonstrated proficiency in radiological work practices have now been trained and have demonstrated competence in radiation protection practices. Also, the Plant Training Organization, with the support of the Radiation Protection staff, are in the process of developing an INPo accredited performance based Radiation Protection training program. This program will be completed by July 1, 1986. This formal training will include

l h Mr. Jcmes G. Kappler 'Attachmont Page 2 of 11 3 systems training to the extent that, with regard to radiation protection, the technician will be knowledgeable about the operation of identified systems. The total training requirement will include over two hundred identified skills and tasks.

5. A policy to control the storage of radioactively contaminated material within controlled areas has been implemented.. This action prevents unauthorized additions or alterations to, radioactive material in a storage area by assuring ownership of the area. In keeping with this policy, areas used for decontaminated material and material release areas have also been identified and clearly marked, and kept to a minimum. Temporary storage areas used for equipment storage have been reduced. The success of this policy is clearly demonstrated: As of Eeptember 30, 1985, there were 17,278 square feet of contaminated hallway which includes 4,709 square feet of contaminated equipment storage areas -- by February 14, 1986 these figures had been i reduced to 7,451 square feet and 2,467 square feet respectively.

It is anticipated that the upcoming Unit 2 refueling outage will temporarily increase the actual number of square feet of contaminated area, but we feel this will be tempered by the fact that previously uncontrolled areas will be controlled when established.

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6. A study was initiated to determine if the requirements of NUREG-0737 Sections II.B.3 and II.F.1 Attachments 1, 2 and 3 have been addressed. The Compliance Analysis Report (Phase Il to evaluate the status of our ccmpliance with these NUREG-0737 Sections was completed in September of 1985. An action item tracking system was established for all open items for which the ,

status had not been completely identified. A Phase II report will contain documentation of all the open items identified in Phase I. For those open items requiring hardware or equipment modifications a schedule will be established by July 31, 1986.

Items not requiring hardware changes are scheduled to be '

completed by July 31, 1986.

7. We are taking a much closer look at skin and clothing contaminations and their reportability to the NRC. Cur goal is to reduce, by 50%, total skin contamination identified as greater than 100 cpm by frisker. We will evaluate our goal by comparing data from the third quarter of 1986 to the same quarter of 1985.

We believe that our skin contamination data appears high because of our strict administrative limits on reporting this data. For example, we have recently upgraded our normal access portal monitor to one that is capable of identifying 25 nano curies of radioactive material contamination, compared to the previous portal monitor limit of 250 nano curies. We would expect then, to have a greater number of portal monitor alarms even though the former 250 nano curie portal monitor was adequate to detect contamination of a worker.

We are undertaking a study to be completed by August 1,1986, of

! other PWR licensee skin contamination reporting levels. We will -

investigate steps to make our reporting levels consistent with I industry practice. We will however, maintain our current

conservative " administrative" level.

o Mr. JemGs G. Keppler Attachment Page 3 of 11 EEFUELING We are disappointed that we did not maintain our previcus Category 1 rating in this area, and our goal is to return to such a rating for the next evaluatien period.

We have inntituted corrective actions in the following areas to improve our refueling performance.

1. We have committed to upgrade our refueling procedures to insure that signoffs for work accomplished in various locations are coordinated through one master copy starting with the 1986 Unit 2 refueling outage. We will work with our refueling contractor to consolidate required signatures. Acequate documentation and signature verification will be maintained.

2. We have modified our spent fuel pool bridge crane position indicator to insure accurate indexing. This modification eliminates the human factors concern which contributed to the mispositioned Auel referred to in the SALP report.

3. We have developed administrative controls (e.g. tags for control room switches) to minimize the potential for a breach of containment during refueling, and cther events of this type. We agree that the prompt identification and correction of a containment valve misalignment furnished evidence of management involvement.

We believe that these enhancements to our refueling program along with the cited evidence of prior planning, proper understanding and implementation of plant procedures, appropriate post-work reviews and tests, continued control over the refueling contractor, and increased control over loose objects indicate a positive attitude by our management in the refueling area. We also believe that we can return to a Category 1 rating in this area in the next evaluation period which includes a complex planned refueling involving control red guide tube split pin replacement.

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4 Mr. James G. K2ppler Attachmsnt ,

Paga 4 of 11 -

QUALITY PROGRAMS AND ADMINISTRATIVE CONTROLS The SALP report and the NRC special evaluation of the Cook Plant operating history for the period January 1983 t' rough September 1985 addressed two concerns with respect to Quality Programs and Administrative controls. These concerns were procedural adherence and ineffective ccrrective action. Programs and enhancements, as described below, are being developed to improve performance in these areas of concern.

Procedural Adherence The AEPSC Quality Assurance Department is preparing a training video tape on the subject of procedural adherence. This tape will be shown to on-site personnel, including temporary craf t personnel, and to corporate support personnel. The general subjects to be addressed area why do we have procedures; the reasons that procedures must be followed as written; what to do, or what not to do if a procedure is wrongs what to do if following a procedural as written will cause preblems; who is responsible for procedural adherence; who is responsible for assuring procedural adherence; and the consequences to the employee, the employee's supervisor, fellow employees, and the company, that lack of procedural adherence can cause.

The D. C. Cook Plant Manager has issued to plant supervisory personnel, the policy with respect to adherence to procedures. The AEPSC Vice Chairman - Engineering and Construction has issued a similar policy which reaf firms the plant manager's policy. These policies emphasize the importance of adhering to procedures and our respensibilities for assuring procedural adherence. The Vice Chairman's policy will be distributed to corporate support personnel and site personnel.

In addition to regularly scheduled audits, inprocess verifications and inspections, the Quality Assurance and Quality Control departments will continue random, unannounced surveillances of work in progress to monitor procedural adherence. If it is perceived that there are continuing deviations from the established procedural adherence policy, a stop work order will be issued. The stop work order will remain in effect until the responsible department supervision ascertains that sufficient controls are in place to assure that the procedure will be complied with or properly changed.

Corrective Action Several efforts are under way to: enhance and streamline the corrective action programs; reduce the current backlog of open Condition Reports; and preclude future backlogs. These actions are described in our previous responses to NRC reports.

Mr. James G. Kappler Attachment Page 5 of 11 As of February 28, 1985 (NRC report 315/316/85007), there were 2131 open Condition Reports (CR). As of February 15, 1986, 3298 CRs had been closed cuts however, there were 2296 new CRs initiated during this time period. Therefore there are approximately 1129 CRs currently cpen.

Revisions have been made to the CR procedure to enhance prccessing and closecut activities. In the past, many CRs have been generated which are not reflective of adverse or uncontrolled conditions. For example, CRs were written for planned entry into a Technical Specification Action

. Statement; poor housekeeping personnel problems industrial safety items; other events / concerns of a nonsafety-related nature that can be corrected by Jcb Orders etc. New criteria will be in place in the near future which define when the initiation of a CR is required and not required.

Events / concerns where another avenue for administrative action is available will be pursued outside the CR system, where appropriate. A meeting with NRR and Region III is tentatively scheduled for early April,1986 to discuss the new criteria for initiating CRs.

We intend to use the new criteria to finalize a corporate wide corrective actions program. Under this new program events / problems will be screened for safety significance. Those deemed to be of safety significance per new definition will be assigned to the responsible depa'rtment for immediate investigation, administrative action, and reporting (if required). This new program will focus attention on items of safety significance thereby assuring that none are overlooked or hidden by the larger number of nonsignificant items.

A Consolidated Trend Program (CTP) is also being developed and is discussed in detail below. One feature planned for the STP will be prompt feedback to management cencerning the timeliness of corrective actions for identified problems. This feedback would aid management in applying proper direction to assure timely resolution of problems.

The AEPSC Action Item Tracking System (AIT) is used to track, among other items, responses to the NRC and commitments made to the NRC. The j ,

procedure which controls the AIT has been revised to incorporate new

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- c controls to preclude overdue items.

An AIT Overdue List is generated twice a month. If an item appears on l v two consecutive Overdue Lists, AEPSC QA issues a Noncompliance Report to

the responsible party. In March, 1985, there were 112 items listed as

! overdue, many of which were overdue by more than one month. As of February 21, 1986, there were 10 items shown on the overdue list, all of which were l first-time listings.

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. Trending i The D. C. Cook Plant Consolidated Trend Program (CTP) is being developed to provide prompt feedback to management when certain activities indicate a decline in expected performance. The program will be composed of an integrated system of collecting and maintaining data, monitoring and l

'. Mr. James G. Keppler Attachment Page 6 of 11 reporting performance, and assuring necessary corrective actions. The program addresses the following major plant topics:

- personnel safety and protection

- nuclear safety

- quality management

- regulatory compliance

- plant efficiency

- equipment efficiency Additional topics may be added or details created to make the best use of information.

Five components of the program arer

- data accumulation

- data entry and maintenance

- data analysis

- data reporting

- corrective action The administration of these components will be controlled by procedures to ensure that information is properly collected, entered and maintained in a computer, analyzed and reported.

Three essential controls of the CTP will be the administrative procedures to assure data integrity, the Trends Guide and the Corrective Actions Guide. The Trends Guide will describe the purpose of individual trends, .how they are to be interpreted, and acceptable or expected trend performance. The Corrective Actions Guide will specify how adverse trends are to be controlled to assure timely and effective adjustments to programmatic deficiencies.

Development of the program involves an assessment of the current trend activities performed by plant and corporate groups. This assessment is near completion and will help to identify controls for data sources.

Additionally, the computer resources (equipment and personnel) used in current trend activities are being assessed for potential applications in the CTP.

Based on the initial conclusions of the assessment we have drafted a list of trends. This list identifies the priorities for developing the trends to be included in the CTP. A meeting is tentatively set for early April, 1986 with NRR and Region III to discuss the CTP, the corrective action guide (discussed above), and the list of priorities. We are continuing to develop the CTP and will adjust our efforts based on the results of the April meeting. The critical path item in developing an effective CTP appears to be the development of a computer system (hardware and software). This critical path item is discussed below with the other key milestone items:

Assessing Past Trends April 38, 1986 Develop Corrective Action Plan May 30, 1986 I

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. Mr. James G. Kcppler Attechm3nt- Page 7 of 11 Assess Best Computer Options (1) o Task Group Proposal to Management Establish Administrative Procedures (1) o Source Data Control o Trend Generation (initial data loading and final Trends Report format)

Develop Trend Guide (1)

First CTP Report Issued (1)

Remaining schedule to be established by April 30, 1986.

(Contingent upon software development schedule)

Need to evaluate what historical data will be loaded.

Management Assessments We have recently visited two nuclear sites which the NRC has rated as SALP 1 in many areas. We evaluated their corrective action practices, onsite review committee methods, and security administration controls. We are using this shared knowledge to identify more efficient and effective ways to administer D. C. Cook Plant activities. Much of this knowledge is being applied to our proposed Corrective Action Program and Plant Nuclear Safety Review Committee revisions that will be discussed in the April, 1986 NRR/ Region III/D. C. Cook ceeting. The potential for significantly reducing the administrative burden on our security force by redefining the plant protective areas was also reviewed:during one of cur visits. The concept of such an undertaking will also be discussed in the April, 198G NRR/ Region III/D. C. Cook meeting.

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- Mr. James G. Kappler Attachment Page 8 of 11 SURVEILLANCE The SALP report concluded that, in general, D. C. Cook exhibited a negative trend during this assessment period with respect to procedural and personnel errors in the area of surveillance. As noted in the SALP report, several Regulatory Performance Improvement Program (RPIP) activities took place during this period which were targeted to reduce these types of errors. RPIP resulted in a major revamping of D. C. Cook surveillance procedures. We believe this large scale procedural revision had an immediate negative effect with respect to the above mentioned errors. This belief is further confirmed by the high number of change sheets for these procedures (as high as approximately 100 per week) at the beginning of the SALP period. However, we are now emerging from this adjustment period and change sheets number on the order of 20 to 25 per week for these procedures. We expect to see a reduction in the number of Condition Reports associated with procedures during the present SALP period. To ,

further enhance our performance during this SALP period, and in response to the NRC recommendations, the following actions have been or are being

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taken: ,

1. A thorough review of the technical specification (T/S) table entries was made to assure our procedures adequately reflect the surveillance requirements, e.g., test frequency, sensor calibraticn. Based on this review we have made adjustments to our procedures to accommodate both our findings and those of the NRC.

2. As part of our normal two year review cycle we are revising those surveillance procedures which may cause entry into a T/S action statement. The procedures, when revised, will alert the person that certain procedural actions may cause entry into an action statement, or that an action statement has been entered and a time limit has been imposed.

3. We have initiated a T/S simplification program that we believe has the potential to significantly reduce nuisance ondition Reports due to attempting to literally comply with T/Ss. As acknowledged by both NRR and Region III staff members, our Technical Specifications are not conducive to literal compliance.

Therefore, we plan to have our simplification program provide (1) interim ways to assure safe operation even though our T/Ss may not be explicitly clear, (2) necessary information to the NRC when questionable interpretations are being administered, and (3) long term plans for revising Technical Specifications without unnecessarily burdening NRC and D. C. Cook staffs. These provisions, we believe, will assist us in our goal of increasing supervisors' time for in plant activities by eliminating unnecessary meetings called to review various drafts of proposed Technical Specification changes.

4. During our normal surveillance procedure reviews we are emphasizing equipment and system operability by carefully reviewing those portions of the procedures that restore the equipment and components to a fully operable condition.

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, Mr. Jtm:s G. Kepplcr Attachment Page 9 of 11

5. During our most recent semi-annual review cf staffing requirements at D. C. Cook, additional positions in the maintenance area were approved. In addition, special consideration will also be given to the surveillance area during the next semi-annual staffing review. We believe these steps will aid in reducing staff workload, distributing tasks more evenly, and increasing management efficiency.

6. As part of cur procedure upgrade program we are strengthening our communication between various organizations by adjusting the precedures to identify interface areas. These procedures will provide for signed acknowledgements in the implenenting portion of the procedure to indicate that the interface portion has been acccmplished. In addition, department head signoffs will be required for procedures that have departmental interface.

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6 Mr. James G. Kappler Attachment Page 10 of 11 SECURITY Management recognizes the need for increased attention to security matters.

The NRC concerns in the areas of access control, management control and training are being aggressively pursued by management.

One major step taken towards improving our security programs as a whole was the recruiting and hiring of a new Security Manager. Since his employment in December 1985, he has initiated programmatic changes and completed several outstanding action items. Upon arrival, he immediately reorganized the contract security group, reducing shift schedules from twelve to eight hours thereby reducing guard fatigue and enhancing guard alertness. He revised the existing lesson plans on search pat down procedures and retrained 100% of security personnel on the procedure (with the exception of two guards on medical leave who will not be allowed to return to work until they have completed the retraining.) The Security Manager conducted a surveillance of search pat downs and concluded that the training had improved performance.

The Security Manager has also addressed equipment problems. He has replaced the existing metal detectors, resulting in a reduction in the nuisance alarm rate from approximately one in five to one in thirty. The

' new metal detectors have improved shielding devices which aid in reducing spurious alarms caused by a nearby metal detector or from electro-magnetic interference from the motor unit. These detectors also have improved discriminator circuits. False alarm rates on security doors have also been addressed. We are evaluating each door and have been taking the appropriate action which has reduced the false alarm rate by approximately 50%.

Administrative changes initiated by the Security Manager to ensure increased attenti6n to security matters include the addition of several levels of management: 1) an Administrative Compliance Coordinator has been appointed to assure that the responses to audits and Condition Reports are timely and that an adequate notice of completion is sent, 2) contract security agency lieutenants have been trained for assuming total supervisory responsibility for their shift. An evaluation has been conducted by the Security Manager and the contract security agency Site Manager to assure that the lieutenants are aware of their new duties and prepared to accept the new responsibility and 3) Assistant Access Control Supervisor, Security Investigator and Training Administrator positions are being developed to further enhance supervisory involvement in security matters.

These changes are designed to increase the contract security guards'

, attention, knowledge and alertness, and to more effectively use available management personnel. Continuing this goal, a number of programs and action items to be completed by the end of 1986 have also been planned.

These programs include:

1. By April 30, 1986, we will review and submit a complete revision to the Suitability Training and Qualification Plan (STQP) , the Contingency Plan'and the Safeguards Security Plan to achieve clarity, eliminate redundancies and inconsistencies, and to make these documents more efficient.

. Mr. James. G. K:ppler Attachm:nt Page 11 of 11 I

2. By April 30, 1966 we will prepare an STQP implementing procedure.

This procedure will provide a place for evaluation standards, will commit to a lesson plan review and will provide a place for an independent qualification record thus assuring management review.

3. By May 1, 1966 new position descriptions for Administrative Compliance Coordinator, Assistant Access Control Supervisor, Security Investigator, and Training Administrator will be implemented. This will bring ownership and specific responsibilities to the incumbents enhancing management control over these important security areas.

4. By June 30, 1986 we will review existing lesson plans to assure that they are complete. Simultaneously, lesson plans will be develeped, if necessary, to cover any unconsidered crucial tasks.

5. By October 31, 1986 we will develop an enhanced contractor audit program for the screening requirements of on-site contractor personnel.

These programs and changes are geared towards increasing the efficiency and organization of security matters. Increased supervision, increased management attention, and programmatic changes are intended to increase the awareness and attention to detail of security personnel. The General Security Employment Training Program and the plant newsletter advises security personnel of changes, enhancements and administrative controls in security areas. We firmly believe these enhancements to the security program will address past problems and build a foundation of aggressive security management.