ML20154Q460

SALP Rept 70-1100/86-99 for Jul 1986 to June 1988.Category 3 Assigned in Areas of Facility Operations,Emergency Preparedness & Licensing Issues

ML20154Q460
Person / Time
Site:	07001100
Issue date:	08/30/1988
From:	NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:
Shared Package
ML20154Q428	List: ML20154Q425 ML20154Q460
References
70-1100-86-99, NUDOCS 8810030405
Download: ML20154Q460 (35)

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SALP BOARD REPORT U.S. NUCLEAR REGULATORY COMISSION REGION I SYSTEMATIC ASSESSMENT OF LICENSEE PE."JORMANCE INSPECTION REPORT NO. 70-1100/86-99 COMBUSTION ENGINEERING. INC.

WINDSOR, CONNECTICUT ASSESSMENT PERIOD: July 1, 1986 - June 30, 1988 BOARD MEETING DATE: AUGUST 30, 1988 j!A2888n8988,?!go  :

SYSTEMATIC ASSESSMENT OF LICENSEE PERFORMANCE COMBUSTION ENGINEERING, INC., WINDSOR, CONNECTICUT I. INTRODUCTION A. Purpose and Overview . . . . . . . . . . . . . . . . . . 4 B. Assessment Panel Meebers . . . . . . . . . . . . . . . . 5 C. B a c k g ro u n d . . . . . . . . . . . . . . . . . . . . . . . 6 II. CRITERIA . . . . . . . . . . . . . . . . . . . . . . . . . . 6 III. SUW4ARY OF RESULTS . . . . . . . . . . . . . . . . . . . . . 7 IV. PERFORMANCE ANALYSIS A. Facility Operations. . . . . . . . . . . . . . . . . . . 9 B. Nuclear Criticality Safety . . . . . . . . . . . . . . . 11 C. Sa feg u a rd s . . . . . . . . . . . . . . . . . . . . . . . 13

0. Equipment Maintenance. . . . . . . . . . . . . . . . . . 14 E. Radiological Controls. . . . . . . . . . . . . . . . . . 16 F. Emergency Preparedness . . . . . . . . . . . . . . . . . 20 G. Vendor Quality Assurance Prograa . . . . . . . . . . . 22 H. Management Control s. . . . . . . . . . . . . . . . . . . 23 I. Fire Protection. . . . . . . . . . . . . . . . . . . . . 25 J. Licensing Issues . . . . . . . . . . . . . . . . . . . . 26 V. SUPPORTING DATA AND SUMMARIES A. Investigations and Allegations Sunnary . . . . . . . . . 28 B. Escalated Enforcement Action . . . . . . . . . . . . . . 28 C. Management Conferences . . . . . . . . . . . . . . . . . 28

0. Licensing Activities . . . . . . . . . . . . . . . . . . 29 2

VI. TABLES

1. Enforcement History 1986 to Present . . . . . . . . . . 30

2. Non-Routine Events . . . . . . . . . . . . . . . . . . 34

3. En fo rcemen t Ac ti vi ty . . . . . . . . . . . . . . . . . 35 t

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SYSTEMATIC ASSESSMENT OF LICENSEE PERFORMANCE COMBUSTION ENGINEERING, WINDSOR, CONNECTICUT I. INTRODUCTION l

A. Purpose and Overview The Systematic Assessment of Licensee Performance (SALP) is an integrated NRC staff effort to evaluate licensee perfomance based on a collection of relevant observations and data. The SALP supplements the nomal regulatory process, which is used to ensure compliance with NRC rules, regulations, and license conditions. The SALP is intended to be sufficiently diagnostic to provide meaningful guidance to licensee management to promote quality and safety of facility operations.

SALP evaluations are not typically performed for non-reactor nuclear facilities. A SALP evaluation of Combustion Engineering Incorporated, is necessary, however, in light of the licensee's sustain,ed poor level of perfomance and the licensee's apparent inability to identify and correct deficiencies in radiation safety, criticality safety, nuclear material accountability, transportation, and other areas.

An NRC SALP Board, composed of the staff members listed below, met on August 30, 1988, to assess the licensee's performance in accordance with generic guidance in NRC Manual Chapter 0516 "Systematic Assessment of Licensee Perfonnance."Section II of this report sumarizes this guidance and the evaluation criteria used in the assessment modified specifically for the unique features of fuel facilities.

This report is the SALP Board's assessment of the licensee's safety performance at Combustion Engineering, Inc.'s facility at Windsor, Connecticut, for the period from July 1, 1986 through June 30, 1988.

B. SALP Board Members gaiman:

S. D. Ebneter, Director, Division of Radiation Safety and '

Safeguards (DRSS) t 4

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R. R. Bellamy, Chief Facilities Radiological Safety and Safeguards Branch (FRS&S). DRSS W. J. Pasciak, Chief. Effluents Radiation Protection Section (ERPS),

FRS&S, DRSS J. Roth, Project Engineer, ERPS, FRS&S, DRSS L. H. Bettenhausen, Chief, Reactor Projects Branch No. 1, Division of Reactor Projects L. C. Rouse, Chief, Fuel Cycle Safety Branch (FCSB), Office of Nuclear Material Safety and Safeguards (NMSS)

G. H. Bidinger, Section Leader, Uranium Fuel Section, FCSB Other Attendees at the SALP Board Meeting J. M. Allan, Deputy Regional Administrator, RI C. E. Norelius, Director, Division of Radiation Safety and Safeguards, RIII E. W. Brach, Chief. Vendor Inspection Branch (VIB), NRR R. R. Xeimig, Chief, Safeguards Section, FRS&S, DRSS M. f.i. Shanbaky, Chief, Facilities Radiation Protection Section (FRPS).FRS&S,DRSS R. L. Cilimberg, Metallurgical Engineer, VIB, NRR G. M. France, Fuel Facilities Inspector, DRSS, RIII M. A. Austin, Radiation Specialist, ERPS, FRS&S, DRSS R. M. Loesch, Radiation Specialist, FRPS, FRS&S, DRSS M. J. A. Gresick, Senior Health Physicist, NMSS A, NMSB, DRSS J

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C. Background Licensee Activities Combustion Engineering, Inc., Nuclear Fuel Manufacturing, is authorized by NRC License No. SNM-1067 to fabricate low-enriched uranium fuel for light water reactors (LWR) and to conduct research and development activities on LWR fuel. The fuel fabrication process consists of mixing uranium oxide powder, foming fuel pellets, removing volatiles and sintering the pellets in electric furnaces, loading the pellets into i zircalloy cladding, and assembling the sealed rods into fuel assemblies.

Of the 2500 employees at the Windsor site, approximately 250 are involved with nuclear fuel fabrication and nuclear fuel research and development.

II. CRITERIA Licensee perfonnance is assessed in selected functional areas that have ~

the potential to significantly affect nuclear safety and the environment.

The following evaluation criteria, where appropriate, were used to assess each functional area:

1. Management involvement and control in assuring quality

2. Approach to resolution of technical issues from a safety standpoint

3. Audits and feedback mechanisms

4. Enforcement history 5.

6. Reporting (and analysis Staffing including of reportable events management) i

7. Training and qualification effectiveness

8. Quality of Procedures and Operations I Based on the SALP Board assessment, each functional area evaluated is classified into one of three perforrance categories. Licensee performance rated belcw the lowest category would have already resulted in escalated enforcement actions, which could include trodification, suspension, or i revocation of the license. The definitions of the performance categories are:

Category 1 - Reduced NRC attention may be appropriate. Licensee .

management attention and involvement are aggressive and oriented toward promoting radiation safety. Licensee resources are ample and effectively L used, resulting in a high level of performance with respect to operational safety.

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Category 2 - NRC attention should be mainteined at nomal levels that are appropriate for the licensee. Licensee management attention and involvement are evident and reflect concern for radiation safety.

Licensee resources are adequate and used effectively so that the licensee achieves satisfactory perfomance with respect to operational safety.

Category 3 - NRC and licensee attention should be increased. Licensee management attention and invol.vement is acceptable and promotes radiation safety, but weaknesses are evident. Licensee resources appear to be strained or not used effectively so that performance with respect to operational safety is only minimally satisfactory.

The SALP Board has also assessed each functional area to compare the licensee's perfomance near the end of the assessment period with that during the entire period to identify any trends in perfomance. The trend l

categories used by the SALP Board are as follows:

Improving - Licensee performance was detennined to be improving near the close of the assessment period.

Declining - Licensee performance was determined to be declining near the close of the assessment period.

III. SU MARY OF RESULTS Our s aluation of the overall assessment of licensee performance indicates that the licensee, at the start of the assessment period, generally did not maintain adequate control over licensed activities to assure effective and responsible performance. In addition, at the beginning of the assessment period, the licensee was not responsive to the NRC initiatives as indicated by the written response to the Operational Safety Assessment. Actions were initiated by the licensee to correct specific violations identified but investigations into the root causes of violations *.e., progranTnatic deficiencies, were not conducted. Toward the end of the assessment period, the licensee initiated actions to strengthen management, investigate root causes of violations, improve staffing and correct deficiencies in process equipment. However, these actions, except for improvements in process equipnent, were taken too late to be adequately addressed or evaluated during this assessment period.

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f Tabulation of ratings for each functional area is as follows:

Ratina for  !

Functional Area Assessment Period Trend Facility Operations 3 Improving Nuclear Criticality Safety 2 -- t

, Safeguards 2 --

Equipment Maintenance 2 --

i Radiological Controls 3 -- i Emergency Preparedness 3 --

Vendor Quality Assurance 2 --

Panagewent Controls 3 --  ;

Fire Protection 2 --

Licensing issues 3 --

i Relative weaknesses which should receive more attention were identified  :

l in the areas of facility operations, radiological controls, emergency pre- l paredness, management controls and licensing. In particular, management  ;

controls should be strengthened through the additional use of internal and -

external audits.

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F IV. _P_ERFORMANCE ANALYSIS A. Facility Operations 1.0 Analys 1, s, Several routine inspections and one special inspection of the special nuclear materials license were conducted during the assessment period. During the early part of the assessment period, the facility production output was expanded without a commensurate increase in personnel staffing. The licensee attempted to operate the facility at the increased rate through the use of required overtime. The expanded production rate also strained the vintage equipment, causing breakdowns that received inadequate corrective maintenance which increased potential for personnel exposures. The licensee employed temporary, makeshift repairs and did not im)lement an effective maintenance program.

This makeshift approac1 to maintenance was an important contributor to regulatory problems. During the last part of the assessment period, the licensee initiated a program of engineered equipment repair and an equipment preventive maintenance program, and recent improvements have been observed.

Over the last several years there has been an inattention to upgrading equipment, a poor preventive maintenance program, a lack of objective quality and safety-related Internal audits, and a primary dedication to production schedules. At the begin-ning of the assessment cycle Combustion Engineering was unresponsive to NRC expressed concerns, in particular, those identified in August 1986 during the operational safety assessment (0SA). For examsle, this facility did not provide a timely or adequate response to t1e OSA. However, a revised response was recently received from the licensee and is being evaluated. Preliminary review indicates it is a substantial improvement over the previous response.

Many of the licensee's problems that were identified during this SALP period could have been resolved had they taken adequate and prompt corrective action in response to the operational safety assessment.

As a result of recent enforcement conferences and nurerous identified viola'. tons (see Table 1), the licensee reorganized the senior staff assor,iated with the Nuclear Fuel Manufacturing facility to improve both product quality and safety programs.

This included all staff positions from the Manager, Nuclear and Industrial Safety to the Vice President, Nuclear Fuel Manufacturing.

The new incumbents in those positions appear to be well qualified and cecriitted to improving the licensed programs. The new 9

organizational structure is a significant improvement over the previous one. However, these staffing changes were only recently made and the effects have not yet been evident to the NRC in the operation of the facility.

There were no reportable events during the assessnant period. l NRC identified a number of nonroutine events which occurred and are listed in Table 2. The NRC identified these because they occurred during or shortly before onsite inspections. It became apparent in discussions with plant management that they were not fully aware of non-routine events in the facility which impact upon the safety of process operations, in sunmary, current Combustion Engineering management recognizes the need for consider 4ble improvement in facilities, procedure.*.

training, and management. Some actions heve been completed. 9 t as the implementation of an interim General Employee Traini u, program. Other actions have been initiated or planned with scheduled completion dates, such as the writing of radiation protection procedures.

2.0 Conclusions Category 3, Improving 3.0 Board Recommendations Licensee: 1. Conduct periodic self-assessments and independent audits of facility operations.

2. Establish and maintain a performance improvement program.

NRC: Perform periodic reviews of licensee actions to identify and achieve milestones in the performance improvement program.

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l B. Nuclear Criticality Safety 1.0 Analysis Three routine inspections and one special operational safety assessment of the nuclear criticality safety aspects of the licensee's operations were conducted during the assessment period.

There were no conditions observed which represented a potential for a criticality incident; however, NRC inspections identified a lack of objective evidence that nuclear criticality safety evaluations were being perfomed on all equipment changes and inadequate nuclear criticality safety training for personnel.

It was noted tN.t the licensee had not established the criteria to determine the type of facility or equipment changes that must be evaluated for criticality safety. In addition, the licensee had not established procedures to assure that each process and equipment change was properly reviewed, evaluated, fabricated, installed and initially operated in accordance with the criteria established as a result of the evaluation.

The licensee had not established an effective mechanism to determine if the criticality safety training given to operators is adequate. The nuclear criticality safety training 3rogram for the facility was improved during the latter part of t1e assessment period. In addition, facility modifications have been 'eade to improve control over process material and reduce the potential for loss of containment. Exarcples are the use of sturdier powder containers and the installation of rigid spacing bars on storage racks.

Management of the nuclear criticality safety program was assigned to the Manager, Nuclear Licensing, Safety, Accountability, and Security, whose responsibilities covered a wide range of activities. The wide range of responsibilities, lack of safety staff, inadequate staff experience and training, and inadequate knowledge of acceptable nuclear criticality safety practices contributed to the poor progran performance.

Technical analyses and reviews were assigned to individuals in the Combustion Engineering Physics DepartrPant who had other substantive responsib111 ties. During the last quarter of the assessment period, corporate management recognized the need to change the program management, and a new individual was appointed to a new position of Hanager, Nuclear and Industrial Safety. Although the individual is qualified to assume safety rnanagement responsibilities, the lack of professional nuclear criticality safety personnel remains as a major deficiency in the program.

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Conclusion:

Category 2 3.0 Board Recommendations Licensee: Establish a fonnal change control system to assure that each process end equipment change is properly reviewed, evaluated, fabricated, installed and operated in accordance with the criteria established as a result of the nuclear criticality safety evaluation.

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P C. Safeguards (Material Control & Accountability and Physical Security) 1.0 Analysis At the beginning of the assessment period, the manager responsible for the MC&A function at Building 17 had limited knowledge in this area and also was assigned several other diverse management responsibilities. The other individual responsible for the ac-countability of special nuclear material was reassigned from an '

audit function following the retirement of the former incumbent.

Minor problems were identified by the NRC during this period

involving inadequate inventories and non-destructive assays.

However, the licensee measurement systems, tested by inter-laboratory comparisons, yieldeo favorable results.

The problems identified by the NRC were attributed, in part, to the responsible individuals' initial lack of familiarity of the MCSA program, and lack of management oversight because of other 1 diverse management duties. By the end of the assessment period,  ;

both incumbents had acquired the needed training and experience and the responsible manager had been relieved of other management duties which enabled this individual to focus attention upon and I improve the Safeguards program.

At the end of this assessment period, the licensee engaged in appropriate prior planning, established realistic priorities and had well stated and defined written procedures for material control and accountability (MCa#) of special nuclear material (SNM) and

for physical security of the facilities. These procedures were generally complete, comprehensive and were generally adhered to.

The licensee's audits were complete, generally timely and thorough.

Additionally, records were observed to be complete, well maintained i

and easily retrievable.

2.0 Conclusions Category 2 3.0 Board Recomrrendations None 13

D. Equipment Maintenance 1.0 Analysis As a result of an incident at the Sequoyah fuels facility, the NRC perfortred operational safety assessments (0SA) of all uranium processing and several major materials licensees. At the start of the assessment period, the NRC conducted an OSA of the Windsor facility. As a result of this OSA, the NRC identified inadequate preventive maintenance conducted on important systems e.g., relief valves on anhydrous anrnonia tanks and equipment, installed water sprinkler systems, annonia disassociators and equipment, and uranium powder processing equipnent. The licenste was reluctant to provide a comprehensive response to the findings of the OSA at that time.

The result of inadequate preventive maintenance on process equipment was illustrated on August 13, 1987 when a shuttlebox on one of the pellet presses malfunctioned and broke away from the uranium powder feed hopper, causing an incident in which 11 operators were exposed to airborne uranium. The shuttlebox was subsequently repaired by the licensee.

During an inspection conducted in October 1987, the inspector identified nany sources of airborne uranium which resulted from inadequate maintenance on equipnent. For example, holes were found in gloveboxes used to contain uranium powder and flexible hoses on various powder delivery systems were repeatedly cracked and repaired with tape. Similar examples of inadequate maintenance were still being identified by inspectors during inspections conducted in May and June 1988.

One problem was identified with respect to inadequate maintenance of ventilation systems to preclude the spread of contamination within the facility. Subsequent to the October 1987 inspection, the licensee initiated a facility ventilation system upgrade program to identify and repair the deficiencies found by the inspectors. This specific upgrade program is still in progress.

The licensee also recently initiated a general preventive main-tenance program and improvements have been observed. For example, an automatic timer has been installed on the grinder which periodically shuts the equipment down to ensure preventive maintenance is performed before it can be restarted. In addition, the licensee hired a maintenance engineering specialist and tasked him with the development and implementation of a preventive naintenance program that will cover all systems and equipnent used in the fabrication cf uranium bearing materials and fuel assemblies.

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In surenary, at the start of the assessment period the licensee's preventive maintenance program at the Windsor facility was inadequate and the licensee did not take timely action to initiate upgrades. However, new and upgraded programs were implemented during the latter part of the period and improvements have been recently observed.

2.0 Conclusions Category 2 3.0 Board Recomendations Licensee: Continue emphasis on the implementation of upgraded programs in this area.

NRC: Conduct comprehensive inspections of maintenance support at the facility.

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E. Radiological Controls There were seven routine and two reactive inspections during this assessment period. Several problems with the radiological controls at the Windsor facility were identified during this assessment period including an inadequate respiratory protection program and excessive contamination levels in the radiologically controlled area.

1.0 A_nalysis This assessment period was characterized by generally poor performance in radiological controls due to inadequate management oversight of the radiation protection program. Audits to identify program status were superficial and lacked independence. The audits performed by the manager of the radiation protection program did not identify the programatic breakdowns subsequently found by NRC inspectors. Corporate and divisional management were not involved in the effective support, oversight and control of the radiological safety program at the fuel manufacturing plant prior to October 1987.

Management of the program was assigned to the Manager, Nuclear Licensing, Safety, Accountability and Security, whose responsi-I bilities covered a wide range of activities, including radiological safety. The wide range of his responsibilities, lack of professional radiation safety staffing, inadequate staff experience and training, and inadequate knowledge of current acceptable radiatisn safety practices contributed to the poor performance of the program.

During the last quarter of the assessment period, corporate management recognized the need to change the radiation orotection program management, and a new individual was appointi.d to a new position entitled "Manager, Nuclear and Industrial Safety". s Although the individual is qualified to assume these management responsibilities, the lack of professional technical personnel remains as a major deficiency in the program.

Radiation protection program staffing was marginal throughout most of the assessment period. In the first half of the period, the radiation protection staff consisted of one Health and Safety Supervisor and three health physics technicians to cover manufacturing operations around the c!ock (three shifts), seven days a week. Subsequently, the licensee hired a radiation specialist (senior health physics technician) and several more health physics technicians. However, there was frequent departure and replacement of health physics technicians which resulted in continual disruption of program implementation.

Health physics training and qualification program inadequacies were found to be a major contributing factor to poor understanding of work and appropriate radiological controls by operators. The 16

training program was designed only to meet minimum regulatory requirements. Toward the end of the assessment period, the licensee hired a consultant to train the health physics staff in respiratory protection. The consultant also developed a General Employee Training (GET) program but it did not successfully address the workplace hazards at the fuel manufacturing plant.

Therefore, that consultant was replaced by licensee training personnel.

An effective radiation protection program is a major factor in establishing a work environment "culture" in which both the general employee and management share a genuinely positive attitude toward safety in all aspects of facility operations. Absence of this "cultural" attitude was evident by the numerous allegations related to workplace safety made by workers to the NRC during the assessment period. These allegations were provided to the licensee during various inspections throughout the assessment period. This situation was exacerbated by the licensee's failure to promote a workplace "culture" or establish an upward comunications system to pemit workers to relate these concerns to management instead of the NRC.

Implementation of the radiation protection program was also hampered by a lack of clear, concise policies and procedures for radiation protection activities. In the first half of the assessment period, the failure to establish radiation safety procedures was identified as a problem by the NRC. The licensee's overall response to assure that they had implementing procedures for radiation safety activities was weak. Additional examples of lack of procedures to control radiological work activities were subsequently identified by NRC. The licensee then committed to review and revise all radiation safety procedures. However, at the end of the assessment period, little progress had been made in establishing and implementing the new procedures.

Deficiencies were found in the licensee's internal exposure control Jnd monitoring programs. Radioactive materials on surfaces in the Pellet Shop had far exceeded license limits. There was no breath!ng zone air sampling program, and the fixed air sampling system sample heads were too far away to adequately measure concentrations of airborne radioactive materials near the workers' breathing zones. The licensee had a poorly established and improperly maintained respiratory protectirn program, that was administered by untrained personnel. The bicassay program was inadequate to measure workers' intake of radioactive materials.

Personnel administering the routine bioassay program were unable to relate the bioassay data to regulatory requiraments.

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O During this assessment period, the licensee did not pursue comprehensive resolution of NRC identified safety issues. Actions were taken to correct items specifically identified by the NRC, but a thorough evaluation of potential programatic weaknesses was never initiated by the licensee. During the assessment period, the NRC identified twenty violations in the area of radiological controls, ten of which were the subject of a Confirmatory Action Letter (CAL) in October 1987 and an enforcement conference in December 1987.

As a result of the October 1987 CAL, the licensee comitted to reduce Pellet Shop contamination levels, establish controls to prevent contamination levels from exceeding the license limit, and establish a respiratory protection program that would be in compliance with the regulations. Toward the end of this assessment period, notable progress was made in the application of engineering controls to minimize the spread of. airborne and surface radioactive contamination. The licensee installed stainless steel sheet metal around facility equipment (pellet presses and hoses) to contain leaking uranium powder. Stainless steel sheet metal was also used to cover conveyor belts and storagt areas to facilitate decontamination efforts. Ventilation systems were replaced to improve air flow. As a result of these facility improverents, general area airborne radioactivity levels and surface contamination levels decreased.

Weaknesses were identified in the licensee's effluent monitoring and cortrol program during this assessment period. There had been no evaluation of the effluent monitoring and control system performance to assure that sampling was represen';ative of discharge streams for gaseous releases. The licensee had hired a consultant to evaluate the monitoring capability of ventilation systems.

That evaluation was not complete by the end of the a,sessment period.

Envirorrental sample analysis was found to be technically sound.

The radiochemist managing the program was highly qualified.

Laboratory equipment was properly calibrated and maintained.

Although not fonnally required in a procedure, participation in the EPA Intercomparison Test for quality assurance of radio-analytical reasurenents was noted. The measurements mada by the licensee's laboratory coepared favorably to the EPA results.

Inadequate management comitment and support for establishing policies and procedures were identified as weaknesses for activities in the radioactive waste management and transportation programs.

Waste materials were inappropriately characterized resulting in improper labeling of waste packages, the improper use of containers, 18 l

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l and improper identification of the radioactive materials on the burial site waste manifest. No training on the regulatory requirements was provided to personnel working in these areas, including the program manager. The implementing procedures for the transportation program had not been updated since 1974.

In sumary, inadequate management support and comitment to a technically sound radiation protection program and practices was evident at the Windsor Nuclear Fuels Manufacturing facility during l this assessment period. This was observed in all aspects of program implementation from exposure controls to radioactive waste management and transportation, with the exception of the environmental sample analysis program, which was well implemented.

Although personnel changes were made in the management of the radiation protection program, these changes occurred too late in the assessment period to ascertain the effectiveness of the new management. NRC fonnally notified the licensee of significant, widespread weaknesses in their radiation protection progran in a December 1987 enforcement conference. Little programatic improvement has been observed through the end of the assessment period.

2.0 Conclusion i Category 3 3.0 Board Recommendations  :

Licensee: 1. Expand and maintain a technically qualified, professional radiation protection staff.

2. Review and revise, as necessary, the facility Radiation Protection Program.

3. Place high priority on the establishment, completion and implementation of written radiation protection procedures.

4. Promote an improved workplace relationship.

"culture", between management and operators.

NRC: Conduct periodic meetings with the licensee to assess the licensee's progress in radiation protection program improvements.

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I F. Emergency Preparedness 1.0 Analysis At the beginning of the assessment period, emergency preparedness activities were evaluated as part of an operational safety assessment ,

(0SA). A comprehensive evaluation was performed of both the l corporate and site emergency preparedness programs. Primary ,

focus was on program administration, organization, implementing procedures, training, facilities, equipment, and coordination with offsite groups.

As a result of the OSA, several key assessment areas were identified that were incomplete or in need of corrective action. .

Deficiencies were found in the following areas: control and distribution of the Radiological Contingency Plan (RCP),

emergency classification schemes in the RCP, emergency noti-fications,drillsandexercises(training),useoftheEmergency Control Center (ECC), availability of an alternate ECC, ,

interface with offsite groups, evaluation of certain fire and -

explosion scenarios, availability of qualified Emergency _

Directors during backshifts, quality of the emergency preparedness audits, and adequacy of emergency preparedness management ,

staffing, j An initial licensee response to the OSA was received in February l 1987 which addressed two NRC violations, however, a comprehensive response to all NRC concerns was not received until near the end  ;

of the assessment period in May 1988.  ;

Initial review of this May 1988 response shows the licensee generally acknowledges many NRC concerns with corrective actions [

scheduled for completion during the last quarter of 1988 through I to the second quarter of 1989, but there still remains areas in which no actions are planned. As some specific examples of this, the licensee comitted to implement program changes in an ECC ,

upgrade, emergency classification scheme revision, and improving i offsite grou) interface; however, the licensee shows no initiative  ;

to improve tie conduct of emergency preparedness audits, external ,

RCP distribution, training of Emergency Directors, and exercise b of the site-wide emergency plan.

In summary, timely response and resolution to the NRC-identified i deficiencies has not been evidenced in al? cases. Weaknesses in -

the key progran areas of staffing, training, and management oversight have been prevalent throughout the period.

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i 2.0 Conclusions t i

Category 3 3.0 Board Recomendations ,

Licensee: Conduct a site-wide dtmonstration of the emergency plan and include offsite support agencies.

NRC: 1. Observe a demonstration exercise of the emergency I plan. ,

2. Perfonn a reinspection of the emergency preparedness  !

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I G. Vendor Ouality Assurance Program 1.0 Analysis The Vendor Inspection Branch (VIB) performed two inspections at the Combustion Engineering (CE) Nuclear Fuel Manufacturing facility at Windsor, Connecticut, during the assessment period. Vendor Inspection Branch inspections focused on implementation of the product (fuel pellets, rods and assembly) quality assurance program to assure the quality of the fuel used in the nuclear power plant reactors. Numerous weaknesses with regard to the adequacy of procedures and following of procedures were identified. In addition, a programatic deficiency concerning the use of temporary procedures was found in that the facility quality assurance program did not address this type of procedure.

However, in general, it was determined that the licensee maintained and implemented a quality assurance program for the fabrication of nuclear fuel assemblies which complied with the requirements of 10 CFR 50, Appendix B. Specifically, the welding program, zircalloy tubing specifications, purchase orders material certifications, supplier audit program and welder qualifications were appropriate for the activities undertaken at the facility.

2.0 Conclusions Category 2 3.0 Board Recomendations 1.icensee: Apply appropriate sections of the facility quality assurance program to the facility safety and cornpliance activities.

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H. Management Controls 1.0 Analysis During the operational safety assessment conducted at the be-ginning of the assessment period, the inspection team identified a significant weakness in the corporate or division policies or -

procedures that provided for the establishment and execution of a written safety program. As a result of this deficiency, the workplace "culture" of the facility, previously mentioned in Section E of this SALP report, did not foster an attitude toward improving the safety and compliance of licensee activities.

A management control mechanism used by the licensee is the Nuclear Safety Comittee. This cotnittee met annually during the assessment period in accordance with the minimum meeting frequency required by the license. The usefulness of this comittee is significantly diminished when it meets on such an infrequent basis.

Another management control tool used by the licensee is the performance of internal audits in the areas of nuclear criticality safety, radiological safety, and material control and accounta-bility. During the assessment period, the NRC identified that the licensee had failed to conduct an annual audit of the material control program and hac not used personnel independent of nuclear criticality and radiological safety to perform the annual audits of these two respective programs. These deficiencies contributed to an ineffective internal audit program. As a result, objective self-assessment by the licensee was difficult to achieve. ,

During the assessment period, the NRC identified that licensee management has not established a fomal mechanism by which il can assure that corrective actions were completed on NRC-identified or licensee-identified roncompliance items. The licensee also tended to focus attention only on the specifically identified program without taking a broader view toward correcting programatic deficiencies.

In sumary, there is little evidence to indicate that the licensee improved its self-assessment capabilities during the assesstnent period. The failure to utilize effective management controls ,

contributed to a poor compliance status during the assessment period.

2.0 Conclusions c

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3.0 Board Recomendations -

Licensee: 1. Improve self-assessment capabilities.

2. Develop an internal inspection and audit program, i

3. Increase the meeting frequency and effectiveness  !

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NRC: Conduct more frequent inspections of management controls. l 7

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I. Fire Protection 1.0 Analysis An assessment of the fire fighting and suppression capabilities at this facility was conducted near the start of the assessment period. As a result of that assessment, it was determined that management attention in the area of fire protection appeared to be lacking. Excessive combustible materials such as paint, paint thinners, and empty cardboard boxes were observed throughout the work area. Poor housekeeping conditions were also observed throughout the plant. Several fire extinguishers were misplaced in that they were located in the direction away from nomal egress paths available during energency evacuation. In addition, there was a lack of proper surveillance and testing of installed fire suppression systems. For example, a dry fire sprinkler system was never tested to assure proper operation following initial installation.

Subsequent to that initial NRC assessment, the licensee purchased and installed flamable material storage cabinets. However, each of those cabinets has been filled to capacity with flamable materials. Persennel other than health physics technicians have been trained in the use of fire extinguishers. The fire sprinkler systens have been placed on a periodic testing schedule. However, procedures for the implementation of fire fighting techniques will not be written until mid-1989.

In general, it was detemined that management attention to fire protect ion aspects of the facility has improved.

2.0 conclusions Category 2 3.0 Board Recomendations, None 25

J. Licensing Issues 1.0 Analysis The quality of license amendment applications submitted during the assessment period has been poor. With the exception of two arendments to store shipping containers and to extend the expiration date of the license, all applications required numerous revisions or supplements which followed telephone conferences and/or meetings.

However, it was noted that Combustion Engineering responded promptly to the need for additional information. Even so, the quality of the information provided is lacking and this results in the sub-mission of additional supplements or revisions. The numerous revisions of each amendment application has placed the NRC staff in the role of consultant as well as regulator.

Usually Combustion Engineering initiates the amendment process in a timely manner. However, combustion Engineering's overall administration of the licensing process has been poor. For example, an amendment application submitted on January 20, 1988 was written l by the licensee such that it would have inadvertently eliminated the nuclear criticality safety controls and requirements which were the basis of approval for two previous amendments that had been recently issued on August 20, 1987 and January 4,1988.

In another example related to the aforeaantioned January 20, 1988 amendment applicati m , the licensee deleted certain infor-mation, that was required for the approval of this amendrent and of the subsequent license renewal application submitted en April 27, 1988. The inadequate information in both the amendment and renewal applications was due, in part, to the licensee's failure to confer with the NRC licensing staff and non-use of the guidance in pegulatory Guide 3.52 to detennine what inforration was required for licensing submittals.

The licensing function was reassigned early in 1988 to a dedicated licensing staff. The expected ir.proverent in the licensing practices has not been realized. This may be due to the lack of experience by the newly assigned personnel in Part 70 licensing requirenents and practices.

On the positive side, Combustion Engineering has cooperated with the NRC licensing staff's requests for improvements. For example, starting with the second revision of the application for kendment No. 10 issued August 20, 1987, the licensee uses the date of each submittal (rather than the date of the first submission) on revised pages of the application which pennits easy identification 26

I of current pages of the application. A second example of cooperation was provided in the revision of the application for Amendment No.11 issued January 4,1988, which was written so that all requirements steming frem the amendment would be incorporated into Part I of the license application by the licensee and thus -

would not require introduction of special license conditions by the NRC. f e

2.0 Conclusions Category 3 3.0 Board Recommendations Licensee: 1. Continue the use of a dedicated licensing staff. [

2. Assure that the dedicated licensing staff is trained in the preparation of Part 70 license modification submittals. ,

3. Provide adequate technical support to the licensing staff, i

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Y. SUPPORTING DATA AND SUMMARIES A. Investigations and Allegations Sunnary There were no investigations during the assessment period. A total i of 24 allegations were received by inspectors during or in response i to inspections in October and November,1987; Harch,1988; and June, 1988.

B. Escalated Enforcement Action  ;

Violations during the assessment period are sunnarized in Table 1.

As a result of Radiological Protection inspections during Octobe'a .

1987, a Confirmatory Action Letter (CAL) was issued to the licensee on October 27, 1987. The CAL confirmed that the licensee would .

innediately take actions to reduce contamination levels in the Pellet ,

Shop and modify the existing respiratory protection program to ensure i that it is in accordance with Regulatory Guide 8.15.

Inspection Report No. 070-1100/87-05 identified 10 violations of license conditions or federal regulations in the area of radiological safety.

As a result, an enforcement conference was held with licensee representatives on December 1,1987. A proposed Civil Penalty in the ,

amount of $12,500 was issued on January 25, 1988. The licensee paid  ;

the Civil Penalty by letter dated February 23, 1988. ,

Inspection Report No. 070-1100/88-03 identified 8 apparent violations of license conditions or federal regulations in the area of nuclear '

criticality safety. A second enforcement conference was held on May 10, 1988. A Notice of Violation containirg seven violations was subsequently issued to the licensee on June 6, 1988. The licensee's ,

response to that hotice of Violation, dated July 8,1988, is currently i being reviewed for adequacy.

Inspection Report Nos. 070-1100/88-05 and 070-1100/88-06 identified a L total of 8 more apparent violations of license ccnditions or federal '

regulations in the areas of radiation safety, nuclear material control and measurements, transportation, and other areas. A third enforcement conference was held on August 3,1988, to discuss failures in the 6 management control system that allowed the violations to occur, corrective r actions and progran upgrades to rectify these management control l deficiencies. Further enforcement actions are currently being evaluated i by Region 1 managerent.  !

I C. Managerent Conferences j No management conferences occurred during the assessment period other than three enforcement conferences that were held on Decenter 1,1987- i May 10, 1988; and August 3, 1988.  !

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i D. Licensing Activities A chronology of licensing actions is tabulated below. For each amendment, the tabulation includes the dates of the original amendment applications and all subsequent meetings, supplements, l and/or revisions. [

/aendment No. 7. Dated 8-4-86 [

Application Dated 12-16-85  :

Supplements Dated 3-18 86, 5-19-86, and 6-20-86 l Amenderent No. 8. Dated 3-13-87 Application Dated 3-20-87  :

/eendment No. 9. Dated 4-8-87 l Application Dated 11-6-86 Supplements Dated 2-18-87 and 3-18-87 I i

/mendment No.10. Dated 8-20-87 i Application Dated 12-17-86 '

Meeting Dated 2-18-87 Revision Dated 3-18-87  ;

Peeting Dated 7-13-87 Revision Dated 7-24-87 i Amendment No.11. Dated 1-4-88  :

Application Dated 10-9-87 Meeting dated 12-10-87  ;

Revision Dated 12-5-87  ;

r Attendment No, 12. Dated 2-9-88 i Application Dated 1-7-88  ;

6 Arnendment Pending j Application Dated 1-20-88 Meeting 6-29-88 i:

Meeting 7-25-88 .

Revision to be sutnitted ,

Amendment Pending ,

Application Dated 7-13-88 l Reorganization effective 6-2-88  :

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! Combustion Engineering Enforcement History 1986 to Present 1988 l Inspection Report No. 070-1100/88-06: 2 proposed violations in Radiation l Safety Proposed Failure to survey radioactive material during trash compaction to l assure coepliance with 10 CFR 20.201(b).

1 1 Proposed Failure to provide indium foil criticality dosimeters to visitors in the Pellet Shop.

Inspection Report No. 070-1100/88-05: 6 proposed violations in Radiation Safety and Nuclear Material Accountability l Proposed Failure to follow requirements of Radiation Work Pennit.

Proposed failure to post all of the documents required by 10 CFR 19.11 at sufficient locations in Building 5.

Proposed Failure to label waste containers in accordance with 49 CFR 172.403.

Proposed Failure to provide infonnation specified in 10 CFR 20.311(b) on waste manifest fonns.

Proposed Failure to measure uranium and uranium-235 on all waste discards as required by the Fundamental Nuclear Material Control Plan (FNMCP).

Proposed Uranium-235 measurements were not within the calibrated range for absolute filters as required by FNMCP Annex Section 4.1.3.

Inspection Peport No. 070-1100/88-04: No violations in Material Control and Accounting l Inspection Report No. 070-1100/88-03: 7 violations in Administrative and l Criticality Safety Controls SL4 Failure to nark each mass-limited container with the actual uranium content and enrichnent.

SL4 Failure of the and Security to Manager.

approve Operations Nuclear Licensing.(Safety.

sheets Accountabilityprocedures) to include appropriate safety precautions in Operations sheets.

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SL4 Failure to maintain pellets within the required four-inch slab thickness on the fuel pellet storage shelves.

SL4 Failure to evaluate the effects on nuclear criticality safety of an accumulation of uranium oxide powder under the conveyor adjacent to t

the Batch Makeup Hood.

SL4 Failure to control the addition 'f uranium oxide to the Harrrermill Hood to assure that the posten N ',s limit is not exceeded.

SL4 Failure to include uranium-235 contained in sedirent removed from liquid waste tanks and pipes in Building 6 on inventory.

SL4 Failure to provide training in nuclear criticality safety and failure to test workers to ascertain the effectiveness of the training provided.

Inspection Report No. 070-1100/88-02: No new violations in Radiological Safety inspection Report No. 070-1100/88-01: No violations in Material Control and Accounting (Measurer.ents) 1987 Inspection Report No. 070-1100/87-06: 1 violation in Radiological Safety

--- Failure to maintain docurnentation of surveys as required by 10 CFR 20.401(b)i Continuation of violation identified in Inspection Report No. 070-1100/87-05.

Inspcetion Report No. 070-1100/87 05: 9 proposed violations in Radiological Controls. Issued one SL3 violation in the aggregate; CP issued 1/25/88

--- Failure to maintain Pallot Shop contamination levels below license limits, as specified in SNH-1067 Section 3.2.8.1.

--- Failure to perform bioassay measurerrents to assess intake by 4 workers,10CFR20.103(a)(3).

--- Failure to perform , adiological surveys.10 CFR 20,201(b).

--- Failure to maintain a respiratory protection program.10 CFR 20.103(c).

Failure to take suitable measurerents of concentrations of radicactive materials in air.10 CFR 20.103(a)(3).

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--- Failure to use process or engineering controls to limit concentrations of radioactive mater (als in air 10 CFR 20.103(b)(1).

--- Failure to instruct workers, 10 CFR 19.12.

--- Failure to post notices to workers 10 CFR 19.11.

--- Failuretomaintainrer.ordsofsurveys,10CFR20.401(b).

Inspection Report No. 070-1100/87-04: 1 violation in Material Centrol and Accounting SL5 Failure to provide written instructions to personnel that were  !

sufficient for the verification of inventory data as required by l') CFR 70.51(t)(4)(v).

Inspection Report No. 070-1100/87-03: 3 violations and a safety concern in Radiological and Criticality Safety Controls SL5 Failure to post four of five furnaces (work stations) with nuclear safety limit signs.

SL4 Failure to maintain at least a 20-foot separation between two arrays of shipping containers.

SL4 Failure to comply with all nuclear safety controls specified by a nuclear safety evaluation.

Dev Failure to provide remanent corrective actions to cleanup and store uranium-centaminated waste solutions following a spill; identified as a safety concern.

Inspection Report No. 070-1100/87-02: 1 violation in Safeguards SL4 Failure to perform a management review and audit of the measurement control progran within a 12-month interval.10 CFR 70.57(b)(2). t Inspection Report No. 070-1100/87-01: 5 violations in Radiological Controls  !

SL4 Failure to perform annual audits of criticality safety and radiological safety by independent reviewers.

SL4 Failure to establish procedures for radiation protection activities, i S'.4 Failure to post area with "Caution - Radioactive Materials" signs.

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SL4 Failure to label containers with "Caution - Radioactive Materials" signs.

SL4 Failure to calibrate radiation detection instrumentation.

Inspection Report No. 999900002/87-01: 5 Nonconformances observed as part of a Quality Assurance Review Contrary to Criterion 8 of Appendix B, traceability was traintained only when required by contract.

No procedures established to describe the use of temporary shop instructions.

The procedures for grinding pellets was not adequate.

End cap protection was not installed on guidetubes as required by procedures.

Contrary to procedures, the door to the stacking and loading room was propped open.

1986 Inspection Report No. 070-1100/86-05: No violations in Material Control and Accounting Inspection Report No. 070-1100/86-04: 2 violations detected as part of the Operatienal Safety Review SL4 Failure to verify, on a quarterly basis, the operation of the automatic fire door in the virgin powder prep storage area under power failure conditions.

SL4 Failure to conduct a nuclear criticality safety evaluation for storage of natural uranium rods on top of a safe slab in Building 2 vault.

Inspection Report No. 99900002/86-01: 2 Nonconformances observed as part of a Quality Assurance Revi&w Ink changes were nade to Sections B.4.0 and B 5.0 of Operation Sheet (0.S.) Number 945, "Leak Test " Revision 32, dated June 1, 1984, without proper approvals.

Helium leak test was not being conducted for a minimum of 30 seconds as required in Section B 7,0 of 0.S. Nunter 945, "Leak Test,"

Revision 32.

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...s TABLE 2 r L

Non-Routine Events During Assessment Period i Date Description  !

8/13/87 A shuttlebox en a pellet press malfunctioned while pressing l uranium oxide powder into fuel pellets. A shuttlebox is a  :

device used to carry the powder from the feed hopper to the i die platen of the pellet press. Eleven operators received  !

measurable intake of uranium oxide. These individuals were l restricted access to further exposures until full evaluation j of the exposures was completed. j t

12/17/87 Hydrogen analyzer fire caused by internal short circuit.  :

Pellet Shop workers evacuated because of dense smoke. No i significant contamination and no release of radioactive  !

materials to unrestricted areas. [

3/1/88 Uranium oxide powder ssill caused by break in hydraulic pressure f of lift mechanism. Worcer's face and are contaminated. Area was  !

imediately decontaminated. No release of radioactive material t to unrestricted areas. [

l 3/3/88 Uranium oxide pellet spill caused by entanglement of pellet  ;

cart with rollup dcor at west end of Pellet Shop Annex during j routine security check. Required 3) to 4 hours4.62963e-5 days <br />0.00111 hours <br />6.613757e-6 weeks <br />1.522e-6 months <br /> to be reported  ;

to licensee management. No release of radioactive material to  ;

unrestricted areas.

l 6/9/88 Air sample on FA-1 Filter Bank exceeded action limit of 1E-12 I microC1/cu.cm caused by failure of tension mechanism that I holds absolute filters in place. The FA-1 ventilation system j was im ediately shutdown. No significant release of radioactive t material to unrestricted areas occurred. [

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TABLE 3 ENFORCEMENT ACTIVITY FUNCTIONAL NO. OF VIOLATIONS IN EACH SEVERITY LEVEL AREA Y IV  !!!  !!  ! DEV TOTAL Facility Operations 1 1 Nuclear Criticality 1 9 10 Safety Safeguards 1 4 5 General Equipenent 1 1 Maintenance Radiological Controls 1 16 2 19 Ernergency Preparedness Vendor QA Progran 7 7 Hanagement Centrols 1 1 2 Fire Protection Licensing Activities TOTAL 4 31 2 8 45 35

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