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{{#Wiki_filter: | {{#Wiki_filter:0 Quality Directorate Audit Report WNP-2 Emergency Preparedness Audit Audit 296-01S April 3, 1996.Audit Dates: March 4, 1996 through March 25, 1996 Entrance Date: March 4, 1996 Exit Date: March 25, 1996 WASHINGTON PUBLIC POWER kN SUPPLY SYSTEM+>0~2q03b4 05000897 0 pDp ADO<~pDR)j | ||
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~ | ~mnb 0 QUALIIY DIRECTORATE AUDIT 296-018 TABLE OF CONTENTS Executive Summary I.Purpose and Scope H.Report Details Section 1.0 Emergency Plan and Implementing Procedures | ||
................... | ................... | ||
3 Section 1.1 Licensee On-Shift Responsibilities........................ | |||
3 Section 1.2 Staffing Adequacy................................. | |||
3 Section 1.3 Identification of Interfaces | |||
............................ | ............................ | ||
4 Section 1.4 Emergency Plan Implementing Procedures | |||
.................. | .................. | ||
4 Section 1.5 FSAR Alignment.................................. | |||
.................................. | 4 Section 2.0 Emergency Response Organization Training..................... | ||
4 Section 2.1 Emergency Response Organization Training................. | |||
4 Section 2.2 Offsite Agency Training.............................. | |||
5 Section 3.0 Readiness Testing-Exercises and Drills......;................ | |||
5 Section 3.1 Drill Observation.................................. | |||
5 Section 3.2 Drill and Exercise Program........................... | |||
6 Section 4.0 Facilities and Equipment................................. | |||
7 Section 4.1 Maintenance of Emergency Equipment..................... | |||
7 Section 4.2 Emergency Communications | |||
........................... | ........................... | ||
8 Section 5.0 Interfaces with State and Local Governments and Agencies............ | |||
8 Section 5.1 Interface Capability | |||
................................ | ................................ | ||
8 Section 5.2 Interviews with State and County Emergency Personnel9... | |||
Section 5.3 Emergency Decontamination Facility............... | |||
~~~~~' | ~~~~~'i 9~~~~~~~9 Section 6.0 Effectiveness of Previous Corrective Actions................... | ||
'. | '.9 Section 6.1 Emergency Preparedness Program Corrective Action Process.......9 Section 6.2 PER Corrective Action Review.....:.................. | ||
10 Section 6.3 Quality Audit Recommendations | |||
.. | ..Section 7.0 Other Audit Issues~~~~~~'e~~~~~~~~~~~~~~~10~~~~~~~~~~~~~~~~~~~~~~1 1 Appendix A Personnel Contacted During the Audit....................... | ||
12 Appendix B Additional Supporting Documentation........................ | |||
13 Appendix C References........................................ | |||
14 Appendix D Problem Evaluation Requests............................ | |||
15 | 15 QUALITY DIRECTORATE AUDIT 296%18 EXECUTIVF>>. | ||
==SUMMARY== | |||
An audit of the WNP-2 Emergency Preparedness Program is performed every twelve months as required by Technical Specification 6.25.2.8.f and 10CFR 50.54(t).Specific areas were assessed as required by NUREG 0654.Additionally, the effectiveness of previous corrective actions was assessed, and alignment of the program with licensing basis documents were reviewed.The Emergency Preparedness organization has continued to be responsive to Quality's questions and concerns.The Emergency Preparedness organization has continued to demonstrate a strong desire for self improvement, as illustrated by their performance of a self-assessment issued in February, 1996.The self-assessment identified several areas for enhancement which were reviewed by the audit team.Emergency Preparedness is urged to implement the recommendations. | |||
Several areas needing remedial actions were noted by the audit team during the observation of the training drill performed by Team D on March 8, 1996.Areas for improvement were primarily communications and procedure knowledge and use.One recommendation issued with this audit report is to initiate corrective actions relative to identified concerns.A second recommendation is issued to perform a follow-up Quality assessment on another drill after corrective actions are implemented. | |||
The WNP-2 Emergency Plan, which comprises Chapter 13.3 of the FSAR, was compared to other sections of the FSAR applicable to Emergency Preparedness and the specific implementing procedures. | |||
Discrepancies were noted, particularly in Chapter 12, Radiation Protection, of the FSAR.In one case, the method for processing TLDs was changed without first consulting the FSAR and processing'an FSAR Change Notice.These discrepancies resulted in the issuance of PER 296-0213.One PER and seven Quality Recommendations were issued as a result of audit activities. | |||
In addition, four"proper use" gold cards were issued during the course of the audit for commendable indivi ual perform ce.M.ter, Au it Team Lea er.J.ut, uperv sor, Qu ity Services~Adi Team F.J.Englebracht, Utility Loanee (Waterford 3)B.J.Hahn, Quality Technical Specialist S.S.Kim, Quality C.R.Madden, Radiation Protection J.C.Wiles, Quality 4 QUALITY DIRECTORATE AUDIT 296%18~~ | |||
Discrepancies | I.PUIU'OSE AND SCOPE This annual audit of Emergency Preparedness (EP)is required by Technical Specification 6.5.2.8.f and Title 10 of the Code of Federal Regulations, Part 50.54(t).Audit activities evaluated that the WNP-2 Emergency Preparedness Plan and implementing procedures included the requirements of 10CFR50, Appendix E and NUREG 0654.The following areas were assessed as required by NUREG 0654, Section II.P.9 and implemented in WNP-2 Emergency Plan, Section 8.3:~Emergency Response Organization Training~Readiness Testing-Exercises and Drills ,~Facilities and Equipment~Emergency Communications | ||
~Interfaces with State and Local Governments and Agencies Additionally, the effectiveness of previous Problem Evaluation Requests (PER)corrective actions was evaluated, focusing on Human Performance PERs.A review of the Licensing Basis documents was also performed to ensure alignment with actual practices. | |||
II.REPORT DETAILS SECTION 1.0 Emergency Plan and Implementing Procedures 1.1 Licensee On-Shift Responsibilities On-Shift responsibilities are adequately defined in the WNP-2 Emergency Plan (E-Plan).Section 2.2 clearly defines the responsibilities for emergency response.It states"The Shift Manager on duty has the immediate responsibility for the plant at all times, and has full authority and responsibility for recognizing and declaring emergencies." The Shift Manager initially assumes all duties and responsibilities of the Emergency Director and continues to serve in this capacity.until relieved by the TSC Manager or the EOF Manager as described in Section 2 of the E-Plan, paragraph 2.3.1.4.The guidance in PPM 13.10.1 to the Shift Manager in the event of an emergency is clear and easy to follow.1.2 Staffing Adequacy Adequate emergency staffing is maintained, but potential conflicts should be clarified. | |||
I.PUIU' | Shift staffing in modes 1, 2, and 3 appears to meet the requirements of NUREG 0654, table B1.By PPM 1.3.1, a Control Room Supervisor (CRS)is not required in modes 4 and 5.This may conflict with the Emergency Plan in that the CRS is designated to assume the Emergency Director duties should the Shift Manager not be available. | ||
Interviews with Emergency Response Organization (ERO)staff who formerly worked in the Operations Department indicated that there is always a CRS on shift QUAIIIV DIRECTORATE AUDIT 296%18'ven though the procedures and plans do not support this position.They stated that Technical Specifications do not require a CRS in modes 4 and 5, therefore, a decision was made not to include one in the staffing requirements for modes 4 and 5.This item will be discussed in further below in Section 1.5.On-site craft coverage is adequate but needs improvement. | |||
~Emergency Communications | During a four hour period between 0200 and 0600 no I&C or Electrical maintenance coverage is available on-site.If needed, the Shift Manager would call someone off site.This concern has been previously identified in the Emergency Preparedness Self-Assessment performed February, 1996.The Self-Assessment recommended that the minimum on-shift required staffing be identified. | ||
~Interfaces | Emergency Preparedness Manager stated that recommendations from the Self-Assessment will be implemented. | ||
II. | |||
===1.3 Identification=== | |||
of Interfaces Interfaces with supporting agencies and governments are adequately described in the Emergency Plan.The interfaces are illustrated in Table 1-1 of the Emergency Plan.Section 3 of the Emergency Plan specifies the coordination between State and Local governments as well as local agencies.Emergency Plans of supporting organizations are referenced in Appendix 1 of the E-Plan.Appendix 3 lists the agreement letters with local hospitals and government agencies.Additional details concerning interfaces are discussed in Section 5.0.1.4 Emergency Plan Implementing Procedures Selected implementing procedures were compared to the Emergency Plan and no discrepancies were noted.Section 2.3 of the Emergency Plan, Emergency Response Organization, identifies a team'concept consisting of four teams assigned duties on a rotating basis.General duties are also outlined in the Emergency Plan.Specific duties are discussed in detail in the Emergency Plan Implementing procedures (EPIP).A review of these procedures indicates that they are very detailed and clearly identify authorities and responsibilities. | |||
A checklist is provided to ensure that turnover of responsibilities is smooth and that all requirements are met.1.5 FSAR Alignment The Emergency Plan was compared to other sections of the FSAR as well as plant procedures to ensure alignment. | |||
Discrepancies were noted and resulted in PER 296-0213.Appendix D of this report describes the specific discrepancies in detail.SECTION 2.0 Emergency Response Organization Training 2.1 Emergency Response Organization Training The audit team reviewed the Personnel Qualification Database (PQD)and verified ERO members were qualified. | |||
The qualifications for ERO trainers were also verified.No discrepancies were noted. | |||
Interviews | 0 QUALITY DIRECTORATE AUDIT 296%18 2.2 Offsite Agency Training The audit team verified that training is offered to offsite agencies.Emergency Preparedness produced copies of letters offering training to offsite agencies.This was noted as an improvement from last year's audit where the training had not been offered.SECTION 3.0 Readiness Testing-Exercises and Drills 3.1 Drill Observation The audit team observed performance of the training drill conducted March 8, 1996 with ERO Team D.Audit members were stationed at the Emergency Offsite Facility (EOF), Technical Support Center (TSC), Operations Support Center (OSC), and Security Support Center (SSC).The Main Control Room and Joint Information Center (JIC)were not observed since their role was simulated. | ||
The audit team also observed and participated in the post-drill player critique at each location.Following the drill, the audit team identified concerns in communications issues, procedure knowledge and use issues, and hardware discrepancies. | |||
The concerns were evaluated and discussed with Emergency Preparedness to determine if any met the criteria for a PER.Both Quality and Emergency Preparedness agreed that these concerns were identified as part of a training drill which is designed, in part, to identify weaknesses. | |||
Had the same concerns been noted as part of the annual exercise, a PER would be necessary. | |||
Emergency Preparedness | Emergency Preparedness categorized the drill as"adequate, with issues".Significant issues are outlined below: ATI N~Announcement of the General Area Emergency (GAE)was made eleven minutes after the GAE was declared in the EOF.~Announcements for site and exclusion area evacuations were made following a considerable time lapse after the emergency classifications. | ||
1. | The Site Area Emergency was declared at 1253;Site Evacuation followed at 1309.The General Area Emergency was declared at 1313;the Exclusion Area Evacuation was announced at 1353.~The Classification Notification Form (CNF)for the General Emergency classification indicated an airborne and waterborne release even though indications did not support any release.~Plume maps were not sent to the outside agencies.~One of the OSC Repair Teams was sent to work the wrong equipment piece number (EPN).PR ED E KN WLED E AND E~The TSC and OSC Managers did not use their respective procedures resulting in some elements not being performed. | ||
Emergency | ~Field teams were issued forms from outdated or deleted procedures. | ||
Additional | 0 QUALITY DIRECTORATE AUDIT 296%18~An outdated revision of PPM 13.5.5 was in the OSC.~Volume 5 PPMs were not available in the OSC.Habitability monitoring of the TSC and OSC was not initiated as required by PPM 13.10.10.E PMENT PR BLEMS~The air sampling kit used by Field Team SS-1 was missing the air.sample head.~The emergency public address announcements could not be heard by the repair team in the RW467 critical switchgear room.~The portable radios and batteries were not all charged for field team use.Additionally, the audit team noted that there were several key players that were new on Team D.Also, new drill members are expected to replace certain key players after June, 1996.New players will need additional training to bring them up to the caliber of a seasoned participant. | ||
Quality also noted that some players had not attended all or part of the training session held prior to the drill.The following Quality Recommendations are issued to resolve these concerns: QUALITY RECOMMENDATION AU296-018-A InNate actions to correct concerns identjPed by Quality during observation of the March 8, 1996 training drill for Team D.QUALITY RECOMMENDATION AU296-018-B Perform a follow up assessment of the effectiveness of corrective actions implemented per Quality Recommendation AU296-018-A. | |||
Discrepancies | 3.2 Drill and Exercise Program The audit team compared the Emergency Preparedness Program Six Year Plan to the wording of the Emergency Plan objectives to the objectives contained in NUREG 0654.Most of the objectives contained in the six year plan are a summary of the applicable NUREG requirements. | ||
In some cases, what appears to be important information is not included in the Six Year Plan objectives. | |||
One example is the NUREG requirement for the field teams to demonstrate the ability to take soil and water samples.The audit team reviewed Controller/Evaluator Event Logs, Player Comment Forms, and Objective Evaluation Forms generated during the September 7, 1995, Emergency Drill and the October 11, 1995 Emergency Exercise.This documentation review indicated that the annual demonstration of water sampling was not performed in 1995.In addition, the vegetation sampling performed during the September Drill was not conducted fully in accordance with procedures, and no vegetative sampling was performed during the October Exercise. | |||
QUALITY DIRECTORATE AUDIT 29%18 Concerns with sampling were discussed with the EP Manager who stated that the Supply System program is not committed to the exact wording of the objectives contained in NUREG-0654. | |||
The EP Manager's position is that the Supply System is committed to the positions and objectives as stated in the Emergency Preparedness Plan.The Plan is reviewed and approved by the NRC and, as such, establishes how the Supply System meets the requirements of NUREG 0654.The audit team reviewed player and evaluator comments from the drill and exercise performed in 1995.There does not appear to be a formal method in place to track and resolve concerns.An interview with the lead Emergency Planner indicated that in past years the drill issues were tracked as a punch list in a Word Perfect file.He was not sure that was done during 1995.In the past the lead controHers for each area would go over all the player and evaluator comments and decide which were necessary to resolve.The lead Emergency Planner indicated that probably didn't happen in 1995.Drill weakness were identified from previous drills that had not been resolved.The audit team communicated concern to the Emergency Preparedness Manager regarding implementing corrective actions for identified Drill and Exercise deficiencies. | |||
Emergency Preparedness | He stated this concern had been identified in the Self-assessment and EP had decided to track all drill/exercise deficiencies on the Plant Tracking Log (PTL)data base system.EP personnel are scheduled to receive training on the PTL system during the first week of April.Based on self-identification of the weakness and in-process corrective actions, no Quality finding was issued.SECTION 4.0 Facilities and Equipment 4.1 Maintenance of Emergency Equipment PPM 13.14.4,"Emergency Equipment" (rev 20), was reviewed against the activities listed in PASSPORT to assure all emergency equipment is routinely inventoried or maintained. | ||
A worksheet describing the activity is printed from PASSPORT, the worker signs the sheet after performing the work, and the worksheets are maintained as quality records for compliance to the procedure requirements. | |||
In general, it is difficult to identify the activities in PPM 13.14.4 as they are listed in PASSPORT.This is a repeat concern from the 1995 audit.EP personnel indicated they had established cross references, but the procedure had been revised and the references renumbered. | |||
Following | As a result the following Quality Recommendation is issued to develop a cross reference of PASSPORT activities to PPM 13.14.4: | ||
0 QUALITY DIRECI'ORATE AUDlT 296418 QUALITY RECOMM<2DDATION AU296-018-C Establish a cross reference of PASSPORT activities to PPM 13.14.4 attachments. | |||
Additionally, PASSPORT indicated that HEPA and Carbon filter testing for the TSC and EOF HVAC are performed according to predefined tasks in PASSPORT.This testing is not referenced in PPM 13.14.4.The procedures for testing the units do not reference the TSC or EOF equipment, or require notifying EP in the event the unit does not meet it s acceptance criteria (PPMs 10.2.82, 10.2.83, and 10.2.39).The following Quality Recommendation is issued to address these items: QUALITY RECOMMENDATION AU296-018-D Revise the following procedures to reference the TSC and EOF HVAC equipment. | |||
Emergency Preparedness categorized | Add a note to notify EP jf the equipment does not meet acceptance criteria.PPM 10.2.39-"Pre-Filter, HEPA Filter, and Carbon Absorber Changeout" PPM 10.2.82-"HEPA Fdter In-Place Testing" PPM 10.2.83-"Carbon Filter In-Place Testing" Quality observed inventory activities for the Decontamination Trailer, Headquarters Protective Clothing Kit, Air Sampling Kit, Instrumentation Kit, and River Evacuation Monitoring Kit.The worker was very conscientious in performing the tasks, even going beyond the procedural requirements by verifying battery voltage.Emergency supplies at the'local hospitals were inspected by the audit team in accordance with PPM 13.14.4, Attachment 6.3..PER 295-0294 from the 1995 EP audit noted that radiation protection instruments inspected on 2/2/95 had calibration due dates of 4/1/95, but were not replaced.Based on this 1996 inspection, corrective actions were found effective in preventing recurrence. | ||
4.2 Emergency Communications Emergency Preparedness had requested the audit team assess the readiness of Emergency Communications ability to operate following a severe natural event in preparation to NRC Temporary Instruction 2515/131,"Licensee Offsite Communication Capability". | |||
~ | Adequate hardware and administrative provisions for prompt communication to principal response organizations, emergency response personnel, and the public were noted by the audit team.Redundant equipment is available to provide communication capability in case one system is lost.The Telecommunications organization has reviewed the NRC Temporary Instruction and is currently working on answering the specific questions. | ||
~ | SECTION 5.0 Interfaces with State and Local Governments and Agencies 5.1 Interface CapabBity The audit team observed the training drill conducted on March 8, 1996.During the drill, the auditor observed that the facsimile machine was operated as required for transmitting information to offsite organizations. | ||
The Crash telephone system was also noted to operate as required.The Offsite Agency Coordinator was using PPM 13.4.1 guidance to notify offsite agencies of drill emergency status using a telephone connected to a drill control cell.Following the drill, State of Washington emergency personnel were contacted to verify that the Classification Notification Forms had arrived at the State Emergency Center.5.2 Interviews with State and County Emergency Personnel Interviews were conducted with the Washington State Programs Management and Liaison Unit Manager, and a staff member of the Plans, Exercise, Education, and Training Unit.These personnel described the Supply System interface with the State as"excellent". | |||
Personnel interfaces were strong and positive.The State Liaison felt they were kept well informed of drills and other training opportunities. | |||
Communications tests were conducted regularly, and consistently found in order./An interview with the Franklin County Emergency Director indicated similar support for the Supply System Emergency Preparedness organization. | |||
The Director expressed appreciation for the assistance provided by Supply System Emergency Preparedness personnel during the recent Emergency Center activation resulting from local flooding.The interfaces with offsite agencies was noted as a strength during the audit.5.3 Emergency Decontamination Facility The Memorandum of Understanding (MOU)between Supply System and HEHF for use of the Emergency Decontamination Facility (EDF)was reviewed.It initially appeared from the MOU that the Supply System was to"...be responsible for all decontamination" which could include external and internal decontamination of personnel. | |||
3. | The auditor questioned if Supply System personnel were qualified for internal decontamination methodology. | ||
Based on subsequent discussions with HEHF personnel and Supply System Emergency Planners the wording was agreed to indicate that the Supply System had legal and financial responsibility for decontamination, but HEHF would provide the expertise. | |||
It was further agreed that the MOU intended for the Supply System to perform decontamination of the EDF after an event.Emergency Preparedness should consider rewording the MOU to more clearly define responsibilities. | |||
A walkthrough of the EDF was conducted with HEHF personnel. | |||
The facility is maintained by HEHF and is kept ready to support Supply System emergency events.A wall chart was noted in several locations as an aid to quickly administer the most effective chelate or purgative for the more common radionuclides expected from nuclear facilities in this region.SECTION 6.0 Effectiveness of Previous Corrective Actions 6.1 Emergency Preparedness Program Corrective Action Process The audit team review of the EP Program corrective action process defined in PPM 13.14.8,"Drill and Exercise Program" discovered that it is not consistent with the requirements contained in PPM 1.3.12,"Problem Evaluation Request". | |||
QUALITY DIRECTORATE AUDIT 296%18 PPM 13.14.8 requires the performance of a Root Cause Analysis to determine if a consideration should be given to writing a PER.This corrective. | |||
action process conflicts with the PER requirements contained in PPM 1.3.12.PPM 1.3.12 specifies that a PER shall be initiated for those significant problems defined in the procedure. | |||
Following PER initiation, a Root Cause Analysis is then performed in accordance with PPM 1.3.48.The following Quality Recommendation is issued to address the discrepancies between procedures: | |||
QUALITY RECOMlVEÃDATION 296-018-E Revise PPM 13.14.S corrective action process to align ivith PPM 1.3.12.6.2 PER Corrective Action Review Corrective actions associated with human performance issues were found to have been effectively implemented for the PERs reviewed.The audit team issued a"proper use" Gold Card to the Emergency Planner responsible for disposition of PER 295-0254 to commend the quality of the disposition and the timeliness of the corrective actions.There were no findings associated with NRC inspection reports reviewed during this audit.6.3 Quality Audit Recommendations Seven Quality Recommendations resulting from Quality Audit 295-018,"WNP-2 Emergency Preparedness Program," conducted between March 20 and April 7, 1995, were reviewed to determine if they were effectively implemented. | |||
The following Quality Recommendations resulting from last years EP Audit, 295-018, were not implemented, contrary to the recommendation responses received from the Emergency Preparedness Manager: Recommendation AU 295-018-E"Clarify Emergency Preparedness Plan definition of Annual to be calendar year for exercises. | |||
It is currently defined as twelve months.Also, a definition for Quarterly.and Monthly should be developed for more frequent drills." Recommendation AU 295-018-F"Revise the Emergency Preparedness Plan to require the backshift drills as specified in NUREG-0654 (six p.m.to midnight;midnight to six a.m., every six years)."'he recommendation responses from Emergency Preparedness committed personnel to perform several actions.However, the actions were never completed. | |||
Audit team discussions with'the Emergency Preparedness personnel indicated that they still feel the recommendations are valid and EP intends to implement them.Therefore, the following Quality Recommendation is issued: QUALITY RECO1VMENDATION 296-018-F Implement Quality Recommendations 29$-01S-E and 29$-01S-Il.The audit team did not find any indication that the failure to implement these recommendations resulted in degradation of the Emergency Preparedness Program.10 QUALITY DIRECTORATE AUDIT 296-018 SECTION 7.0 7.1 Other Audit Issues The audit team noted that the Quality Director serves on the Emergency Response Organization as the EOF Manager.This may conflict with the wording in the Operational Quality Assurance Program Description (OQAPD), Chapter 1, Section 13.2.1 which defines the responsibilities of the position as follows: "The Director, Quality, has effective communication channels with all Supply System senior management positions and has no duties or responsibilities unrelated to quality assurance." Discussions with the Quality Director and Licensing staff revealed no licensing basis document requirement for the wording.As such, the following recommendation is issued to clarify position responsibilities: | |||
QUALITY RECO1VMENDATION AU296-018-G Rezone OQ4PD, Chapter 1, Section 13.2.1, for Quality Director responsibilities. | |||
11 QU~DIRECTORATE AUDIT 296%18 APPENDIX A Personnel Contacted During the Audit g Unit Foundation H.L.Aeschliman, Emergency Planner+++Lyle Ball, Emergency Planner+W.H.Barley, ERO Team D++K.K.Cabral, HP Technician J.D.Carpenter, Manager, Telecommunications Services W.S, Davison, ERO Team D J.S.Flood, ERO Team D P.W.Harness, ERO Team D Chuck Hagerhjelm, State of Washington, Plans, Exercise, Education and Trainin M.P.Hedges, Drill Evaluator R.J.Hintz, Principal Health Physicist D.B.Holmes, Emergency Planner R.E.Jorgenson, Emergency Planner+++A.F.Klauss, Emergency Planner+J.A.Landon, Mechanical Craft Supervisor M.J.Mann, TSC Manager Sandi McInturff, Hanford Environmental Health Foundation Fernando Medina del Valle, Physicians Assistant, Hanford Environmental Health L.S.Morris, Drill Controller J.T.Nelson, HP Technician Dianne Offord, State of Washington, Programs Management and Liaison Unit J.F.Peters, Quality L.S.Peters, Quality, WNP-1 G.D.Phillips, HP Technician L.A.Pritchard, ERO Team D G.J.Reed, Emergency Preparedness Manager+++John Scheer, Franklin County Emergency Director W.D.Shaeffer, TSC Manager V.E.Shockley, ERO Team D J.L.Standley, Mechanic, J.M.Taylor, ERO Team D Maillian Uphaus, State of Washington, Programs Management and Liaison Unit R.L.Utter, Training Lead R.E.Welch, ERO Team D D.Wright, Facilities C.E.Young, Radiation Protection N.D.Zimmerman, Drill Controller | |||
Additionally, | +Attended Entrance Meeting++Attended Exit Meeting 12 e QUALITY DIRECTORATE AUDIT 296%18 APPENDIX B Additional Supporting Documentation Applicable Supporting Documentation will be maintained in the permanent audit files as part of the specific checklist questions to which it applies.13 QUALXIV DIRECTORATE AUDIT 296%18 APPENDIX C References 10CFR50.47, Emergency Plans 10CFR50.54, Conditions of Licenses 10CFR50, Appendix E, Emergency Planning and Preparedness for Production and Utilization Facilities NUREG 0654, FEMA REP-1, Rev.1;Criteria for Preparation and Evaluation of Radiological Emergency Response Plans and Preparedness in Support of Nuclear Power Plants;Section II.B WNP-2 Emergency Preparedness Plan, Rev 16 WNP-2 Emergency Preparedness Program Six Year Plan, October 26, 1995 1995 Dress Rehearsal Drill Report 1995 Evaluated Exercise Drill Report NRC Inspection Procedure 82301,"Evaluation of Exercises for Power Reactors" Drill and Exercise manual for WNP-2, Rev 2 EP Program Self-Assessment, February 29, 1995 EPPP-03, 01/26/96,"Maintaining the Six Year Plan" Volume 13 series of Emergency Plan Implementing Procedures 1995 Audit of Emergency Preparedness Program AU295-018 Memorandums of Understanding: | ||
Our Lady of Lourdes Hospital, Kadlec Medical Center, Kennewick General Hospital, DOE/HEHF, US FEMA Offsite Agency Phone Number List, Revision 28 NRC Temporary Instruction 2515/131,"Licensee Offsite Communication Capability" PASSPORT Predefined Database Completed PASSPORT Worksheets Work Orders: MS1601, MS1801, KZ8801, YV8401, YV8701 Problem Evaluation Requests (PERs): 295-285, 295-296, 295-286, 295-1188, 295-1231, 295-1010, 294-303, 295-254, a!ld 295-293 14 QUALITY DIRECTORATE AUDIT 296%18 APPENDIX D PROBLEM EVALUATION REQUESTS: PER 296-0213D-The foHowing discrepancies were noted in the Final Safety Analysis Report (FSAR): MER EN Y PREPARED PLA F AR Err r FSAR, Section 12.3.1.2-Traffic Patterns The description of the basic traffic flow for personnel entering the plant is incorrect. | |||
FSAR, Section 12.5.2.2 The description of the EOF backup chemistry area references an incorrect figure (10-8)in the Emergency Preparedness Plan.FSAR, Figure 12.5-1-EOF/PSF Floor Plans This figure does not reflect the last remodeling of the EOF.FSAR, Section 6.4.1 This section states that emergency supplies for the Control Room, TSC, and OSC will be provided by the TSC.The Control Room and the OSC now have their own supplies.FSAR, Section 12.1.1.1-Organization This section incorrectly states that the Safety Department reports to the Operations Directorate. | |||
FSAR, Section 12.1.2.1.r The process description for radwaste drums is not accurate.Emergency Preparedness Plan, Appendix 3 The Plan incorrectly states that two decontamination kits are located in the Service Building.Emergency Preparedness Plan, Section 2.3.1.5 This section states that a Control Room Supervisor is on shift, as required by Technical Specifications, to respond to the Emergency Plan.However, Technical Specifications and PPM 1.3.1 state that a CRS is not required in Modes 4 and 5.Emergency Plan, Section 6.2.8 Contrary to this section, the TLD processing equipment was outsourced to TMA/Eberline and removed from the Supply System external dosimetry area.In this example, changes in the Emergency Plan were implemented prior to the performance of a Licensing Basis Impact Determination and submittal of a SCN.Supply System contract C31087 was initiated with TMA/Eberline on September 25, 1995, to process personnel and REMP environmental TLDs.15 | |||
/QUALIIY DIRECTORATE AUDIT REPORT 296-018 WNP-2 EM<AGENCY PREPAREDNESS PROGRAM ri uti n JP Albers/927K JW Baker/1023 WH Barley/PE21 KM Gunter/PE21 BJ Hahn/PE21 SS Kim/PE21 GJ Kucera/130 DE McCauley/927R CR Madden/927H MM Monopoli/927S | |||
*JJ Muth/PE21 JV Parrish/1023 JF Peters/PE21 | |||
4. | *GJ Reed/1020 CJ Schwarz/9270 GO Smith/927M JH Swailes/PE27 DA Swank/PE20 RL Webring/1021 JC Wiles/PE21 | ||
.Q Routing Audit File 296-018 BK (3)*RESPONSE REQUBU<3)SEE AUDIT REPORT RECOMVXENDATIONS eQUALITY DIRECTORATE AUDIT 296%18 QA RECOMINFWDATION EVALUATION NUMBER: AU296-018 RECOMhQPlDATION MlMBER: AU296-018-A DATE: April 3, 1996 ORGANIZATION: | |||
Emergency Preparedness PERSON CONTACTED: | |||
G.J.Reed RESPONSE DUE DATE: June 3, 1996 AUTHOR: K.M.Gunter RECOMNO~22IDATION: | |||
The | Initiate actions to correct concerns identtji ed by Quality during observation of the March 8, 1996 quarterly training drill.RESPONSE:* | ||
Personnel interfaces | The response should address action to be taken and proposed completion date.If no action is deemed necessary, the logic for this conclusion should be presented. | ||
16 QUALITY DIRECTORATS AUDIT 296%18 QA RECOMNF~ATXON EVALUATION NUMBER: AU 296-018 RECOMMXNDATION NUMBER: AU296-018-B DATE: April 3, 1996 ORGANIZATION: | |||
Communications | Quality PERSON CONTACTED: | ||
W.H.Barley RESPONSE DUE DATE: June 3, 1996 AUTHOR: K.M.Gunter RECOMMENDATION: | |||
Perform a follow up assessment of the effectiveness of corrective actions implemented per Quality Recommendation AU255-018-A. | |||
Following | |||
conducted | |||
Discussions | |||
11 QU~DIRECTORATE | |||
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- | |||
FSAR, | |||
FSAR, | |||
FSAR, | |||
Emergency Preparedness Plan, | |||
Emergency Preparedness Plan, | |||
/ | |||
* | |||
* | |||
. | |||
Emergency Preparedness | |||
G.J. | |||
16 | |||
W.H. | |||
RESPONSE:* | RESPONSE:* | ||
F~ | F~e response should address action to be taken and proposed completion date.If no action is deemed necessary, the logic for this conclusion should be presented. | ||
17 | 17 QUALITY DIRECTORATE AUDIT 296-018 QA RECOMCEM)ATION EVALUATION NUMBER: AU296-018 RECOMM2$DATION NUMBER: AU296-018-C DATE: April 3, 1996 ORGANIZATION: | ||
Emergency Preparedness | Emergency Preparedness PERSON CONTACTED: | ||
D.B. | D.B.Holmes RESPONSE DUE DATE: June 3, 1996 AUTHOR: K.M.Gunter RECOMMPlDATIO¹ Establish a cross reference of PASSPORT activities to PPM 13.14.4 attachments. | ||
RESPONSE:* | RESPONSE:* | ||
* | *The response should address action to be taken and proposed completion date.If no action is deemed necessary, the logic for this conclusion should be presented. | ||
18 | 18 | ||
~.~ | ~.~QUALITY DIRECTORATE AUDIT 296418 QA RECOMMENDATION EVALUATION NUMBER: AU296-018 RECOMMENDATION NUMBER: AU296-018-D DATE: April 3, 1996 ORGANIZATION: | ||
Emergency Preparedness | Emergency Preparedness PERSON CONTACTED: | ||
D.B. | D.B.Holmes RESPONSE DUE DATE: June 3, 1996 AUTHOR: K.M.Gunter RECOMMENDATION: | ||
Revise the following procedures to reference the TSC and EOF HVAC equipment. | |||
Add a note to notify EP if the equipment does not meet acceptance criteria.PPM 10.2.39-"Pre-Filter, HEPA Filter, and Carbon Absorber Changeout PPM 10.2.82-"HEPA Filter In-Place Testing" PPM 10.2.83-"Carbon Filter In-Place Testing" RESPONSEP The response should address action to be taken and proposed completion date.If no action is deemed necessary, the logic for this conclusion should be presented. | |||
19 QUALITY DIRECTORATE AUDIT 296%18 QA RECOMNFKDATION EVALUATION NUMBER: AU296-018 RECOMMFADATION NUMBER: AU296-018-E DATE: April 3, 1996 ORGANIZATIO¹ Emergency Preparedness PERSON CONTACTED: | |||
19 | G.J.Reed RESPONSE DUE DATE: June 3, 1996 AUTHOR: J.C.Wiles RECOMMFADATIO¹ Revise PPM 13.14.8 corrective action process to align with PPM 1.3.12." RESPONSE:* | ||
G.J. | *The response should address action to be taken and proposed completion date.If no action is deemed necessary, the logic for this conclusion should be presented. | ||
* | |||
20 | 20 | ||
~~ | ~~QUALITY DIRECI'ORATE AUDIT 296%18 QA RECOMNEM)AYjON EVALUATION NUMBER: AU296-018 RECOMM<221DATION NUICBER: AU296-018-F DATE: April 3, 1996 ORGANIZATION: | ||
Emergency Preparedness | Emergency Preparedness PERSON CONTACTED: | ||
G.J. | G.J.Reed RESPONSE DUE DATE: June 3, 1996 AUTHOR: J.C.Wiles RECOMMENDATION: | ||
Implement | Implement Quality Recommendations 295-OI8-E and 295-018-F. | ||
RESPONSEP | RESPONSEP~e response should address action to be taken and proposed completion date.If no action is deemed necessary, the logic for this conclusion should be presented. | ||
~ | 21 QUALITY DIRECTORATE AUDIT 29618 QA RECOMMENDATION EVALUATION NUMBER: AU296-018 RECOMMENDATION NUMBER: AU296-018-G DATE: April 3, 1996 ORGANIZATION: | ||
21 | Quality PERSON CONTACTED: | ||
W.H.Barley RESPONSE DUE DATE: June 3, 1996 AUTHOR: K.M.Gunter RECOMMENDATION: | |||
W.H. | Reword OQAPD, Chapter 1, Section 13.2.1, for Qualiry Director responsibilities. | ||
RESPONSE*The response should address action to be taken and proposed completion date.If no action is deemed necessary, the logic for this conclusion should be presented. | |||
RESPONSE* | |||
22 0~~~+4'}} | 22 0~~~+4'}} | ||
Revision as of 12:35, 6 July 2018
| ML17292A148 | |
| Person / Time | |
|---|---|
| Site: | Columbia  |
| Issue date: | 04/03/1996 |
| From: | GUNTER, MUTH J J WASHINGTON PUBLIC POWER SUPPLY SYSTEM |
| To: | |
| Shared Package | |
| ML17292A146 | List: |
| References | |
| 296-018, 296-18, NUDOCS 9604290364 | |
| Download: ML17292A148 (27) | |
Text
0 Quality Directorate Audit Report WNP-2 Emergency Preparedness Audit Audit 296-01S April 3, 1996.Audit Dates: March 4, 1996 through March 25, 1996 Entrance Date: March 4, 1996 Exit Date: March 25, 1996 WASHINGTON PUBLIC POWER kN SUPPLY SYSTEM+>0~2q03b4 05000897 0 pDp ADO<~pDR)j
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~mnb 0 QUALIIY DIRECTORATE AUDIT 296-018 TABLE OF CONTENTS Executive Summary I.Purpose and Scope H.Report Details Section 1.0 Emergency Plan and Implementing Procedures
...................
3 Section 1.1 Licensee On-Shift Responsibilities........................
3 Section 1.2 Staffing Adequacy.................................
3 Section 1.3 Identification of Interfaces
............................
4 Section 1.4 Emergency Plan Implementing Procedures
..................
4 Section 1.5 FSAR Alignment..................................
4 Section 2.0 Emergency Response Organization Training.....................
4 Section 2.1 Emergency Response Organization Training.................
4 Section 2.2 Offsite Agency Training..............................
5 Section 3.0 Readiness Testing-Exercises and Drills......;................
5 Section 3.1 Drill Observation..................................
5 Section 3.2 Drill and Exercise Program...........................
6 Section 4.0 Facilities and Equipment.................................
7 Section 4.1 Maintenance of Emergency Equipment.....................
7 Section 4.2 Emergency Communications
...........................
8 Section 5.0 Interfaces with State and Local Governments and Agencies............
8 Section 5.1 Interface Capability
................................
8 Section 5.2 Interviews with State and County Emergency Personnel9...
Section 5.3 Emergency Decontamination Facility...............
~~~~~'i 9~~~~~~~9 Section 6.0 Effectiveness of Previous Corrective Actions...................
'.9 Section 6.1 Emergency Preparedness Program Corrective Action Process.......9 Section 6.2 PER Corrective Action Review.....:..................
10 Section 6.3 Quality Audit Recommendations
..Section 7.0 Other Audit Issues~~~~~~'e~~~~~~~~~~~~~~~10~~~~~~~~~~~~~~~~~~~~~~1 1 Appendix A Personnel Contacted During the Audit.......................
12 Appendix B Additional Supporting Documentation........................
13 Appendix C References........................................
14 Appendix D Problem Evaluation Requests............................
15 QUALITY DIRECTORATE AUDIT 296%18 EXECUTIVF>>.
SUMMARY
An audit of the WNP-2 Emergency Preparedness Program is performed every twelve months as required by Technical Specification 6.25.2.8.f and 10CFR 50.54(t).Specific areas were assessed as required by NUREG 0654.Additionally, the effectiveness of previous corrective actions was assessed, and alignment of the program with licensing basis documents were reviewed.The Emergency Preparedness organization has continued to be responsive to Quality's questions and concerns.The Emergency Preparedness organization has continued to demonstrate a strong desire for self improvement, as illustrated by their performance of a self-assessment issued in February, 1996.The self-assessment identified several areas for enhancement which were reviewed by the audit team.Emergency Preparedness is urged to implement the recommendations.
Several areas needing remedial actions were noted by the audit team during the observation of the training drill performed by Team D on March 8, 1996.Areas for improvement were primarily communications and procedure knowledge and use.One recommendation issued with this audit report is to initiate corrective actions relative to identified concerns.A second recommendation is issued to perform a follow-up Quality assessment on another drill after corrective actions are implemented.
The WNP-2 Emergency Plan, which comprises Chapter 13.3 of the FSAR, was compared to other sections of the FSAR applicable to Emergency Preparedness and the specific implementing procedures.
Discrepancies were noted, particularly in Chapter 12, Radiation Protection, of the FSAR.In one case, the method for processing TLDs was changed without first consulting the FSAR and processing'an FSAR Change Notice.These discrepancies resulted in the issuance of PER 296-0213.One PER and seven Quality Recommendations were issued as a result of audit activities.
In addition, four"proper use" gold cards were issued during the course of the audit for commendable indivi ual perform ce.M.ter, Au it Team Lea er.J.ut, uperv sor, Qu ity Services~Adi Team F.J.Englebracht, Utility Loanee (Waterford 3)B.J.Hahn, Quality Technical Specialist S.S.Kim, Quality C.R.Madden, Radiation Protection J.C.Wiles, Quality 4 QUALITY DIRECTORATE AUDIT 296%18~~
I.PUIU'OSE AND SCOPE This annual audit of Emergency Preparedness (EP)is required by Technical Specification 6.5.2.8.f and Title 10 of the Code of Federal Regulations, Part 50.54(t).Audit activities evaluated that the WNP-2 Emergency Preparedness Plan and implementing procedures included the requirements of 10CFR50, Appendix E and NUREG 0654.The following areas were assessed as required by NUREG 0654,Section II.P.9 and implemented in WNP-2 Emergency Plan, Section 8.3:~Emergency Response Organization Training~Readiness Testing-Exercises and Drills ,~Facilities and Equipment~Emergency Communications
~Interfaces with State and Local Governments and Agencies Additionally, the effectiveness of previous Problem Evaluation Requests (PER)corrective actions was evaluated, focusing on Human Performance PERs.A review of the Licensing Basis documents was also performed to ensure alignment with actual practices.
II.REPORT DETAILS SECTION 1.0 Emergency Plan and Implementing Procedures 1.1 Licensee On-Shift Responsibilities On-Shift responsibilities are adequately defined in the WNP-2 Emergency Plan (E-Plan).Section 2.2 clearly defines the responsibilities for emergency response.It states"The Shift Manager on duty has the immediate responsibility for the plant at all times, and has full authority and responsibility for recognizing and declaring emergencies." The Shift Manager initially assumes all duties and responsibilities of the Emergency Director and continues to serve in this capacity.until relieved by the TSC Manager or the EOF Manager as described in Section 2 of the E-Plan, paragraph 2.3.1.4.The guidance in PPM 13.10.1 to the Shift Manager in the event of an emergency is clear and easy to follow.1.2 Staffing Adequacy Adequate emergency staffing is maintained, but potential conflicts should be clarified.
Shift staffing in modes 1, 2, and 3 appears to meet the requirements of NUREG 0654, table B1.By PPM 1.3.1, a Control Room Supervisor (CRS)is not required in modes 4 and 5.This may conflict with the Emergency Plan in that the CRS is designated to assume the Emergency Director duties should the Shift Manager not be available.
Interviews with Emergency Response Organization (ERO)staff who formerly worked in the Operations Department indicated that there is always a CRS on shift QUAIIIV DIRECTORATE AUDIT 296%18'ven though the procedures and plans do not support this position.They stated that Technical Specifications do not require a CRS in modes 4 and 5, therefore, a decision was made not to include one in the staffing requirements for modes 4 and 5.This item will be discussed in further below in Section 1.5.On-site craft coverage is adequate but needs improvement.
During a four hour period between 0200 and 0600 no I&C or Electrical maintenance coverage is available on-site.If needed, the Shift Manager would call someone off site.This concern has been previously identified in the Emergency Preparedness Self-Assessment performed February, 1996.The Self-Assessment recommended that the minimum on-shift required staffing be identified.
Emergency Preparedness Manager stated that recommendations from the Self-Assessment will be implemented.
1.3 Identification
of Interfaces Interfaces with supporting agencies and governments are adequately described in the Emergency Plan.The interfaces are illustrated in Table 1-1 of the Emergency Plan.Section 3 of the Emergency Plan specifies the coordination between State and Local governments as well as local agencies.Emergency Plans of supporting organizations are referenced in Appendix 1 of the E-Plan.Appendix 3 lists the agreement letters with local hospitals and government agencies.Additional details concerning interfaces are discussed in Section 5.0.1.4 Emergency Plan Implementing Procedures Selected implementing procedures were compared to the Emergency Plan and no discrepancies were noted.Section 2.3 of the Emergency Plan, Emergency Response Organization, identifies a team'concept consisting of four teams assigned duties on a rotating basis.General duties are also outlined in the Emergency Plan.Specific duties are discussed in detail in the Emergency Plan Implementing procedures (EPIP).A review of these procedures indicates that they are very detailed and clearly identify authorities and responsibilities.
A checklist is provided to ensure that turnover of responsibilities is smooth and that all requirements are met.1.5 FSAR Alignment The Emergency Plan was compared to other sections of the FSAR as well as plant procedures to ensure alignment.
Discrepancies were noted and resulted in PER 296-0213.Appendix D of this report describes the specific discrepancies in detail.SECTION 2.0 Emergency Response Organization Training 2.1 Emergency Response Organization Training The audit team reviewed the Personnel Qualification Database (PQD)and verified ERO members were qualified.
The qualifications for ERO trainers were also verified.No discrepancies were noted.
0 QUALITY DIRECTORATE AUDIT 296%18 2.2 Offsite Agency Training The audit team verified that training is offered to offsite agencies.Emergency Preparedness produced copies of letters offering training to offsite agencies.This was noted as an improvement from last year's audit where the training had not been offered.SECTION 3.0 Readiness Testing-Exercises and Drills 3.1 Drill Observation The audit team observed performance of the training drill conducted March 8, 1996 with ERO Team D.Audit members were stationed at the Emergency Offsite Facility (EOF), Technical Support Center (TSC), Operations Support Center (OSC), and Security Support Center (SSC).The Main Control Room and Joint Information Center (JIC)were not observed since their role was simulated.
The audit team also observed and participated in the post-drill player critique at each location.Following the drill, the audit team identified concerns in communications issues, procedure knowledge and use issues, and hardware discrepancies.
The concerns were evaluated and discussed with Emergency Preparedness to determine if any met the criteria for a PER.Both Quality and Emergency Preparedness agreed that these concerns were identified as part of a training drill which is designed, in part, to identify weaknesses.
Had the same concerns been noted as part of the annual exercise, a PER would be necessary.
Emergency Preparedness categorized the drill as"adequate, with issues".Significant issues are outlined below: ATI N~Announcement of the General Area Emergency (GAE)was made eleven minutes after the GAE was declared in the EOF.~Announcements for site and exclusion area evacuations were made following a considerable time lapse after the emergency classifications.
The Site Area Emergency was declared at 1253;Site Evacuation followed at 1309.The General Area Emergency was declared at 1313;the Exclusion Area Evacuation was announced at 1353.~The Classification Notification Form (CNF)for the General Emergency classification indicated an airborne and waterborne release even though indications did not support any release.~Plume maps were not sent to the outside agencies.~One of the OSC Repair Teams was sent to work the wrong equipment piece number (EPN).PR ED E KN WLED E AND E~The TSC and OSC Managers did not use their respective procedures resulting in some elements not being performed.
~Field teams were issued forms from outdated or deleted procedures.
0 QUALITY DIRECTORATE AUDIT 296%18~An outdated revision of PPM 13.5.5 was in the OSC.~Volume 5 PPMs were not available in the OSC.Habitability monitoring of the TSC and OSC was not initiated as required by PPM 13.10.10.E PMENT PR BLEMS~The air sampling kit used by Field Team SS-1 was missing the air.sample head.~The emergency public address announcements could not be heard by the repair team in the RW467 critical switchgear room.~The portable radios and batteries were not all charged for field team use.Additionally, the audit team noted that there were several key players that were new on Team D.Also, new drill members are expected to replace certain key players after June, 1996.New players will need additional training to bring them up to the caliber of a seasoned participant.
Quality also noted that some players had not attended all or part of the training session held prior to the drill.The following Quality Recommendations are issued to resolve these concerns: QUALITY RECOMMENDATION AU296-018-A InNate actions to correct concerns identjPed by Quality during observation of the March 8, 1996 training drill for Team D.QUALITY RECOMMENDATION AU296-018-B Perform a follow up assessment of the effectiveness of corrective actions implemented per Quality Recommendation AU296-018-A.
3.2 Drill and Exercise Program The audit team compared the Emergency Preparedness Program Six Year Plan to the wording of the Emergency Plan objectives to the objectives contained in NUREG 0654.Most of the objectives contained in the six year plan are a summary of the applicable NUREG requirements.
In some cases, what appears to be important information is not included in the Six Year Plan objectives.
One example is the NUREG requirement for the field teams to demonstrate the ability to take soil and water samples.The audit team reviewed Controller/Evaluator Event Logs, Player Comment Forms, and Objective Evaluation Forms generated during the September 7, 1995, Emergency Drill and the October 11, 1995 Emergency Exercise.This documentation review indicated that the annual demonstration of water sampling was not performed in 1995.In addition, the vegetation sampling performed during the September Drill was not conducted fully in accordance with procedures, and no vegetative sampling was performed during the October Exercise.
QUALITY DIRECTORATE AUDIT 29%18 Concerns with sampling were discussed with the EP Manager who stated that the Supply System program is not committed to the exact wording of the objectives contained in NUREG-0654.
The EP Manager's position is that the Supply System is committed to the positions and objectives as stated in the Emergency Preparedness Plan.The Plan is reviewed and approved by the NRC and, as such, establishes how the Supply System meets the requirements of NUREG 0654.The audit team reviewed player and evaluator comments from the drill and exercise performed in 1995.There does not appear to be a formal method in place to track and resolve concerns.An interview with the lead Emergency Planner indicated that in past years the drill issues were tracked as a punch list in a Word Perfect file.He was not sure that was done during 1995.In the past the lead controHers for each area would go over all the player and evaluator comments and decide which were necessary to resolve.The lead Emergency Planner indicated that probably didn't happen in 1995.Drill weakness were identified from previous drills that had not been resolved.The audit team communicated concern to the Emergency Preparedness Manager regarding implementing corrective actions for identified Drill and Exercise deficiencies.
He stated this concern had been identified in the Self-assessment and EP had decided to track all drill/exercise deficiencies on the Plant Tracking Log (PTL)data base system.EP personnel are scheduled to receive training on the PTL system during the first week of April.Based on self-identification of the weakness and in-process corrective actions, no Quality finding was issued.SECTION 4.0 Facilities and Equipment 4.1 Maintenance of Emergency Equipment PPM 13.14.4,"Emergency Equipment" (rev 20), was reviewed against the activities listed in PASSPORT to assure all emergency equipment is routinely inventoried or maintained.
A worksheet describing the activity is printed from PASSPORT, the worker signs the sheet after performing the work, and the worksheets are maintained as quality records for compliance to the procedure requirements.
In general, it is difficult to identify the activities in PPM 13.14.4 as they are listed in PASSPORT.This is a repeat concern from the 1995 audit.EP personnel indicated they had established cross references, but the procedure had been revised and the references renumbered.
As a result the following Quality Recommendation is issued to develop a cross reference of PASSPORT activities to PPM 13.14.4:
0 QUALITY DIRECI'ORATE AUDlT 296418 QUALITY RECOMM<2DDATION AU296-018-C Establish a cross reference of PASSPORT activities to PPM 13.14.4 attachments.
Additionally, PASSPORT indicated that HEPA and Carbon filter testing for the TSC and EOF HVAC are performed according to predefined tasks in PASSPORT.This testing is not referenced in PPM 13.14.4.The procedures for testing the units do not reference the TSC or EOF equipment, or require notifying EP in the event the unit does not meet it s acceptance criteria (PPMs 10.2.82, 10.2.83, and 10.2.39).The following Quality Recommendation is issued to address these items: QUALITY RECOMMENDATION AU296-018-D Revise the following procedures to reference the TSC and EOF HVAC equipment.
Add a note to notify EP jf the equipment does not meet acceptance criteria.PPM 10.2.39-"Pre-Filter, HEPA Filter, and Carbon Absorber Changeout" PPM 10.2.82-"HEPA Fdter In-Place Testing" PPM 10.2.83-"Carbon Filter In-Place Testing" Quality observed inventory activities for the Decontamination Trailer, Headquarters Protective Clothing Kit, Air Sampling Kit, Instrumentation Kit, and River Evacuation Monitoring Kit.The worker was very conscientious in performing the tasks, even going beyond the procedural requirements by verifying battery voltage.Emergency supplies at the'local hospitals were inspected by the audit team in accordance with PPM 13.14.4, Attachment 6.3..PER 295-0294 from the 1995 EP audit noted that radiation protection instruments inspected on 2/2/95 had calibration due dates of 4/1/95, but were not replaced.Based on this 1996 inspection, corrective actions were found effective in preventing recurrence.
4.2 Emergency Communications Emergency Preparedness had requested the audit team assess the readiness of Emergency Communications ability to operate following a severe natural event in preparation to NRC Temporary Instruction 2515/131,"Licensee Offsite Communication Capability".
Adequate hardware and administrative provisions for prompt communication to principal response organizations, emergency response personnel, and the public were noted by the audit team.Redundant equipment is available to provide communication capability in case one system is lost.The Telecommunications organization has reviewed the NRC Temporary Instruction and is currently working on answering the specific questions.
SECTION 5.0 Interfaces with State and Local Governments and Agencies 5.1 Interface CapabBity The audit team observed the training drill conducted on March 8, 1996.During the drill, the auditor observed that the facsimile machine was operated as required for transmitting information to offsite organizations.
The Crash telephone system was also noted to operate as required.The Offsite Agency Coordinator was using PPM 13.4.1 guidance to notify offsite agencies of drill emergency status using a telephone connected to a drill control cell.Following the drill, State of Washington emergency personnel were contacted to verify that the Classification Notification Forms had arrived at the State Emergency Center.5.2 Interviews with State and County Emergency Personnel Interviews were conducted with the Washington State Programs Management and Liaison Unit Manager, and a staff member of the Plans, Exercise, Education, and Training Unit.These personnel described the Supply System interface with the State as"excellent".
Personnel interfaces were strong and positive.The State Liaison felt they were kept well informed of drills and other training opportunities.
Communications tests were conducted regularly, and consistently found in order./An interview with the Franklin County Emergency Director indicated similar support for the Supply System Emergency Preparedness organization.
The Director expressed appreciation for the assistance provided by Supply System Emergency Preparedness personnel during the recent Emergency Center activation resulting from local flooding.The interfaces with offsite agencies was noted as a strength during the audit.5.3 Emergency Decontamination Facility The Memorandum of Understanding (MOU)between Supply System and HEHF for use of the Emergency Decontamination Facility (EDF)was reviewed.It initially appeared from the MOU that the Supply System was to"...be responsible for all decontamination" which could include external and internal decontamination of personnel.
The auditor questioned if Supply System personnel were qualified for internal decontamination methodology.
Based on subsequent discussions with HEHF personnel and Supply System Emergency Planners the wording was agreed to indicate that the Supply System had legal and financial responsibility for decontamination, but HEHF would provide the expertise.
It was further agreed that the MOU intended for the Supply System to perform decontamination of the EDF after an event.Emergency Preparedness should consider rewording the MOU to more clearly define responsibilities.
A walkthrough of the EDF was conducted with HEHF personnel.
The facility is maintained by HEHF and is kept ready to support Supply System emergency events.A wall chart was noted in several locations as an aid to quickly administer the most effective chelate or purgative for the more common radionuclides expected from nuclear facilities in this region.SECTION 6.0 Effectiveness of Previous Corrective Actions 6.1 Emergency Preparedness Program Corrective Action Process The audit team review of the EP Program corrective action process defined in PPM 13.14.8,"Drill and Exercise Program" discovered that it is not consistent with the requirements contained in PPM 1.3.12,"Problem Evaluation Request".
QUALITY DIRECTORATE AUDIT 296%18 PPM 13.14.8 requires the performance of a Root Cause Analysis to determine if a consideration should be given to writing a PER.This corrective.
action process conflicts with the PER requirements contained in PPM 1.3.12.PPM 1.3.12 specifies that a PER shall be initiated for those significant problems defined in the procedure.
Following PER initiation, a Root Cause Analysis is then performed in accordance with PPM 1.3.48.The following Quality Recommendation is issued to address the discrepancies between procedures:
QUALITY RECOMlVEÃDATION 296-018-E Revise PPM 13.14.S corrective action process to align ivith PPM 1.3.12.6.2 PER Corrective Action Review Corrective actions associated with human performance issues were found to have been effectively implemented for the PERs reviewed.The audit team issued a"proper use" Gold Card to the Emergency Planner responsible for disposition of PER 295-0254 to commend the quality of the disposition and the timeliness of the corrective actions.There were no findings associated with NRC inspection reports reviewed during this audit.6.3 Quality Audit Recommendations Seven Quality Recommendations resulting from Quality Audit 295-018,"WNP-2 Emergency Preparedness Program," conducted between March 20 and April 7, 1995, were reviewed to determine if they were effectively implemented.
The following Quality Recommendations resulting from last years EP Audit, 295-018, were not implemented, contrary to the recommendation responses received from the Emergency Preparedness Manager: Recommendation AU 295-018-E"Clarify Emergency Preparedness Plan definition of Annual to be calendar year for exercises.
It is currently defined as twelve months.Also, a definition for Quarterly.and Monthly should be developed for more frequent drills." Recommendation AU 295-018-F"Revise the Emergency Preparedness Plan to require the backshift drills as specified in NUREG-0654 (six p.m.to midnight;midnight to six a.m., every six years)."'he recommendation responses from Emergency Preparedness committed personnel to perform several actions.However, the actions were never completed.
Audit team discussions with'the Emergency Preparedness personnel indicated that they still feel the recommendations are valid and EP intends to implement them.Therefore, the following Quality Recommendation is issued: QUALITY RECO1VMENDATION 296-018-F Implement Quality Recommendations 29$-01S-E and 29$-01S-Il.The audit team did not find any indication that the failure to implement these recommendations resulted in degradation of the Emergency Preparedness Program.10 QUALITY DIRECTORATE AUDIT 296-018 SECTION 7.0 7.1 Other Audit Issues The audit team noted that the Quality Director serves on the Emergency Response Organization as the EOF Manager.This may conflict with the wording in the Operational Quality Assurance Program Description (OQAPD), Chapter 1, Section 13.2.1 which defines the responsibilities of the position as follows: "The Director, Quality, has effective communication channels with all Supply System senior management positions and has no duties or responsibilities unrelated to quality assurance." Discussions with the Quality Director and Licensing staff revealed no licensing basis document requirement for the wording.As such, the following recommendation is issued to clarify position responsibilities:
QUALITY RECO1VMENDATION AU296-018-G Rezone OQ4PD, Chapter 1, Section 13.2.1, for Quality Director responsibilities.
11 QU~DIRECTORATE AUDIT 296%18 APPENDIX A Personnel Contacted During the Audit g Unit Foundation H.L.Aeschliman, Emergency Planner+++Lyle Ball, Emergency Planner+W.H.Barley, ERO Team D++K.K.Cabral, HP Technician J.D.Carpenter, Manager, Telecommunications Services W.S, Davison, ERO Team D J.S.Flood, ERO Team D P.W.Harness, ERO Team D Chuck Hagerhjelm, State of Washington, Plans, Exercise, Education and Trainin M.P.Hedges, Drill Evaluator R.J.Hintz, Principal Health Physicist D.B.Holmes, Emergency Planner R.E.Jorgenson, Emergency Planner+++A.F.Klauss, Emergency Planner+J.A.Landon, Mechanical Craft Supervisor M.J.Mann, TSC Manager Sandi McInturff, Hanford Environmental Health Foundation Fernando Medina del Valle, Physicians Assistant, Hanford Environmental Health L.S.Morris, Drill Controller J.T.Nelson, HP Technician Dianne Offord, State of Washington, Programs Management and Liaison Unit J.F.Peters, Quality L.S.Peters, Quality, WNP-1 G.D.Phillips, HP Technician L.A.Pritchard, ERO Team D G.J.Reed, Emergency Preparedness Manager+++John Scheer, Franklin County Emergency Director W.D.Shaeffer, TSC Manager V.E.Shockley, ERO Team D J.L.Standley, Mechanic, J.M.Taylor, ERO Team D Maillian Uphaus, State of Washington, Programs Management and Liaison Unit R.L.Utter, Training Lead R.E.Welch, ERO Team D D.Wright, Facilities C.E.Young, Radiation Protection N.D.Zimmerman, Drill Controller
+Attended Entrance Meeting++Attended Exit Meeting 12 e QUALITY DIRECTORATE AUDIT 296%18 APPENDIX B Additional Supporting Documentation Applicable Supporting Documentation will be maintained in the permanent audit files as part of the specific checklist questions to which it applies.13 QUALXIV DIRECTORATE AUDIT 296%18 APPENDIX C References 10CFR50.47, Emergency Plans 10CFR50.54, Conditions of Licenses 10CFR50, Appendix E, Emergency Planning and Preparedness for Production and Utilization Facilities NUREG 0654, FEMA REP-1, Rev.1;Criteria for Preparation and Evaluation of Radiological Emergency Response Plans and Preparedness in Support of Nuclear Power Plants;Section II.B WNP-2 Emergency Preparedness Plan, Rev 16 WNP-2 Emergency Preparedness Program Six Year Plan, October 26, 1995 1995 Dress Rehearsal Drill Report 1995 Evaluated Exercise Drill Report NRC Inspection Procedure 82301,"Evaluation of Exercises for Power Reactors" Drill and Exercise manual for WNP-2, Rev 2 EP Program Self-Assessment, February 29, 1995 EPPP-03, 01/26/96,"Maintaining the Six Year Plan" Volume 13 series of Emergency Plan Implementing Procedures 1995 Audit of Emergency Preparedness Program AU295-018 Memorandums of Understanding:
Our Lady of Lourdes Hospital, Kadlec Medical Center, Kennewick General Hospital, DOE/HEHF, US FEMA Offsite Agency Phone Number List, Revision 28 NRC Temporary Instruction 2515/131,"Licensee Offsite Communication Capability" PASSPORT Predefined Database Completed PASSPORT Worksheets Work Orders: MS1601, MS1801, KZ8801, YV8401, YV8701 Problem Evaluation Requests (PERs): 295-285, 295-296, 295-286, 295-1188, 295-1231, 295-1010, 294-303, 295-254, a!ld 295-293 14 QUALITY DIRECTORATE AUDIT 296%18 APPENDIX D PROBLEM EVALUATION REQUESTS: PER 296-0213D-The foHowing discrepancies were noted in the Final Safety Analysis Report (FSAR): MER EN Y PREPARED PLA F AR Err r FSAR, Section 12.3.1.2-Traffic Patterns The description of the basic traffic flow for personnel entering the plant is incorrect.
FSAR, Section 12.5.2.2 The description of the EOF backup chemistry area references an incorrect figure (10-8)in the Emergency Preparedness Plan.FSAR, Figure 12.5-1-EOF/PSF Floor Plans This figure does not reflect the last remodeling of the EOF.FSAR, Section 6.4.1 This section states that emergency supplies for the Control Room, TSC, and OSC will be provided by the TSC.The Control Room and the OSC now have their own supplies.FSAR, Section 12.1.1.1-Organization This section incorrectly states that the Safety Department reports to the Operations Directorate.
FSAR, Section 12.1.2.1.r The process description for radwaste drums is not accurate.Emergency Preparedness Plan, Appendix 3 The Plan incorrectly states that two decontamination kits are located in the Service Building.Emergency Preparedness Plan, Section 2.3.1.5 This section states that a Control Room Supervisor is on shift, as required by Technical Specifications, to respond to the Emergency Plan.However, Technical Specifications and PPM 1.3.1 state that a CRS is not required in Modes 4 and 5.Emergency Plan, Section 6.2.8 Contrary to this section, the TLD processing equipment was outsourced to TMA/Eberline and removed from the Supply System external dosimetry area.In this example, changes in the Emergency Plan were implemented prior to the performance of a Licensing Basis Impact Determination and submittal of a SCN.Supply System contract C31087 was initiated with TMA/Eberline on September 25, 1995, to process personnel and REMP environmental TLDs.15
/QUALIIY DIRECTORATE AUDIT REPORT 296-018 WNP-2 EM<AGENCY PREPAREDNESS PROGRAM ri uti n JP Albers/927K JW Baker/1023 WH Barley/PE21 KM Gunter/PE21 BJ Hahn/PE21 SS Kim/PE21 GJ Kucera/130 DE McCauley/927R CR Madden/927H MM Monopoli/927S
- JJ Muth/PE21 JV Parrish/1023 JF Peters/PE21
- GJ Reed/1020 CJ Schwarz/9270 GO Smith/927M JH Swailes/PE27 DA Swank/PE20 RL Webring/1021 JC Wiles/PE21
.Q Routing Audit File 296-018 BK (3)*RESPONSE REQUBU<3)SEE AUDIT REPORT RECOMVXENDATIONS eQUALITY DIRECTORATE AUDIT 296%18 QA RECOMINFWDATION EVALUATION NUMBER: AU296-018 RECOMhQPlDATION MlMBER: AU296-018-A DATE: April 3, 1996 ORGANIZATION:
Emergency Preparedness PERSON CONTACTED:
G.J.Reed RESPONSE DUE DATE: June 3, 1996 AUTHOR: K.M.Gunter RECOMNO~22IDATION:
Initiate actions to correct concerns identtji ed by Quality during observation of the March 8, 1996 quarterly training drill.RESPONSE:*
The response should address action to be taken and proposed completion date.If no action is deemed necessary, the logic for this conclusion should be presented.
16 QUALITY DIRECTORATS AUDIT 296%18 QA RECOMNF~ATXON EVALUATION NUMBER: AU 296-018 RECOMMXNDATION NUMBER: AU296-018-B DATE: April 3, 1996 ORGANIZATION:
Quality PERSON CONTACTED:
W.H.Barley RESPONSE DUE DATE: June 3, 1996 AUTHOR: K.M.Gunter RECOMMENDATION:
Perform a follow up assessment of the effectiveness of corrective actions implemented per Quality Recommendation AU255-018-A.
RESPONSE:*
F~e response should address action to be taken and proposed completion date.If no action is deemed necessary, the logic for this conclusion should be presented.
17 QUALITY DIRECTORATE AUDIT 296-018 QA RECOMCEM)ATION EVALUATION NUMBER: AU296-018 RECOMM2$DATION NUMBER: AU296-018-C DATE: April 3, 1996 ORGANIZATION:
Emergency Preparedness PERSON CONTACTED:
D.B.Holmes RESPONSE DUE DATE: June 3, 1996 AUTHOR: K.M.Gunter RECOMMPlDATIO¹ Establish a cross reference of PASSPORT activities to PPM 13.14.4 attachments.
RESPONSE:*
- The response should address action to be taken and proposed completion date.If no action is deemed necessary, the logic for this conclusion should be presented.
18
~.~QUALITY DIRECTORATE AUDIT 296418 QA RECOMMENDATION EVALUATION NUMBER: AU296-018 RECOMMENDATION NUMBER: AU296-018-D DATE: April 3, 1996 ORGANIZATION:
Emergency Preparedness PERSON CONTACTED:
D.B.Holmes RESPONSE DUE DATE: June 3, 1996 AUTHOR: K.M.Gunter RECOMMENDATION:
Revise the following procedures to reference the TSC and EOF HVAC equipment.
Add a note to notify EP if the equipment does not meet acceptance criteria.PPM 10.2.39-"Pre-Filter, HEPA Filter, and Carbon Absorber Changeout PPM 10.2.82-"HEPA Filter In-Place Testing" PPM 10.2.83-"Carbon Filter In-Place Testing" RESPONSEP The response should address action to be taken and proposed completion date.If no action is deemed necessary, the logic for this conclusion should be presented.
19 QUALITY DIRECTORATE AUDIT 296%18 QA RECOMNFKDATION EVALUATION NUMBER: AU296-018 RECOMMFADATION NUMBER: AU296-018-E DATE: April 3, 1996 ORGANIZATIO¹ Emergency Preparedness PERSON CONTACTED:
G.J.Reed RESPONSE DUE DATE: June 3, 1996 AUTHOR: J.C.Wiles RECOMMFADATIO¹ Revise PPM 13.14.8 corrective action process to align with PPM 1.3.12." RESPONSE:*
- The response should address action to be taken and proposed completion date.If no action is deemed necessary, the logic for this conclusion should be presented.
20
~~QUALITY DIRECI'ORATE AUDIT 296%18 QA RECOMNEM)AYjON EVALUATION NUMBER: AU296-018 RECOMM<221DATION NUICBER: AU296-018-F DATE: April 3, 1996 ORGANIZATION:
Emergency Preparedness PERSON CONTACTED:
G.J.Reed RESPONSE DUE DATE: June 3, 1996 AUTHOR: J.C.Wiles RECOMMENDATION:
Implement Quality Recommendations 295-OI8-E and 295-018-F.
RESPONSEP~e response should address action to be taken and proposed completion date.If no action is deemed necessary, the logic for this conclusion should be presented.
21 QUALITY DIRECTORATE AUDIT 29618 QA RECOMMENDATION EVALUATION NUMBER: AU296-018 RECOMMENDATION NUMBER: AU296-018-G DATE: April 3, 1996 ORGANIZATION:
Quality PERSON CONTACTED:
W.H.Barley RESPONSE DUE DATE: June 3, 1996 AUTHOR: K.M.Gunter RECOMMENDATION:
Reword OQAPD, Chapter 1, Section 13.2.1, for Qualiry Director responsibilities.
RESPONSE*The response should address action to be taken and proposed completion date.If no action is deemed necessary, the logic for this conclusion should be presented.
22 0~~~+4'