ML20199C131

Insp Rept 70-1151/97-05 on 970922-26.No Violations Noted. Major Areas Inspected:Observation & Evaluation of Licensee Biennial Emergency Preparedness Exercise,Including Safety Operations,Facility Support & Plant Status

ML20199C131
Person / Time
Site:	Westinghouse
Issue date:	10/25/1997
From:	NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION II)
To:
Shared Package
ML20199C125	List: ML20199C120 ML20199C131
References
70-1151-97-05, 70-1151-97-5, NUDOCS 9711190233
Download: ML20199C131 (33)

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. U.S. NUCLEAR REGULATORY COMMISSION-REGION II

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-Docket No.:-- 70-1151

.Licen'se No.: SNM li07 ,

Report No.: 70-1151/97-05 Licensee:- Westinghouse Electric Corporation 1

Facility Name: Comercial Nuclear Fuel Division

-Date: September 22-26, 1997 ,

-Inspectors: -D. Ayres, Fuel Facility Inspector A. Gooden. Radiation Specialist

-W. Tobin. Senior Safeguards Inspector i

Appro'ved by: E. J. McAlpine. Chief Fuel Facilities Branch Division of Nuclear Materials Safety

.h' Enclosure C .PDR. ..

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3 Executive Sumary Commercial Nuclear Fuel Division NRC Inspection Report 70-1151/97-05' The primary focus of this routine announced inspection was.the_ observation and evaluation of the licensee's biennial emergency preparedness exercise.

Additional areas-that were reviewed included the fire safety program, and

plant operations. The report covered a one week period and included the results of--inspection efforts of three regional fuel facility inspectors.

4 Safety Doerations a

e Minimization of respirator use during normal operations through the use of engineered controls as specified in a licensee procedure was not evident'(Section 2.a).

e Deletion of the procedural prohibition against use of chewing gum, food-products and tobacco products in the chemical area w: .ndertaken to avoid NRC violation: because corrective actions to pi ent such use had F been ineffective (Section 2.a).

e Response to loss of the uranium recovery ventilation scrubber system was quick and effective (Section 2.b).

e Fire Safety program was effectively managed (Section 3.c).

n e- Electronic procedure control system assured that only the proper 4

revision were available to workers (Section 4.a),

e Formal monthly audits were being conducted with sufficient depth to

identify operational safety problem areas, ar>d were focused on inherent risks, Corrective action closure documentation, however, was incomplete 7 (Section 4.b).

e Regulatory Comaliance Committee was performinc its functions in accordance wit 1 license requirements, but meet:igs minutes did not clearly differentiate between staff and committee findings, conclusions, and recommendations (Section 4.c).

Facility Suonort

-e = Employee training materials were well produced, and covered all required

, areas, but inclusion of plant specific examples would improve the-level

[ _of worker knowledge (Section 5.c).

e- Independent external audit of emergency preparedness was ineffective because detailed management ex external auditor (Section 6.a)pectations had not been provided to the

• Checklist format for emergency procedures and use of a decision flow chart for event-classification was effective and user-friendly, but inconsistencies were noted between two emergency procedures and the Site Emergency Plan (Section 6.b).

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-Executive Summary Commercial Nuclear Fuel Division NRC Inspection _ Report-70-1151/97-05 i

-The primary focus of this routine announced inspection was the observation and evaluation of the licensee's biennial emergency preparedness exercise. .

E Additional areas that were reviewed included the fire safety program, andL plant operations,- The' report covered a one week period and included the-F results-of inspection efforts of three-regional fuel facility inspectors. -

Safety Doerations -

e Minimization of respirator use during normal operations through the use

, of engineered controls as specified in a licensee procedure was not evident (Section 2,a).

• -Deletion of the procedural prohibition against use of chewing gum, food  !

products and tobacco products in the chemical area was undertaken to avoid NRC violations because corrective actions to prevent such use had been-ineffective (Section 2.a),

e Response to loss of the uranium recovery ventilation scrubber system was quick and effective (Section 2.b). >

e- Fire Safety- program was- effectively managed (Section 3.c).

. Electronic procedure control system assured that only the proper revision were available to workers (Section 4.a).

, o Formal monthly audits were being conducted with sufficient depth to identify operational safety problem areas, and were focused on inherent risks. Corrective action closure documentation, however, was incomplete (Section 4.b), ,

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• Regulatory Com)11ance Committee was performing its functions in i

accoraance wittlicense requirements, but meetings minutes did not clear'yl differentiate between staff and committee findings, conclusions, and recommendations (Section 4.c),

F cility Sucpott

• Employee training materials were well produced, and covered all required areas, but inclusion of. plant specific examples would improve the. level of worker knowledge.(Section 5.c),

e- -Independent external-' audit.of emergency preparedness was ineffective because detailed management expectations had not been provided to the external auditor (section 6.a),

el Checklist format for emergency procedures and use.of a-cecision flow b chart for event classification was effective and user-friendly. but

" inconsistencies were noted between two emergency procedures and the Site Emergency Plan _(Section_6.b). ,

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l 2 e- Adequacy of the program to provide for staffing the Emergency Response -

Organization and activating the Emergency Control Center during off-hours remains open from Inspection Report 70-1151/96 03 pending implementation of corrective actions (Section 6.c). l e- Poor performance by the controller organization due to inadequate training (Section 6.e).  !

e' The conduct of the exercise disclosed three weaknesses requiring corrective actions to assure protection of plant personnel and offsite' i populations (Section 6.e).

• A bomb search team was not activated in response to the bomb threat as required by emergency procedures and resulted in failure to demonstrate exercise objective 3.-

• The Emergency Response Organization did not initiate a search for the missing employee in accordance with an emergency procedure and resulted in failure to demonstrate exercise objective 9.

+ Untimely response by security personnel to unlock a gate resulted in evacuees remaining in an area of potential radiological impact (from explosion) for an unnecessary additional period of time, e Emergency exercise scenario posed numerous challenges not previously Jostulated was considered a program strength because of the training senefits provided (Section 6.e).

e The criticality warning system was inaudible inside the respiratory protection facility (Section 6.f).

Attachment:

Persons Contacted and Exit Interview List of Items Opened, Closed.-and Discussed List of Acronyms Scenario Description and Exercise Objectives t

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l Reoort Details-

1. Summary of Plant Status This-report covered a-one week period? Saecial activities scheduled during the reporting period included the- )iennial' emergency exercise involving onsite and offsite organizations. There were no unusual plant operational occurrences during the onsite inspection.

2. Plant Ooerations (88020) (03)  ;

a. Conduct of Ooerations (03.01)

(1) Inspection Scope The operation of the contaminated waste incinerator, handling and storage of bulk uranium powder, and UFs cylinders were reviewed for verification of adherence to safety requirements.

(2) Observations and Findings The inspector received a thorough explanation of-the operation of the incinerator from the area engineer. The inspector observed the operation of the incinerator fire box, the combustion gas scrubbing system, the scrubbing

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system water filtration and recirculation loop, the-incinerator ash handling system. the incinerator ventilation system including Torit filters, and the incinerator control system electronics.

The inspector observed a drain in the floor of the incinerator room in the area of the scrubbing system water filters and observed a mop and bucket nearby. The inspector found that clightly contaminated spillage due to changing filters or from other leaks could escape into the floor drain. The inspector also observed piping runs ta t ended at the floor drain opening and liquids dripping f am the pipes into the drain. One of these pipes was found to be a bleed line from the scrubber water recirculation system itself. -The floor drain was found to be pi >ed to an outdoor

-low-level waste tank, and so leakage from tie replacement-of scrub water filters was not a significant safety concern.

The inspector observed the loading of some material into the incinerator. The operator performing this loading donned a half-face res>1rator with particulate filter cartridges as.

required by tie operating procedure. However, the inspector

. observed that during the loading operation, there was no temporary exclusion zone established within which respiratory protection was required, and no warning to other personnel that airborne contamination may be present.

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2 Although establishment of such an exclusion zone is not required, it would be consistent with the concept of ALtRA.

Other portions of the incinerator operation also have ,

similar respiratory protection requirements. This is '

inconsistent with Respiratory Protection Procedure RA-205 ,

which states, "The mandatory routine use of respirators '

should be kept to a minimum." and "The use of respiratory protection devices as a substitute for [

engineering) controls is not acceptable. process or The inspector observed the bulk powder blending room, its associated storage bins, and blending equipment. The inspector observed that a semi-permanent respirator zone had been established for an indefinite length of time in one corner of the bulk blending room. This was found to have been established due to high air contamination levels associated with transfer of powder between certain containers. The inspector found one safety posting concerning the use of hearing protection in the area that was outdated. Modifications to the ventilation system had lowered the ambient noise level such that hearing protection was no longer needed. The licensee took steps to remove the posting. The inspector found that other safety postings in the area were adequate and were being followed.

The inspector observed the storage area for UFs cylinders in the controlled area near the va3orizers. Cylinders were stored vertically with safety clains in place. However, the inspector found their usefulness in question when it vpeared that the weight of a full or partially filled cylinder, if tipped over, could break the chain. The inspector observed the equipment used to transfer the cylinders to and from the controlled area through an access door. The ins)ector found no problem with the equipment being used. T1e inspector reviewed the survey records of empty cylinders leaving the controlled area and found that 20% to 30% of the cylinders had to undergo some decontamination (usually around the valve) before being released from the controlled area. The inspector found that subsequent contamination surveys were adecuately performed before actual transfer from the controllec area occurred.

During facility tours. the inspector observed two examples or discarded candy wrappers on the floor in the chemical area and one example of discarded gum in the same vicinity.

Actual consumption or chewing was not observed. The inspector was informed by a licensee representative that previous procedural requirements (associated with Regulatory Affairs Procedure RA-203. General HP Rules and Recommendations) which forbid the use of chewing gum. food products and tobacco products in all chemical areas had been deleted. The licensee stated that the radiation worker and t

3 general radiation training continue to specify that the use of chewing gum food products and tobacco products is strictly forbidden in all chemical areas. During the exit meeting, the inspector discussed with licensee representatives the disappointment with the licensee's response to delete the procedural requirement rather than take aggressive and effective management actions to prevent recurrence. The inspector stated that the significance of this matter would be further reviewed with regional management. The licensee acknowledged the inspector's concerns, and also indicated that they did not condone eating and drinking in controlled areas but corrective actions in the past have been unsuccessful and repeat findings of undesirable. procedural non-compliance by NRC was (3) Conclusions The operation of the contaminated waste incinerator and the bulk powder blending areas were performed per approved procedures and applicable safety postings. The minimization of respirator use during normal operations thro g h the use of engineered controls as specified in Respiratory Protection Procedure RA-205 was not evident. The handling of UFs cylinders is adequate for protection of workers and the environment. The deletion of a procedural requirement as a form of corrective action to 3revent a non-compliance reflected a non-aggressive approau to problem solving,

b. Review of Previous Events (03.07)

(1) Inspection Scope The inspector reviewed the facts surrounding the recent event involving the leak of contaminated scrubber water on the roof of the Uranium Recovery bui; ding.

(2) Observations and Findings On September 18. 1997, a seal failed on the pum) that circulated water through the scrubber serving tie Uranium Recovery area ventilation system. The seal failure permitted several liters of slightly contaminated (69 ppm Jranium) scrubber water to leak onto the roof of the building where the scrubber was located. The licensee took swift action to remove the water, clean the area of contamination, and repair the pump. The cleanup effort included the removal and washing of all gravel on the roof in the vicinity of the leak, cleaning the roof membrane, and removal and cleaning of the elevated catwalk grating immediately above the scrubber pump.

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The inspector observed the scrubber system-on the roof of:  ;

-the Uranium Recovery building on September 24,-1997, and found the system remained shut down. The inspector took independent gama readings with NRC survey equipment. The ins)ector found-no discernable radioactivity above-bac(ground on the roof, the catwalk grating, or the re) aired f pump.: The inspe: tor questioned the reportability of tie  :

incident since the system had been shut down more than

'24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> due to a contamination event and had not been reported to the NRC Operations Center. Section 3.7.3(c.1)  ;

of the License Application states that the NRC Operations Center will be notified within 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> of "(a)ny incident for which the work area is unavailable for normal use for an entire da control."y, following The work aarea : loss of radioactivity affected contamination by this incident included the scrap dissolution and solvent extraction areas. The licensee indicated that the decontamination and repairs to the scrubber pump did not take more than an entire day and thus was available for use if the licensee had chosen to use it. Instead, the licensee had chosen to keep the scrubber system down for an extended period in order to facilitate other cleaning and maintenance activities. Since the area was available, but was kept shut down for reasons other than the loss of contamination control, this incident was not reportable to the NRC Operotions Center.

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(3) Conclusions-The licensee responded quickly and effectively to the loss of contamination control incident.

c. Follow-uo on Previously Identified Issues (03.08)

(1) Inspection Scope A review of the progress of corrective actions toward resolving Inspector Follow-up Item (IFI) 97-03-01, Notice Of Violation (NOV) 97-03-02, and IFI 97-03-03 was conducted for possible closure.

(2) Observations and Findings IFI 97-03-01 involved defense elements identified in the Criticality Safety Evaluation (CSE) for the Ammonium Diuranate (ADU) conversion area dewatering centrifuge, The defense elements are controls of )arameters important to criticality safety, and keep the yr within license limits, .

One defense identified for the dewatering centrifuge involved maintaining the speed of the centrifuge scroll at a) proximately 50 Revolutions Per Minute (RPM) greater than t1at of the centrifuge bowl. The licensee was unable to verify the speed by a direct RPM indicator and attempted to i

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. utilize'other operating data to verify proper operation of the equipment. The licensee used an indirect method to determine proper scroll rotation by monitoring the oil temperature for the scroll bearings. However, the thermistor that measures this temperature had not been tested to verify its accuracy. Another indirect method used was monitoring the motor amperage. However, the amperage smuh had not been properly tested and functionally veri M d. Thus, the licensee did not have an adeouate, reliabis method of verifying the speed difference between the scroll and the bowl of the centrifuge.

Even without controlling the speed difference between the scroll and the bowl, the original CSE stated that the k of '

the. system would not exceed the allowed limit of 0.95, ,,the .

inspector found that the licensee had re-evaluated the defenses listed in the CSE for the dewatering centrifuge.

Since the differential speed control between the centrifuge scroll and bowl was not necessary for criticality safety, the licensee's corrective action was determined to be revising the CSE to delete the scroll / bowl speed control from the list of defenses to initiating events. This >

revision was not completed and IFI 97-03-01 remains open.

The inspector reviewed the corrective actions associated with violation (VIO) 97-03-02 that involved Configuration Control Forms (CCFs) (TAF 500-1 Forms) that erroneously indicated the completion of documentation associated with a facility change. Various drawings, loop sheets. and schematics had not been updated as required by procedure TA-500. Corrective actions included revision of Form TAF-500-1 and Procedure TA-500 to include the requirement that the responsible project engineer arovide a wrking list of documents and drawings, that lave actua'ily been affected by a modification, at aroject closure. The inspector verified the completion of t1ese corrective actions and item VIO 03-02 is considered closed.

IFI 97-03-03 conce ned the licensee not updating the CSE as facility changes were made. The CSE is noted as

' essentially a subset of the Integrated Safety Analysis" in the license application and that.the Integrated Safety Analysis (ISA) will be maintained in "real-time." Thus, the CSE should have also been maintained as a real-time document as much as practicable. Supplements had been developed for portions of the CSE to correspond with certain process changes, but were not attached to. contained in, nor referenced by the CSE document. The ins)ector reviewed the

-licensee's action item tracking system. )ut no significant progress had been made in including the appropriate supplemental information with the CSE document. IFI 97 03 remains open.

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-(3): Conclusions-Corrective actions associated with VIO 97-03-02 were

-adequately completrx Corrective actions on IFIs 97-03-01 and 97-03-03, inv0 eng updates to CSEs. had not significantly progressed in the four months since they were identified to the licensee..

3. Dre Sefetv (88055) (04)- ,

a.. Fire Prevention. Detection and Suooression (1) -Inspection Scope This inspection was conducted to review the licensee's program for preventing, detecting and suppressing fires.

Specific attention was given to the Incinerator-Room in the Radiation Controlled Area -(RCA); Chapter 8 of the License.

"Fira Safety." was the primary inspection requirement and, as th. was the standard of this inspection. Other ,

cr1 ria included the NRC Branch Technical Position (BTP) on Fire Protection for Fuel Facilities. published in the Federal Reoister dated August 10, 1992. Additionally. NRC Generic Letter No. 95-01. "NRC Staff Technical Position on Fire Protection for Fuel Cycle Facilities." and the licensee's response of February 25, 1995, were also-utilized.

(2) 00servationc and Findings (a) Fire Prevention The licensee's Safety Committee is currently the-Regulatory Compliance Committee (RCC) and is further discussed in section 4.c. The RCC is responsible for the completion of the ongoing ISA. The inspector 4

reviewed the ISA and noted that a fire hazard analysis had been completed for the ventilation system.

Chapter 5.4 of the analysis, considered the accident sequence. fire potential and control elements, along with such issues as fire loads, risks mitigating systems, and manual / automatic sup)ression techniques. '

The inspector reviewed Procedure M-102. " Regulatory

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-29,pliance Inspections."

1997. This ProcedureRevision calls for:(Rev.)

monthly9. dated May inspections by area and plant managers for criticality, safeguards, industrial.-and fire safety. I As a result of such inspections.' Regulatory Affairs '

Inspection Reports have addressed leaking pipes.

, overhead extension cords, and an inoperative emergency -

-exit door (which was fixed immediately). 1 L

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r c 7 l The licensee's Pre-Fire Plan (PFP).was an extension of the Fire Hazard Analysis and provided further details i of each building and work area involved in licensed activity. Outlying support facilities were not .

-addressed. The PFP explained what production occurs  !

inside the areas, what-fire hazards exist therein- and' what special precautions need to be exercised. The  :

inspector determined that the PFP was in need of l revision due to recent reorganizations and

' retirements. The licensee stated-its intention to-further provide in the PFP details of fire detection and suppression equipment, the location of vents, doors and dampers, as well as electrical control boxes. The inspector was advised that the PFP has beea provided to the local fire department. The licensee's effort to revise the PFP will be tracked as an IFI to be closed by mid 1998 (IFI 97-05-01).

The licensee's fire safety program is managed by a Regulatory Engineer who also performs-industrial .and

• nuclear safety functions. Maintenance technicians assist in the testing and repair of equipment. His

)rocedures include Cutting / Welding (No. 207),

iousekeeping (No. 300). -Storage of Zirconium -

(No. 301). Fire Extinguisher In nection (No. 303),

Fire Watch Safety (No. 305) and rire dystem Impairment Reporting (No. 306).

The inspector toured the nuclear and non-nuclear areas

- of the facility. Storage containers for flammable liquids were observed as were flame curtains, gas shut-off valves, lightning protection cables, and welding watches. Housekeeping-was strictly enforced outside the buildings and inside.the manufacturing area. Storage of unused material was minimal, fire loads were low, and " lay down" pads were well organized. Special attention was afforded the ,

presence of zirconium.

The. inspector reviewed the last two audits performed by the fire insurer which included reviews of the fire brigade training, offsite emergency notification. use of plastic ducts, maintenance of the systems, and

protection of the roof. filter houses. The licensee was still studying the one' recommendation relative to an automatic-sprinkler system along the north side of E the UFs Bay.

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8 (b) Fire Detection The inspector toured the nuclear and non-nuclear areas of this facility-and noted the )resence of either heat or smoke detectors-throughout tie facility. Heat detectors were observed to be inside air ducts. The detector alarms annunciate in both the security receptionist office and the Production Control Room.

Pull-boxes also alarm at these locations. Once authorized by the Production Shift Supervisor, the security officer informs the Columbia Fire Department by telephone of a request for response. The inspector positioned himself inside the Production Control Room similar to the Shift Supervisor who was seated at the operations monitor board at the time of a test of the fire annunciator panel. The visual feature of the panel could not be seen from that position. however. >

the audio feature attracted the supervisor's attention. The inspector noted that the security officer routinely telephones the Shift Supervisor to ask for guidance upon the annunciation of an alarm. ,

At the security desk the alarm also annunciated audio-visually as well as printing out a hard copy record.

All alarms are followed with a public address announcement from the security desk. At the entrances to the RCA the licensee has installed blue lights and a panel which informs responders of the specific type of alarm (fire, criticality, smoke, water flow etc.).

The ins)ector reviewed several plant drawings titled

" Plant Jtilities/ Fire Protection System."

No. 510F01ELO3 and randomly chose a pullbox to be tested by the licensee during the weekly test of the system. The alarm annunciated successfully and all indicators / lights / announcements were effective in alerting the three inspectors located throughout the facility. The inspector reviewed several records of the various maintenance and routine tests of the detection system (weekly, monthly, quarterly and annually).

(c) Fire Suppression The inspector observed the presence of-fire extinguishers of various types, hose houses, position indicator valves. standpipes, deluge guns. dompers and fire hoses a3propriately located throughout the facility. T11s was also true of the Incinerator Room which was provided with automatically closing doors-t* and dampers. sprinklers, fire barrier walls, extinguishers, detectors and pull boxes. The suppression system consisted of two tanks of water

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9 which provided 450,000 . gallons via pumps that were provided with emeroency power. The inspector conducted a valve hneup walkdown of the water supply >

from the tanks through the pipes, pumps and risers to the sprinklers._ and drain-lines-for Risers A and B.

Two vehicles provided the Fire Brigade with hoses, axes, air supplies, wrenches, protective clothing, lights and spill kits The inspector verified the ignition keys were readily available and identified 1 inside the nearby guard house.

Moderation controlled areas were well marked to

. preclude the use M water. These areas were also

. identified in the <FP. The inspector verified the  !

resence of dry sprinklers inside the roof air landling unit over tha Integrated Fuel Burner Absorber facility. Tne licensee no longer used halon but did i have a supply of Incrgen (nitrogen / argon / carbon 4

dioxide) under the floor of the telephone room. the computer room, and the quality control (OC) vault which starves out a fire.

There were 80 members on the Fire Brigade. On back shifts, six members are routinely present. There were 24 mana ers, supervisors.-and salaried employees on

'the Bri ade. The inspector reviewed the training schedul for 1997 which included four days at the State Training Academy. Site specific training

, addressed the moderation control areas RCA hazards, and manual operation of the fire suppression pumps.

Additional training occurs with the South Carolina

. Department of Health and Environmental Control (SCOHEC). The inspector randomly chose the training records of six brigade members and found them to be.

current.

The Memorandum of Understanding with the Columbia Fire Deoartment was dated May 15, 1997, and referenced on' site visits and response capabilities.

(3) Conclusion Based upon observations. interviews, testing, walkdown, and records review,- the inspector concluded that the licensee's Fire Safety program was well managed and effective Housekeeping was strictly enforced. Ecuipment was maintained. Fire Brigade training anc deployment is a strength. The PFP was in need of revision-(IFI 97-05-01).

There were.no violations identified.

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5. Procedure Controls (05.02)

(1)- Inspection Scope-  :

The licensee's system for approving and controlling procedure changes was reviewed for_ adequacy and compliance- ,

with license requirements. t

-(2) Observations and Findings The inspector received a thorough introductiori to the licensee's Electronic Procedure System (EPS) from the Document Control Technician. The inspector observed how 3rocedure changes.were initiated, and revisions were drafted

)y the Document Control Technician and placed into the EPS.

The draft revision was electronically sent to each reviewer simultaneously, and comments and approvals / disapprovals were electronically sent back to the Document Control Technician.

The inspector observed the approval pages for a sampling of each procedure category and found them to be in accordance with the requirements in the license application. The ins ector also observed that the EPS electronically provided t on1 the current revision of each procedure to the users suc thot outdated revisions could not be mistakenly used.

(3) Conclusions The licensee's procedure control system met the license ,

requirements, and assured that only the proper revision were available to workers.

Internal Reviews and Audits (05.03) b.

(1) Inspection Scope

-Monthly licensee internal audits were reviewed to verify adequacy of scope and depth of the audits technical capability of auditors, and documentation of findings and corrective actions. Operations "Redbook" items of

.o)erational upsets and the items included in the Health P1ysics (HP) reports were also reviewed.

(2) Observations and Findings The inspector reviewed files containing monthly aucits for 1997. The inspector found the audits to be conducted by -

staff familiar with process operations and safety significant issues. The inspector found that audits were conducted in each area of the )lant at least twice per year, and audits were performed in_ t1e chemical conversion area

11 every month. This focus on the chemical conversion area was consistent with the inherent safety risks associated with the chemical process. The monthly audits routinely identified seven-to ten items for corrective actions and were documented on corrective action forms. The inspector found that corrective actions were usually completed within a few days, but that some (10%-20%) involved longer-term actions such as procedure revisions and design changes. The inspector also found that documentation of completed longer-term corrective actions was not always included in the monthly audit file. In other instances, documentation of completed corrective actions was no more than a self-adhesive note attached to the corrective action form. The inspector observed that the corrective action form included sections for auditors to complete concerning information on the problem found, the immediate or short-term corrective actions taken, and any long-term actions to be taken. The inspector found no provision on the form to document completion of corrective actions. The inspector informed the licensee that documenting the completion of corrective actions on the corrective action form would facilitate closure of the audit findings.

The inspector reviewed the licensee's "Redbook" items of operational events for responses to process upsets and equipment failures. The inspector found that no significant issues were reported that did not already have corrective actions in place. The ins)ector also reviewed the file containing the licensee's iP findings, with again no significant items that were not already being addressed with corrective actions. The inspector reviewed the purpose of the two sets of information files with licensee managemer,t and questioned why they did not appear to be congruent. The inspector found that the two systems covered process events from two directions, the "Redbook" system from ar.

operational viewpoint, and the HP records from a (normally radiological) safety viewpoint. Both sets of informatico, when combined, gave a thorough picture of the process upsets and anomalies that occur in the facility. Items in the "Redbook" system may not appear in the HP records if they are not considered safety significant. Conversaly, items in the HP records may not appear in the "Redbook" system if they are not considered a significant process upset. Each set of information was sent to the Manager of Regulatory Affairs for condensing before being presented to the Plant Manager. The inspector found no conflicting information between the two systems.

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The licensee's monthly formal audits were being conducted with sufficient depth to identify operational safety pmblem.' '

areas, and.were: focused on inherent risks, Correcthe -

action closure documentation was incomplete : The; combination of- *Redbook" and HP unusual incident reports 4 provided a complete picture of identified operational and safety concerns,  !

c. Safety Committees (05.04)

(1) Inspection Scope The 7Cr factions were reviewed to verify proper membership.

6R , frequency and scope of ineetings, and actions '

taken..

-(2) Findings and Observations  ;

The inspector reviewed the RCC meeting minutes for 1996 and ,

1997, and determined th3t the committee's membership, ,

attendance at meetings and meeting frequency met the applicable license requirements. RCC meetings were being held monthly instead of the required quarterly minimum frequency. The inspector reviewed the topics covered in the several most recent meetings and found that a wide range of safety and regulai.ory issues were covered. The inspector observed that the RCC meeting minutes included a synopsis of each topic-covered, and contained attachments of informational r.iaterials presented to the committee for their review,

• The minutes reports fo- one meeting that was reviewed in depth included information on a project for a new groundwater monitoring system. The inspector reviewed the project with the environmental engineering staff and compared it with the information contained in the RCC meeting minutes. The inspector verified through the discussions with the staff that the project was solely for monitoring of chemical constituents not regulated by NRC, and did not include monitoring for urcnium concentrations in areas of known present or past soil contamination (i.e. soil around waste treatment areas) that are monitored with other systems. Thus, the information provided:in the RCC meeting 4 Firutes was found to be consistent with the_ project scope.

The inspector observed that the License Application includes a requireuent that the RCC's findings, conclusions, and recommendations will be formally documented. However, the inspector found that it was difficult to determine whether the information in the neeeting minutes included the c

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4 13 committee's findings, conclusions, and recommendations: or if all of the information in the minutes was that which was presented to the comittee from other sources. The inspector discussed this situation with the scribe for the RCC who indicated that the comittee's output was indeed imbedded within the minutes. The inspector found that even though the comittee's findings, conclusions, and recomendations were a part of the meeting minutes, that the minutes needed to more clearly identify which items were inputs to the comittee and which items were outputs from the comittee. This need for clearer identification of the comittee's outputs in the meeting minutes will be tracked as IFI 97-05-02.

(3) Conclusions The licensee's RCC was performing its functions within the prescribed requirements of tha License Application. The minutes of RCC meetings do not clearly differentiate between staff and comittee findings, conclusions, and recommendations.

5. TRAINING (88010) (F2)

a. Inspection Scope The licensee's training program [10 CFR 19.12 Training (F2.01),

General Nuclear Criticality Safety Training (F2.02), General Radiological Safety Training (F2.03), and General Emergency Training (F2.04)] was reviewed to determine whether it was adequate to promote safety and in compliance with regulatory requirements and license conditions,

b. Observations and Findings The inspector observed the training materials used for initial training and biennial retraining of radiation workers. These training materials included the Regulatory Training Manuals for the Chemical Area and the Mechanical Area (October 1996 versions).

plus the videotaped instruction on general regulatory issues. The inspector observed that sections in the training manuals were dedicated to ALARA. radiation exposure. HP, nuclear criticality safety, safeguards, industrial safaty/ hygiene and fire protection, emergency response, and informttion from selected NRC regulatory guides. Additionally, the inspector observed that guidance for area-specific requirements were provided for the HP and criticality safety sections.

The inspector observed that some portions of the training materials lacked some simple examples that would be helpful in illustrating certain topics. One of these topics involved a discussion of the difference between transportable and non-

. u f . I 14 transportable forms of uranium in the body, but the training materials did not mention which forms found at the-licensee s facility were in the two categories. Attitional information may-also be warranted in the chemical hazai% section such that specific effects of exposure to chemicals used or produced at the facility is-included.

c. Conclusions The training materials were well roduced, and covered all required areas, but inclusion of lant specific examples would  ;

improve the level of worker knowl dge. i

6. EMERGENCY PREPARE 0 NESS (88050)(F3)

a. Review of Proaram Chanaes (F3.01) l (1) Inspection Scope Changes-to the licensee's Site Emergency Plan (SEP),

procedures, organization, facilities, and equipment were reviewed to assess the impact on the effectiveness of the program; and to verify that changes met commitments, license conditions, and were provided to NRC in accordance with I 10 CFR 70.32(1). Examine the adequacy of the emergency l preparedness independent audit program.

(2) Observations and Findings Since the September 1996 inspection, organizational changes were made as were Plan and procedural changes. Regarding the organizational changes, changes involved both onsite and offsite personnel and were as follows:

e During July 1997, a new Pla.* Manager was appointed to replace the previous Plant Manager who was selected to the position of Division General Manager. The appointments stemed from the retirement of the previous Division General Manager. The individual filling the Plant Manager's position in the normal ^

organization is also assigned primary responsibility as the Emergency Director (ED) for implementing the emergency procedures and direct'ng the emergency response organization (ER0). During the biennial exercise discussed in Section 6.e. no performance problems were noted with the newly assigned Plant Manager's< response as the E0.

r e Regarding offsite changes. the day-to-day contact at the offsite medical su) port facility on emergency preparedness matters clanged: however, no changes were made to the Hospital Administrator po.sition or the-u

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.~ - . . .~ . _--

-l y s 15 Letter of Agreement between the licensee and the hospital. Consequently, the aforementioned change had -

no impact on the state of preparedness, e Since the last inspection, revisions dated February 19. 1997, were made.to Sections III (Rev 9),

V (Rev. 7), and VII (Rev.~ 8) of the Plan. Changes in  !

Section III resulted frce a previous inspection "

finding documented as an IFI (NRC Inspection Reoort No. 70-1151/96 03) involving the revised emergency action levels (EALs) reducing the effectiveness of the Plan.Section V change was strictly an editorial r u>date. Regarding Section VII, the change removed tie requirement to perform drills biennially on each shift in the years in which exercises are not required.= As revised, the Plan comitment remains to perform drills biennially in the years in which exercises-are not required; however, drills will not ,

be 3erformed on each shift. The inspector discussed wit 1 the licensee.that althougn the changes were approved by NRC and no requirement exist for biennial drills be held on each shift, the change potentially reduces the effectiveness of the ER0 training program in that team concept training for each shift is removed. The inspector further stated that the shift (team) training approach for emergency response provides a more realistic portrait of what response capability or state of readiness exist on each shift, rather than the state of readiness by individual components. A change was also made to Section VII to reflect NRC guidance associated with the scenario submittal to NRC in advance of the exercise date for consistency with Regulatory Guide 3.67. Changes were made to the emergency procedures which implement the Plan and are discussed below in Section 6.b. The aforementioned Plan revisions were reviewed and approved by NRC via letter dated May 15, 1997.

Section 7.8 of the SEP required an annual independent audit of the emergency preparedness program including the SEP and implementing procedures, training activities, emergency facilities, equipment, su plies, records.-etc. The inspector was )articularl focused on the licensee's audit program in lig1t of a vio ation identified during the last inspection of this area (see Section 7.b below).

'Accordingly, this area was reviewed to determine if the licensee had aerformed the independent review or audit, and-

verify that tle licensee had eveluated any significant changes on the emergency preparedness program. The inspector reviewed audit documentation and interviewed the '

Auditor for the Calendar Year (CY) 96 audit conducted on

- December 13. 1996. The inspector determined that the audit t

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16 lacked depth and thoroughness based on the following: lack ~

-of guidance (detailed audit checklist or protocol) was o provided to the auditor to ensure the audit adequately-addressed areas. identified.in Section 7.8 of the-SEP:- '

-duration of the audit (a) proximately five hours): and the-auditor's knowledge of tie licensee's )rogram (SEP.

. emergency procedures), in addition, tie independent review -

or audit did not include an evaluation of the Plan or procedure changes on the emergency preparedness ,

Consequently, the inspector discussed as an IFI program.- the1 development of an audit checklist and audit plan detailing the areas of the audit and the acceptance criteria for area (s) audited (IFI 97-05-03).

(3) Conclusions-Based on the review of records and interviews, the inspector; .

determined that the changes to the licensee's SEP and organization met commitments, license conditions, and NRC requirements. The revision to the licensee's drill program for the years in which exercises are not required, presents a challenge to the program for maintaining emergency response proficiency on all shifts. The independent external audit of emergency preparedness was ineffective because detailed management expectations had not been provided to the external auditor. The licensee was distributing the SEP_ changes to onsite and offsite copy holders, and inserting changes into control documents in a timely manner in accordance with 10 CFR 70.32(1) and Regulatory Affairs Procedure RA-100-A. Copies of the SEP ,

were checked at select locations and determined to be current revisions.

^

b. Plan and Imolementino Procedures (F3.02)

(1) Inspection Scope Selected implementing procedures'were reviewed for adequacy in the implementation of the SEP.

(2) Observations and Findings Four procedures (A 04 " classification:" A-03 " Evacuation.

Accountability, and General Response:" A-07 " Equipment and Supplies:" and Emergency Guide G-02 " Classification Logic

. Flow") were reviewed for applicability and adequacy in implementing the SEP. Two items were noted as follows:

a.6 '

. q' 's  :

17 e Procedure A-04. classification Logic Flow Chart .

(Rev. 2. dated August 25, 1997) did not include in a.

.* decision box the bomb threat EAL as an Alert condition ,

consistent with Section 3.1.2 of the SEP and/or Section 7.12 of Procedure A-04.

e Emergency Guide G-02 " Classification Logic Flow-(Rev. 0, dated July 10, 1996) contained EALs for- fire, hazardous material release, and UFs release that were -

inconsistent with the wording of EALs in Procedure A -

04 Classification Logic Flow Chart.- Emergency Guide G-02 had not been revised to reinstate the EALs containing conditions for the emergency as a function of time. For example. A-04 indicates that a fire which cannot be extinguished within approximately 15 minutes should be declared an Alert. Emergency Guide G-02 indicates a fire which can not be extinguished quickly and threat of further escalation.

. In response to the above inconsistencies, the licensee issued Commitment Tracking System (CTS) No.564 and assigned the corrective action for completion by March 31, 1998. The inspector reviewed the assigned corrective actions and will raview the licensee's-implementation of the corrective actions during a subsequent inspection.

Controlled copies of the SEP and procedures were examined in the Conversion Control Room. Guard Shack, fire brigade truck, and all verified as current and'up to date. The inspector also verified that an emergency telephone listing was available and maintained current and up to date.

(3) Conclusions Two procedures selected for review contained EALs that were inconsistent with details contained in the SEP. The procedure checklist format and use of a decision flow chart for event classification appeared to be effective and user-friendly.

c. Trainina and Staffino of Emeraency Oroanization (F3.03)

(1) Inspection S se Emergency response training was reviewed'tc determine if the licensee had-provided training to response personnel in accordance with Section 7.2 of the Plan.

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-18

-(2)- Observations and Findings ,

The inspector reviewed training for those individuals 3articipating in the biennial exercise and cssigned to the ERO as the ED or alternate E0. -It- was also noted that an emergency telephone directory coritained a listing of individuals assigned to key ERO positions. The inspector verified that selected individuals from the directory had been trained during the calendar year. According to documentation, E0 training was attended by appropriate individuals during August 1997.

Regarding offsite support training, the inspector noted that the following training was conducted:

e On December 30. 1996. State (SCOHEC and Emergency Preparedness Division) and leal (Columbia Fire Department. Richland County Emergency Planning, and Richland County Emergency Services) personnel were provided training. Training included a discussion of the changes to the Plan and procedures: CY 96 emergency events: the toxic and radiological effects of probable accidents at the Columbia site: a site tour including a review of the fuel fabrication process: and participatiori in a hazardous material drill during CY 97.

• By letter, personnel from the offsite support groups were invited to attend CY 97 training conducted on August 28. 1997. Included in the training were changes to the Plan and procedures; discussions regarding the biennial exercise planned for September 1997: personnel exposure guidelines: personnel monitoring devices and basic contamination control principles.

Regarding ERO staffing and activation of the Emergency Control Center (ECC) the inspector discussed with the licensee results from recent drills demonstrating that minimum staffing levels for ECC activation could be achieved in a timely manner. The discussion disclosed that the drill procedure was inadequate for providing an assessment due to:

(1) licensee had not identified what positions (minimum staffing) would be required for activating the ECC: and (2) the notification procedure for contacting personnel to

.- obtain an estimated time of arrival was limited to telephone i: contact only and did not include pager notification in the o event contact was not available via telephone. The t licensee's program for staffing the ER0 and activating the i

ECC during off hours was previously discussed and identified as an IFI (see IR 70-1151/96-03). The licensee on this matter indicated that a misunderstanding during the initial e

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- .3 19 o

discussion of this item contributef to the inadequacy, butt i based on the additional details.,the appropriate actions: i would be taken to resolve this matter. The. inspector---  !

informed the licensee ~that the results of the additional  ;

actions will be reviewed during a subsequent inspection. .

Therefore IFI 96-03 06 remains open.

(3)- Conclusions l Based on documentation reviews, and an interview with '

licensee personnel, the inspector determined.that training provided sufficient information to assist responders in -

their roles and responsibilities to the ERO. An area requiring licensee attention is the program for that the appropriate staffing level is availableensuring- , and can be-notified and activated in a timely manner to augment the ERO during off hours.

d. Offsite Sucoort (F3.04)

- (1) Inspection Scope Licensee activity in the areas of training, agreements, and exercises, was reviewed to determine if the licensee was properly coordinating with offsite authorities.

~

(2) Observations and Findings Discussions were held with a member of the licensee's staff regarding the coordination of emergency planning with offsite support agencies. Section 7.6 of the Plan required

. the licensee to annually offer training to offsite groups.

The inspector discussed with an offsite contact hazardous materials training provided by the licensee during CY 97, and reviewed documentation to show.that training was offered to personnel from State and local- organizations on December 30, 1996 and August 28. 1997 (discussed above in Section 6.c). According to documentation and discussions with the licensee, the offsite support groups were also invited to participate in the biennial exercise held on September 25. 1997. During the exercise evaluation discussed below, the ins;ector noted the arrival of the offsite fire support agency and emergency medical services a as exercise participants.

All agreement letters were reviewed and renewed in

-accordance with Section 4.4 of the SEP and Regulatory Guide 3.67.

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1 20 l l

(3) Conclusions Based on the licensee's contact with offsite support I agencies to provide training and a review of the agreement letters, the inspector concluded that the licensee was maintaining the interface in accordance with the SEP .

commitments. All changes to the SEP were transmitted to 1 State and local copy holders in a timely manner as reflected by transmittal documentation.  !

e. Drills and Exercist.s (F3.05) l (1) Inspection Scope Section 7.4 of the SEP recuired that one biennial on-site exercise will be performec involving a full-scale test of the entire emergency response organization.

(2) Observations and Findings The last full-scale NRC observed exercise was conducted on September 28, 1995, and involved participation by offsite support agencies includirg NRC. Consequently, the exercise i conducted on September 25, 1997, was conducted in ,

fulfillment of the requirement in Section 7.4 of the SEP. 1 The exercise scenario postulated events that were both realistic and challenging to the ERO and resulted in an effective test of the SEP anti emergency procedures.

The licensee submitted for NRC review and approval the information on the scope. objectives, and scenario in advance of the exercise date. The scenario was rev1ewed in advance of the exercise and was discussed with licensee representatives prior to the exercise. The exercise scenario simulated an explosion resulting from one of two bombs planted at different locations within the facility.

Minor problems with scenario details and message cards were identified during the review, and discussed with the licensee for resolution in advance of the exercise. The licensee took actions to resolve items identified during the review, but minor inconsistencies became apparent during the exercise. The major inconsistencies during the exercise resulted from exercise controller errors in data provision, or the lack of providing data. Controller errors appeared to have contributed to numerous artificialities and communication errors which may have impacted the overall

)erformance of the licensee's emergency organization.

Examples included message cards that were in some instances provided prematurely: props used for explosion (smoke bombs and fireworks) werepostulating anin initiatea far advance of scenario time line requirements: and inappropriate or incomplete details were provided to

~

1.

, so-

+

21 o players. The poor performance by the controller- -

organization was attributed to.the follow 1ng. (1) inadequate controller training. (2): lack of guidance to controllers / evaluators regarding evaluation criteria for acceptable or unacceptable performance by exercise participants, and (3) lack of comunication among controller / evaluator organization during the exercise to  !

maintain scenario time line, flow of information. and sequence of events. The inspector informed the licensee that the poor performance by the controller organization appeared to result from inadequate training and was considered as an IFI for review during a follow-up inspection (IFI 97-05-04).

The exercise commenced at approximately 4:13 p.m., and was terminated at approximately 5:15 p.m. due to inclement ,

weather combined with the lack of activity by the bomb search team, fire brigade, and search and rescue team. The scenario and associated props were well developed and provided participants with a set of conditions to exercise and challenge many aspects of the ERO. SEP, and procedures.

Exercise participants included off:.)'.e fire support and emergency medical services. Offsi .. observers included State. local, and inJustry persont d . The NRC evaluators observed the licensee's actions it. We following areas:

e Notification and communication with offsite authorities e Interface between the ED. the ECC staff, and on-scene response personnel e On-scene response by various emergency teams (onsite and offsite fire brigade. ..edical, transport. HP. and security l e Event classification and accident assessment I e Security access controls During the simulated emergency, the ER0 was effective in I ever.; classification and timely notification to offsite  !

authorities. The overall ERO perfo mance. however..was  ;

considered minimally successful in taat certain procedurally l required actions were not implemented and resulted in '

specific objectives not being met. Thrae examples were

' noted where the ERO response was inadequcte and the..

inadequate responses were considered as Exe cise Weaknesses (EW) for failure to implement actions in acccrdance with the SCP and ap)licable procedures, and/or failure to meet exercise o)jectives as set out in the scenario package.

I

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1

, 22 \

l e A bomb search team was never activated in response to  :

the bomb threat as required in procedures C 05 and C- -

09. This also was one of many objectives to be demonstrateo during the exercisa (objective 3) and was considered as EW 97-05 05. i e The ERO failed to init9te a search for the missing employee in accordance with Emergency Procedure C 05 to provide medical attention (objective 9) resulted in '

EW 97 05 06, i

e Untimely response by security personnel to unlock the south gate resulted in evacuees remaining in an area i of potential radiological impact (from explosion) for i an inordinate amount of time and was ident1fied as EW  :

97 05 07.  !

With respect to compliance with the commitments of the licensee's Physical Security Plan (PSP), during the exercise the inspector noted the following issues relative to access i controls:

e The responding Columbia Fire Department vehicle was l not escorted while inside the Controlled Access Area (CAA). The driver of the fire truck asked the inspcctor and acc anying controller for directions and instructions. he licensee's PSP requires certain escort controls to be exercised over visiting vehicles.

e Due to the delay by security personnel to unlock the South Gate (in the CAA barrier), a member of the onsite Fire Brigade was observed by the inspector ,

cutting the lock to allow the relocation of the building evacuees site assembly location Actions to relocate evacuees was necessary due to the frequent changes in meteorological conditions altering plume  :

trajectory which potentially impacted the assembly ,

location. However, the PSP requires certain )ositive controls over CAA openings. The inspector o) served that the security officer arrived a minutes after the gate was opened. pproximately The inspector three i observed that no one entered the CAA until the officer took control of the defeated barrier and that everyone in the vicinity was an employee or an offsite agency responder.

e During the critique following the drill it appears that an offsite attendee to the critique exited tk- '

conference room unescorted and left the site. Based t

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i

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.{

• onfurtherrevewofthisde$arture,theinspector confirmed that the individua was wearing an

• Escort  ;

Required" badge. The PSP requires escorts be provided

to visitors. l, The inspector discussed with licensee management their authority to waive PSP requirements during actual  !

emergencies but cautioned them that PSP required access  !

controls cannot be waived to accomodate a drill. The  !

inspector informed the licensee that access control issues  !

! during the exercise may be further discussed with the NRC .

Project Manger and would be reviewed during a future '

security inspection as an IFI (97 05 08). .

The scenario posed a significant challenge to the ERO communications capability in addition to concept of operations. However, the licensee demonstrated good resilience in efforts to communicate and coordinate the response actions in light of the prohibition on radio use in '

a potentia'.ly explosive environment. As an alternative to radio communications, the lic?nsee resorted to cellular phones. The inspector discussed the usability of cellular

, phones in a potentially explosive environment as questionable and requiring further research and evaluation t regarding the implications-and effects on an explosive device. The licensee acknowledged this matter and discussed .

plans to not only evaluate communications but the entire

• response program for bomb threats and explosions, for making changes, and conduct a table top drill to assess the

, effectiveness of the program changes. The licensee's review, evaluation, and corrective actions were considered an IFI for review during a future inspection (IFI 97-05 09).

Good command and control was displayed by the ED. EC. and Health Physics Coordinator (HPC) in managing the response actions. However, the inspector discussed with the licensee for improvement that the incident command personnel (EC and HPC) did not ra iew and consider the impact of explosion (s) '

and/or fire on nearby tank farms drums, etc. as additional source terms.

As required by the SEP. the licensee conducted a critique following the exercise which afforded players, controllers, evaluators, and observers an opportunity to provide ,

comments. Several items were discusse(1 for corrective actions to improve the licensee's response. The inspector indicated that the corrective actions taken to resolve those items discussed in the critique would be reviewed during a ,

subsequent inspection. An item for improvement discussed with the licensee during the exit involved disc ^ntinuing the practice of announcing the drill starting time. ihe aforementioned practice.resulted in a number of examples i

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,( !a 24 where employees were prestaging and therefore did not provide a true and accurate assessment of response  !

timeliness in evacuation and/or activation of ERO. l (3) Conclusions l The exercise scenario )lanning was viewed i.s a program strength in light of tie training benefit that was realized. ,

The scenario induced procedural inadequacies and highlighted l concept of operation areas previously unchallenged which needed improvement. The ERO response to the postulated accident was both timely and effective in the emergency classification. Three exercise weaknesses resulted due to deficiency in procedures or concept of operations. The ineffective performance by the exercise controller / evaluator team impacted exercise flow and control due to inadequate controller training. The licet...e's self critique identified similar items for improvement as the NRC evaluation team and will be reviewed during a future inspection to determine if items recommended for corrective actions were assigned to a responsible manager and/or a tracking system for followup.

f. Emeraency Ecy_toment and Facilities (F3.06)

(1) Inspection Scope Facilities and equipment were inspected to determine whether the licensee's ECC. emergency response equipment.

instrumentation. and supplies were maintained in a state of operational readiness.

(2) Observations and Findings During the exercise, the inspector observed equipment operations at the location of the simulated accident. No problems were noted. In addition to equipment utilized in response to the simulated accident. the inspector also during a facility tour checked the operability of an air sampler and radiation survey instruments at the South Gate Guard Shack, verified the usability of self-contained breathing a>paratus units at three different locations (Guard Shacc chemical area main step off pad, and Conversion Control Room), and a spot check was made of the SEP and emergency procedures to ensure current versions were maintained at key locations. No problems were noted, all equipment was properly maintained and current copies of the SEP. procedures, and the emergency telephone directory were available. One aspect of the licensee's equipment requiring followup was the audibility of the Criticality Warning System (CWS) inside the res)1ratory )rotection facility.

During the weekly test of tie CWS. t1e inspector evaluated t

e 25 the operability and audibility of the CWS/ fire alarm (referred to as the Voice Communication System or VCS) from the respiratory facility. The inspector noted that the VCS announcement and the fire alarm signal was operable and audible

however, no CWS signal was audible within the facility. Consequently the inspector discussed the test results with licensee and NRC personnel who were positioned in other areas of the plant to observe and evaluate the test. According to personnel at other locations, no problems were noted with operability (see above Section 3.a.(2)(b)). A member of the licensee's staff indicated that the CWS was audible albeit faint in the vicinity outside the respiratory facility. In response to the inaudibility results, t!e licensee expressed plans to review this matter for taking the appropriate actions. The inspector informed the licensee that the corrective actions taken to ensure the audibility of CWS alarms within the respirato 3cility was would be reviewed during a future inspection (IFI 97-05 10).

The inspector reviewed documentation ccvering the period October 1996 to September 1997, to confirm the periodic testing and surveillance performed on emergency equipment and supplies stored in health abysics emergency cabinets (main office building and sout1 assembly point). .nd the cellular phone located at the main guard station used for backup communications in the event of a loss of line communications.

(3) Conclusions The emergency equipment was adequately maintained and appeared to be operationally ready for responding to various types of accidents. The licensee's onsite capability for obtaining meteorological d?ta is archaic and possibly inadequate based on the design and its' capability to withstand certain environmental influence (e.g. high winds).

The inspector discussed this matter with the licensee as an area for review to ensure the operability and accuracy in the event of sever weather conditions. The oudibility of the CWS inside the respiratory facility will be reviewed during a future inspection.

7. Followuo on Previous 1v identified Items

a. Inspection Scope The inspector reviewed actions taken by the licensee to correct previous issues to verify that the corrective actions were adequate and had been completed, t

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26

b. Observations and Findings  !

(1) (Closed) IFI 70 1151/95 V  : 6 thre . Tw;R .nake an  !

Alert declaration in act reat v4 % . anb CSEP 0019. l The inspector observed @e Hum > f cmance in event recognition and emergency dy[61on Gui'Ing the biennial exercise conducted on Septeatser 25, 1997 (See Section 6.e). '

The Alert declaration by the ED in response to the postulated accident was both correct and timely. Within 10 minutes of the initial details provided to the Control Room, an Alert was recommended to the E0 by the EC.  !

(2) (Closed) VIO 70 1151/96 03 04: Failure to conduct an independent audit in accordance with Section 7.8 of the SEP.

The inspector reviewed the licensec's response to the NOV  !

dated November 27. 1996, and reviewed the licensee's corre;tive actions taken in response to the NOV. The licensee's actions taken were consistent with those actions '

committed to in the NOV response. All actions were completed as discussed. However, the adequacy of the audit

• could not be determined due to lack of an audit acceptance orrejectioncriteria. Further, the auditor when contacted informed the inspector as to the duration of the audit and the lack of detailed guidance provided for -

audit (see above discussion in Section 6.a) performing

. Corrective the actions were taken by the licensee as stated in the NOV response. Therefore. the NOV was closed, but the adequacy of the audit was considered an IFI (see above Section 6.a).

l (3) (Closed) IFI 70-1151/96 03 05: Verify that EAL changes meet guidance in Regulatory Guide 3.67 and are approved by the Office of Nuclear Material Safety and Safeguards (ONMSS).

The inspector reviewed Section 3.1 of the SEP entitled Emergency Classification, dated February 19. 1997 and noted that the examples of initiating conditions for the Alert classification were consistent with examples of the Alert classification found in Appendix A to Regulatory Guide 3.67

" Standard Format And Content for Emergency Plans For Fuel  ;

Cycle And Haterials Facilities." In addition, the inspector reviewed the NRC letter granting the approval for changes dated May 15. 1997, from ONMSS. As a result this item is considered closed.

.t 6

l 1 :.

1

-[

27 (4) (0 pen) IFI 70 1151/96 03-06: Verify the actions to ensure  !

timely activttion and staffing of the ECC. -l The inspector discussed with the licensee contact assigned I responsibility for this item and reviewed documentation  !

resulting from the drill.- The inspector noted that a drill  !

requesting estimated time of arrival to the site was  !

performed but the procedure in which the drill was conducted j

, was inadequate for assessing the effectiveness of the i administrative and physical mechanism for ensuring timely  ;

activation and staffing. In addition, the licensee had not i identified what minimum staffing would be required for -

activating the ECC during off hours. Consequently, this l item remains open for additional actions by the licensee,

c. Conclusions j With the exception of IFl 96-03 06, the corrective actions were adequate for closure of orevious issues.

8. Exit Interview The inspection scope and results were summarized on September 26, 1997,  ;

with those persons indicated in the Attachment. The inspector described the areas inspected and discussed the inspection results including the repeat issue involving the presence of candy wrappers and discarded i chewing gum in the chemical area, and the likely informational content  ;

of the inspection report with regard to documents and/or processes reviewed during the inspection. Although pro)rietary documents and l processes were occasionally reviewed during t11s inspection, the proprietary nature of these documents or processes has been deleted from this report. Potential violations were discussed during the exit, but based cn a detailed review of the information and requirements specific  ;

to the issues, the licensee was contacted following the inspection and i informed that no violations resulted. Dissenting comments were not -

- received from the licensee.  ;

I l

, l Y

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),t

• e i

[

t ATTACHMENT f

1. . PERSONS CONTACTED i f

Licensee Personng], j

• J. Allen. Plant Mana  :

• C. Alstadt. Manager.ger Maintenance  ;

• J. Bush, Manager. Manufacturing

• S. Gantt. Engineer. Regulatory Engineering and Operations

• 0. Goldbach, Manager, Chemical Operations -!

• W. Goodwin. Manager Regulator Affairs  !

• J. Heath, Manager. Regulatory ngineering and Operations

• J. Hooper. Senior Regulatory E gineer .

• A. Kaminsky. Manager. Human Resources

• E. Keelen, Manager, Product Assurance 1

• S. Mcdonald, Manager, Technical Services  ;

• D. Precht. Materials Manager

• E. Reitler, Fellow Engineer  :

• T. Shannon, Regulatory Affairs Technician  !

• P. Stroud, Manager. Security and Services N. Stevenson.-Team Manager, Chemical Conversion R. Jacobs. Team Manager. Chemical Conversion s

• R. Williams. Regulatory Affairs Advisory Engineer

• H Ruhl. Team Manager. Maintenance  !

?

Other licensee employees contacted included engineers, technicians, ,

production staff. security, and office personnel. l,

• Denotes those present at the exit meeting on September 26, 1997.  !

Other Personnel

.W. Corley South Carolina Department of Health and Environmental Control ,

2. INSPECTION PROCEDURES USED IP 88020 Plant Operations IP 88055 Fire Safety IP 88005 Management Organization and Controls  :

IP 88010 Training IP 88050 Emergency Preparedness  ;

3. LIST OF-ITEMS OPENED, CLOSED, AND DISCUSSED ltemNumber $1,glui Descriotion

-70 1151/95-06 01 Closed IFI - Failure to promptly make an. l Alert declaration in accordance with the SEP and CSEP-0019.

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1 70-1151/96 03 04 Closed VIO - Failure to conduct an  !

independent audit in accordance with  !

Section 7.8 of the SEP. L 70 1151/96-03 05 Closed IFI - Verify that EAL changes meet guidance in Regulatory Guide 3.67  ;

and are approved by ONMSS.  :

70 1151/96 03 06 Open IFI Verify the actions to ensure timely activation and staffing of the ECC 70 1151/97 03-01 Open IFI Follow up on testing of the  !

centrifuge instrumentation. ,

1151/97 03 02 Closed NOV - Failure to update the  ;

drawings, loop sheets, and a schematics listed on various CCFs as t required by Procedure TA 500. 1 i

70 1151/97-03 03 Open IFI Follow up on the licensee's actions to include the appropriste i supplemental information with the , I appropriate CSE documents.

• 70 1151/97 05 01 Open IFI - Revise the PFP by mid-1998. l

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70 1151/97 05 02 Open IFI Provide clearer identification oftheRegulatoryCompliance  ;

Committee s outputs in the meeting i minutes.

70 1151/97-05 03 Open IFI - Develop an audit checklist and  !

-audit plan detailing the areas of l the audit and the acceptance criteria, t 70-1151/97-05 04 Open IFI - Provide training to exercise  !

controller / evaluator personnel to 3 improve performance.

70 1151/97-05 05 Open EW - Failure to activate a bomb search team in accordance with  ;

procedures. j 70 1151/97 05 06- Open EW - Failure to initiate search. and provide medical attention for the l i missing injured employee.

70 1151/97105 07 Open EW Untimely response by security personnel to unlock the south gate. '

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l Open IFI - Review requirements PSP during access control a drill.

70 1151/97-05 08 Open Verify actions taken inresponse to c IFI 70-1151/97-05 09 bomb threat.

Verify corrective actions IFI 70 1151/97-05 10 Open taken to ensure the audibility ofC protection facility.

4. LIST OF ACRONYMS Ammonium Diuranate ADU Branch Technical Position BTP CAA Controlled Access Area Configuration Control Form CCF Code of Federal Regulation CFR Critical Safety Evaluation CSE Commitment Tracking System CTS Criticality Warning System CWS Calendar Year CY Emergency Action Level EAL Emergency Control Center ECC Emergency Director EO EPS Emergency Procedure SystemEmergency Respons ERO Exercise Weakness EW Health Physics HP Health Physics Coordinator HPC Inspector Follow-up Item IFl IR Inspection ReportIntegrated Safety Analysis ISA ds NOV NRC Notice of ViolationNuclear Regulatory Co ONMSS Pre-Fire Plan PFP Physical Security Plan PSP Quality Control OC RCA Radiation Controlled AreaRegulatory Compliance RCC Revision i nmental Rev.

RPM Revolutions Per MinuteSouth Carolina Departmen SCOHEC Control Site Emergency Plan SEP Special Nuclear Material SNM Uranium Hexafluoride UF Voice Communication System VCb Violation VIO

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70-1151/97-05 08 Open IFI - Review PSP access control requirements during a drill.

70-1151/97-05 09 Open IFI - Verify actions taken in res3onse to communications during a bom) threat.

70-1151/97-05 10 Open IFl - Verify corrective actions taken to ensure the audibility of CWS alarms inside the respiratory protection facility.

4. LIST OF ACRCNYMS ADU Ammonium Diuranate BIP Branch Technical Position CAA Controlled Access Area CCF Configuration Control Form CFR Code of Federal Regulation CSE Critical Safety Evaluation CTS Commitment Tracking System CWS Criticality Warning System CY Calendar Year EAL Emergency Action Level ECC Emergency Control Center ED Emergency Director EPS Emergency Procedure System ERO Emergency Response Organization EW Exercise Weakness HP Health Physics HPC Health Fhysics Coordinator IFl Inspector Follow up Item IR Inspection Report ISA Integrated Safety Analysis NOV Notice of Violation N1C Nuclear Regulatory Commission OaMSS Office of Nuclear Material Safety and Safeguards PFP Pre-Fire Plan PSP Physical Security Plan OC Ouality Control RCA Radiation Controlled Area RCC Regulatory Compliance Committee Rev. Revision RPM Revolutions Per Minute SCDHEC South Carolina Department of Health and Environmental Control SEP Site Emergency Plan SNM Special Nuclear Material UF Uranium Hexafluoride VCb Voice Communication System V10 Violation

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