ML20236U138

Submits Response to Violations Noted in Insp Rept 70-1151/96-204.Corrective Actions:Procedure RA-102 Revised to Formally Clarify Insp Policy by Specifically Including Need to Inspect for Process Upsets, Prior to 970531

ML20236U138
Person / Time
Site:	Westinghouse
Issue date:	07/21/1998
From:	Allen J WESTINGHOUSE ELECTRIC COMPANY, DIV OF CBS CORP.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
CON-NRC-98-030, CON-NRC-98-30 70-1151-96-204, NUDOCS 9807290326
Download: ML20236U138 (10)

Text

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Westinghouse Commercial Nuclear Drawa R Electric Corporation Fuel Division

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• 62 NRC-98-030 July 21,1998 l-

11. S. Nuclear Regulatory Commission A'ITN: Document Control Desk Washington, DC 20555 Gentlemen:

SUBJECT:

REPLY TO A NOTICE OF VIOLATION

REFERENCE:

REPORT NO: 70-1151/96-204 Pursuant to the provisions delineated in Section 2.201 of the NRC's " Rules of Practice," Part 2, Title 10, Code of Federal Regulations, Westinghouse herein provides formal response to your letter of June 9, 1997, regarding your inspection of the Columbia Fuel Fabrication Facility (CFFF) conducted during the l

period of December 16-20,1996.

Appendix A of this document addresses the circumstances under which a Reply to a Notice of Violation is being submitted over one year since the Notice was received; and, addresses the general nature of the response to the Notice.

Appendix B provides responses to the particular violations of NRC requirements specified in the Notice of Violation.

I hereby affirm that the statemena made in this response are true and correct to the best of my knowledge and belief. Should you have any questions or require additional information, please telephone Mr. Wilbur

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L. Goodwin of my Staff at (803) 776-2610 Ext. 3282.

Sincerely, h

WESTINGHOUSE ELECTRIC COMPANY k B. Allen, Plant Manager Columbia Fuel Fabrication Facility '

Attachments:

Appendix A and Appendix B cc:

U. S. Nuclear Regulatory Commission i

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l Regional Administrator, Region II Atlanta Federal Center 61 Forsyth Street, SW, Suite 23T85 Atlanta, Georgia 30303-3415 ADOC C

p 70-1151/96 204 Page 1 of 9 July 21',1998 l

APPENDIX A l

DISCUSSION OF THE RESPONSE

' BACKGROUND 4

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On December 16-20,1996, NRC Staff conducted an inspection of the Westinghouse Columbia l

Fuel Fabrication Facility (CFFF). Areas examined in the inspection included implementation of criticality safety requirements in operating facilities, the plant criticality accident alarm

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L system, and inspection, audit and self assessment programs as defined by the license. Within these areas, walkdowns of selected plant activities, procedure reviews, personnel interviews, and observation of a licensee self-inspection were conducted.

On January 23, 1997, Westinghouse was sent NRC Inspection Report 70-1151/%-204 and a Notice of Violations. The Report stated that it had been determined that CFFF was not adequately implementing some requirements of the facility license.

Four violations were identified in an enclosed Notice of Violation. The violations involved the failure to: 1) include reviews for procedural adequacy and ongoing process operations in the formal monthly audit program,2) document the purpose and objectives of the facility management self-assessment policy, 3) adequately trend items reported in the performance based reporting system, and 4) document and conduct process review inspections and audits in accordance with written

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On March 21,1997 (a date agreed upon by CFFF and NRC Staff, and documented in an NRC letter dated February 27,1977), Westinghouse submitted a Reply to the Notice of Violation with Inspection Report 70-1151/ % -204.

In the reply, Westinghouse disputed the four violations. Notwithstanding the disputes, Westinghouse provided a complete response to each of the violations, including; (1) the basis for disputing the violation; (2) the corrective steps that had been taken and the results achieved ("Immediate Action Taken and Results Achie'ced"); and, (3) the corrective steps that had been taken to avoid further violations

(" Actions to-Improve the Program").

Further, additional information to support the Westinghouse contention that the four violations had not occurred was submitted.

On June 9,1997, Westinghouse was sent a Reply to a Notice of Violations (NRC Inspection Report No. 70-1151/96 204).

The Reply' stated that, after careful consideration of the information provided by Westinghouse, Violation (1), (2), and (4) occurred as stated, and Violation (3) was withdrawn. Neither the cover letter to the NRC Staff denial nor the amended Inspection Report required a licensee response, and Westinghouse thus assumed that the March 21,~1997 response, with its immediate and preventive actions as previously discussed, had been deemed adequate.

On June 22-26, 1998, Inspection 70-1151/98-203 was conducted at CFFF. In the course of this inspection, the NRC Inspector disclosed that a response to amended Inspection Report 96-

, 70-1151/ % -204 Page 2 of 9 July 21,1998 204 would, in fact, be required. Subsequently, in Inspection Report No. 70-1151/98-203, dated July 7,1998, CFFF was given 30 days from June 24,1998 to provide the response.

FORMAT AND CONTENTS OF THE RESPONSE j

l Appendix B provides the amended response to Inspection Report %-204. The determined violations have been re-ordered (I, II, and IV) as was done in the amended Inspection Report:

i and, acknowledgment has been given that each violation has now been d:termined by NRC Staff to be correct. The original " Reason (s) for Disputing the Violation (s)" have been updated j

to " Reason (s) for the Violation (s)." The Original "Immediate Action (s) Taken and Results-Achieved" have been updated to include all actions [immediate and to improve the program (s)]

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that have been taken to date. A new section, " Actions to Prevent Recurrence," has been I

added to include relevant Safety Margin Improvement Program (SMIP) initiatives that are ongoing, and their scheduled completion dates. [These SMIP initiatives arose from the CFFF

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i Plant Manager directed " Regulatory Process Review Team" activities conducted late last year and earlier this year; and, reported to NRC Staff in letters dated December 12,1997 (RA-

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WLG-97-057) and April 17,1998 (NRC-98 014). Inspection Reports96-204, original and i

amended, were a specific part of the Team's review.] Finally, for each violation, a statement i

has been provided that full compliance has been achieved.

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In addition to the SMIP initiatives specific to each violation, there is one additional SMIP~

initiative that will serve to enhance response to the subject violations:

MANAGEMENT OVERSIGHT AND CONTROL The CFFF Manager, regulatory staff and Regulatory Compliance Committee (RCC) will review the organizational structure and leadership required to achieve and maintain full regulatory compliance, as well as, sustain an acceptable margin of safety. The formal organizational structure and staffing will be evaluated for effectiveness relative to ongoing regulatory compliance initiatives, current workload and assigned functional responsibilities. In addition, the informal structure and effectiveness of, and continued need for " process review" teams, one of which was recently formed to facilitate and expedite restoration of full regulatory compliance at the CFFF, will be scrutinized and re-evaluated. If the continued use of such teams is found to be appropriate, they will be chartered and assigned responsibilities by the CFFF manager.

Management oversight and control, and monitoring of progress for completion of these initiatives, as well as other ongoing initiatives and regulatory commitments, will be provided by the CFFF manager and RCC, using the existing SMIP and commitment tracking process.

Completion date: June 30,1998 i-Westinghouse believes these aggregate actions and commitments will meet NRC Staff l

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expectations for providing an adequate response to amended Inspection Report 96-204.

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, 70-1151'/ % -204 Page 3 of 9 July 21,1998 APPENDIX B WESTINGHOUSE RESPONSE TO NOTICE OF VIOLATION I.

The following information is provided in response to the Inspector's observations that

"...the monthly formal audit of the regulatory program performance conducted on December 17, 1996, under the guidance provided in RA-102, Regulatory Compliance Inspections, Revision 7, was inadequate in that process upsets and procedural inadequacies beyond those surfaced by simple paperwork reviews could not have been found since the auditor did not review procedural adequacy or ongoing process operations."

I.1 ACKNOWLEDGMENT OF THE VIOLATION The violation has been determined by NRC Staff to be correct as stated in the Notice of Violation.

I.2 -

REASON FOR THE VIOLATION Following approval of the SNM-1107 License Renewal on November 3,1995, the Regulatory Affairs Inspection Coordinator reviewed Procedure RA-102 and the formal monthly inspect!ons practice, and informally compared these with the license requirements.

R'e spcM/ic points regarding process upsets and procedural inadequacies were informally reviewed with the Inspection Coordinator's management.

Management informally agreed that the inspections, as they were being conducted, fulfilled the intent of the license and the expectations of Management; however, RA-102 did not specifically require " inspectors to look for process upsets and procedural inadequacies."

I.3 IMMEDIATE ACTION TAKEN AND RESULTS ACHIEVED On January 24, 1997, the Manager of Regulatory Affairs issued a letter to the Regulatory Affairs Inspection Coordinator, formally clarifying management expectations with respect to paragraph 3.6.1 (b) of the license.

Prior to May 31, 1997, Procedure RA-102 was revised to formally clarify the inspection policy by specifically including the need to inspect for " process upsets" and

" procedural inadequacies."

I.4 ACTIONS TO PREVENT RECURRENCE A Safety Margin Improvement Program (SMIP) initiative is in progress to:

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July 21,1998

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ENHANCE COMPLIANCE QUALITY ASSURANCE l

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" Process" Chapters 1, 2, 3, 4,11 and 12 of the CFFF SNM-1107 License i

Application will be formally " translated" to document how the commitments will be implemented. " Program" Chapters 5, 7, 8, 9 and 10 of the CFFF SNM-1107 License Application will be cross-referenced to applicable implementing procedures. Chapter 6, Nuclear Criticality Safety, of the CFFF SNM-1107 License Application will be re-written as necessary to clearly reflect exactly how the program is being implemented to meet NRC Staff expectations; then, will be cross-referenced to applicable implementing procedures.

Schedules for independent internal and external compliance quality audits will be developed and implemented. A methodology for Regulatory Compliance Committee (RCC) review of compliance quality audit findings and recommendations, including documented tracking to closure, will be developed and implemented.

Completion date: December 31,1998 The " translation" of Chapter 3 of SNM-1107, independent internal and external compliance quality audits, and RCC review and tracking of audit findings and recommendations will prevent recurrence of this type of violation.

I.5 DATE WHEN FULL COMPLIANCE WILL BE ACHIEVED Full compliance has been achieved.

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Page 5 of 9

~ July 21,1998 II.

The following information is provided in response to the Inspector's observations that l

"as of December 20,1996, no written policy documented the purpose and objectives of i

the facility management self-asscasment program."

1I.1 '

ACKNOWLEDGMENT OF THE VIOLATION The violation has been determined by NRC Staff to be correct as stated in the Notice of Violation.

II.2 REASON FOR THE VIOLATION l

During the inspection, CFFF personnel could not locate the letter which was intended to implement Section 3.6.2 of the license. Subsequently, the letter dated January 15, 1992 from R. H. Koga, Columbia Plant Manager at that time, was found and submitted for NRC Staff review. This letter provided comprehensive guidance to assure proper internal reporting of events and NRC notification of unusual occurrences in accordance with license criteria in Section 3.6, " Audits and Self-Assessments"; however, it was inadequate in that it did not specifically state that it was documentation of Columbia Plant policy on the purpose and objectives of self-assessment to Component Managers, including aggressive demand for quality assessment performance.

II.3 IMMEDIATE ACTION TAKEN AND RESULTS ACHIEVED To reiterate the intent of the 1992 letter, on January 17, 1997, the Plant Manager (who is now Westinghouse Commercial Nuclear Fuel Division (CNFD) General _ Manager) formally reaffirmed and updated the long-standing Columbia Plant self-assessment commitment by documenting the Columbia Plant poliev ca the purpose and objectives of self-assessment to Component Managen, irmiuding aggressiee demand for quality assessment performance, thus attaining full compliance. This remains CFFF policy under the existing Plant Manager.

I Further, on Janury 29, 1997, the CFFF individual with principal responsibility for i

consolidation of the License Application completed and distributed, to cognizant l

Regulatory management and professional personnel, a detailed review of the Application's commitments with respect to " Audits and Self-Assessments," to assure that responsible individuals clearly understood the commitments.

II.4 ACTIONS TO PREVENT RECURRENCE A SMIP initiative is in progress to:

l ENHANCE RECORDKEEPING AND DOCUMENT CONTROL t-Regulatory records and documents will be maintained and controlled in accordance with written procedures.

Such documents and records will be

'70-1151/ % -204-

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Page 6 of 9 July 21,1998 indexed in a manner consistent with the goal of " prompt retrieval" (e.g., for timely response to NRC Staff requests, etc.).

l-l The process will begin with identifying documents and records for maintenance and retention. Then, procedures will be developed for document control and recordkeeping. Documented training in, and acknowledgment of,' regulatory document control and recordkeeping policies and procedures will round out the process. This program will be based upon " success-transfer," from how CFFF l

Product Assurance has so effectively controlled their documents and maintained their records, to the analogous regulatory document control /recordkeeping process.

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Completion date: July 31,1998 The indexing of regulatory documents in a manner consistent with the goal of prompt retrieval for timely response to NRC Staff requests, in combination with the SMIP initiative to Enhance Compliance Quality Assurance (previously described in response segment I.4), will prevent recurrence of this type of violation.

II.5.

DATE WHEN FULL COMPLIANCE WILL BE ACHIEVED Full compliance has been achieved.

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Page 7 of 9 July 21,1998 III.

Even though Violation III was withdrawn by NRC Staff, the following information is provided in response to the Inspector's observations that "during 1996, the Regulatory Component did not adequately sununarize and trend the items documented in the performance-based reporting system, and the RCC did not adequately review the summaries and trends. Specifically, RCC minutes for 1996 indicated that the only tiending of items consisted of the total number of reports broken down by one of four general process areas and did not include emerging probbms, declining performance areas, or root cause analysis."

III.1 ACKNOWLEDGMENT OF THE VIOLATION Not applicable.

III.2 REASON FOR THE VIOLATION Not applicable.

III.3 IMMEDIATE ACTION TAKEN AND RESULTS ACHIEVED Following receipt of the apparent violation, the documentation of performance-based reporting items was reviewed by the CFFF Regulatory Compliance Committee (RCC).

As a result of this review, it was decided that the reporting process did provide the RCC with sufficient information for assessment of this program. Notwithstanding, the

. Regulatory Component and RCC further conanitted to periodically review the entire self-assessment program to ensure that.it continued to meet license requirements and continued to provide the RCC with appropriate assessment information.

III.4 ACTIONS TO IMPROVE THE PROGRAM At the June 2,1998 RCC meeting, an action item was generated to develop a more structured RCC agenda. This led to a Standing Agenda that specifically directs RCC review of Self-Assessments of Regulatory Performance on a semi-annual frequency.

This review will substantially enhance RCC oversight of the CFFF self-assessment program.

III.5 DATE WHEN FULL COMPLIANCE WILL BE ACHIEVED l

Not applicable.

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. July 21,1998 IV.

' The following information is provided in response to the Inspector's observations that "between the date of license renewal and December 20, 1996, the process review inspections and audits were not conducted and documented in accordance with a written l

procedure in that no wrinen procedures had been developed and/cr implemented by the

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licensee."

IV.1 ACKNOWLEDGMENT OF THE VIOLATION The violation has been determined by NRC Staff to be correct as stated in the Notice of Violation.

IV.2 REASON FOR THE VIOLATION In 1994, before beginning a program of developing zero-based Criticality Safety Evaluations (CSE's) for the Columbia Plant, a formal document was developed l:

entitled, " Guidelines for Preparing a Criticality Safety Evaluation (Including Resource Estimates)." This document, approved by Plant Management (including the managers of Regulatory Affairs, Manufacturing, and Technical Services) on May 5,1994, specified the format and content of the CSE's for each process system. A synopsis of these " Guidelines..." is contained in Section 6.4.1(a-h) of License SNM-1107.

The schedule for preparation of the CSE's remaining to be completed after approval of License SNM-1107 was given in License Condition S-2.

These process reviews continued on schedule, and applicable reviews were completed in accordance with License Condition requirements. These CSE's were conducted and documented in accordance with the approved piocedure described previously.

Additional process reviews also took place on a continuing basis through two other means: 1) the Columbia Plant Configuration Control Program, governed by Procedure TA-500, and 2) other process reviews as directed by Management.

Westinghouse believed that these activities met the intent of the License commitment; however, the " Guidelines for Preparing a Criticality Safety Evaluation (Including Resource Estimates)" was apparently not provided to the inspectors by the responsible licensee representatives, nor identified at either the exit meeting or a February 25, 1997, conference call, as the procedure intended to meet the license requirement.

IV.3' IMMEDIATE ACTION TAKEN AND RESULTS ACHIEVED In response to the Inspector's observation, Regulatory Affairs Management re-reviewed I

the license requirements an re-confirmed that the ongoing CSE's and their written I

guidelines would fulfill the license commitment. In was further confirmed that these i

j reviews would be augmented by process reviews in accordance with the continuing i

CFI<F Configuration Management process (described in approved procedures RA-104 and TA-500); and would be followed by process reviews required by ongoing CFFF W

70-1151/ % -204

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July 21,1998 Integrated Safety Assessments (described in approved " Guidelines for Preparing a Baseline Integrated Safety Assessment).

These acdons assured annual process reviews through most of the year 2000.

IV.4 ACTIONS TO PREVENT RECURRENCE A SMIP initiative is in progress to:

ENHANCE REFLECTION OF LICENSE REQUIREMENTS IN ADMINISTRATIVE AND OPERATING PROCEDURF3 Applicable SNM-1107 license conditions will be evaluated, and their incorporation into policies and procedures will be assured by appropriate plant management prior to their required use. Such policies and procedure will clearly document how a license condition is being met without reliance on the informal judgments of individual plant personnel. Where written policies and procedures are required by the license, they will be developed and approved for use, and be available to the personnel responsible for their implementation.

Any assertion that a plant activity meets an explicit license condition will be supported by a policy or procedure.

The process will begin with gaining a common understanding of license commitments, as stated in the SNM-1107 License Application, required Plans, etc., (see SMIP initiative for " Enhance Compliance Quality Assurance").

Then, the requirements will be linked to, or reflected in, regulatory guidance procedures, policy manuals, handbooks, etc. Ultimately, such guidance will be linked to, or reflected in, appropriate operating procedures, quality control instructions, etc. Documented training in, and acknowledgment of, policies ~and procedures will round out the process. This program will also be based upon

" success-transfer," from how CFFF Product Assurance has so effectively reflected their requirements into administrative and operating procedures, to the analogous regulatory requirements / procedures process.

Completion date: December 31,1998 This action will assure license commitments (including process review inspections and audits) are conducted and documented in accordance with written procedures, and will thus prevent recurrence of this type of violation.

IV.5 DATE WHEN FULL COMPLIANCE WILL BE ACHIEVED Full compliance has been achieved.

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