ML19242D479

Peer Review of the Division of Fuel Facility Inspection 2019 Inspection Reports

ML19242D479
Person / Time
Issue date:	08/29/2019
From:	Thomas Grice, Jonathan Rivera, Timothy Sippel NRC/RGN-II, NRC/RGN-II/DFFI
To:	Eric Michel, Robert Williams NRC/RGN-II, NRC/RGN-II/DFFI
Reeder D
References
Download: ML19242D479 (9)

Text

UNITED STATES NUCLEAR REGULATORY COMMISSION REGION II 245 PEACHTREE CENTER AVENUE NE, SUITE 1200 ATLANTA, GEORGIA 30303-1257 August 29, 2019 MEMORANDUM TO: Robert Williams, Acting Chief Projects Branch 1 Division of Fuel Facility Inspection Eric C. Michel, Chief Projects Branch 2 Division of Fuel Facility Inspection FROM: Joel Rivera, Senior Fuel Facility Inspector (Lead) /RA/

Projects Branch 1 Division of Fuel Facility Inspection Thomas Grice, Senior Fuel Facility Inspector /RA/

Project Branch 1 Division of Fuel Facility Inspection Timothy Sippel, Fuel Facility Inspector /RA/

Project Branch 2 Division of Fuel Facility Inspection

SUBJECT:

PEER REVIEW OF THE DIVISION OF FUEL FACILITY INSPECTION 2019 INSPECTION REPORTS This memorandum documents the results of a peer review for inspection reports that were issued by the Division of Fuel Facility Inspection (DFFI) in calendar years 2018 and 2019. The peer review was conducted in accordance with Regional Office Instruction (ROI) No. 2240, Peer Reviews of Inspection Report, Revision 9. This ROI instructs regional staff to: (1) conduct a peer review, at least once a year, of inspection reports issued by the Division and (2) use an Inspection Report Review Checklist provided in the ROI to conduct the reviews. The ROI-2240 checklist is designed to evaluate inspection reports for operating power reactors, power reactors under construction, and fuel facilities; and therefore, it should be noted that the checklist goes beyond the scope of Inspector Manual Chapter (IMC) 0616, Fuel Cycle Safety And Safeguards Inspection Reports.

Overall, the peer review team did not identify major deviations from the inspection report guidance included in IMC-0616 and the cover letter templates contained in the NRC Enforcement Manual. The team did identify several findings and recommendations for consideration of DFFI management and staff.

Enclosure:

Peer Review of Inspection Reports CONTACT: Joel Rivera, RII/DFFI 404-9974825

ML19242D479 OFFICE RII/DFFI/PB1 RII/DFFI/PB1 RII/DFFI/PB2 NAME JRivera TGrice TSippel DATE 8/29/2019 8/29/2019 8/29/2019 Peer Review of Inspection Reports Division of Fuel Facility Inspection 1.0 Peer Review Approach

• The team used the Reports function of the Reactor Program System (RPS) to identify the list and attributes of inspection reports that were issued in calendar years 2018 and 2019. Since this peer review is typically performed in the middle of the year, the timeframe of inspection reports considered for review overlapped, to some extent, with the timeframe of the previous peer review to ensure continuity between assessments and maximum coverage.

• The team selected a sample of 12 inspection reports for review.

• The inspection sample focused on publicly available inspection reports and reports documenting compliance issues.

• The inspection sample did not include performance assessment reports since this type of report receives considerable peer review during the License Performance Review process.

• For objectivity, each team member selected inspection reports in which they were not involved.

• The team reviewed each report using the checklist in ROI-2240; the guidance in IMC-0616; NUREG-1379, NRC Editorial Style Guide; and the templates in the NRC Enforcement Manual.

• Since none of the findings represented significant deviations from the inspection report guidance, in most cases, findings and recommendations are generally described without specifying the report, facility, branch or staff member. Findings and Observations are also organized based on the applicable report section.

2.0 Findings

For the purpose of this audit, findings are issues that are not consistent with the applicable inspection report guidance or require clarification of the existing guidance.

Section 4.0 contains recommendations and corrective actions for the findings in this report. Some findings did not need standalone corrective actions and will be covered under the first recommendation.

Cover Letter Section 2.1 Some inspection reports did not include the event notification (EN) number in the upper left corner of the cover page as required by IMC-0616. However, IMC-0616 is the only manual chapter that requires the EN number to be included in the cover letter.

2.2 Some stand-alone reports did not follow the format recommended in the NRC Enforcement Manual for the cover page.

Executive Summary Section 2.3 Some inspection reports included open items in the Executive Summary such as open violations that were reviewed and remained open. Inspection Manual Chapter 0616 states that open items should not be listed in the Executive Summary, but it does not elaborate if it is acceptable to discuss open items in certain cases.

Enclosure

2 Report Details Section 2.4 Many reports were inconsistent about the use of Chapter, Section and Paragraph with respect to the Code of Federal Regulations (CFR) and the license application. The CFR is organized by title, part, section, paragraphs in multiple levels like (a)(1)(i)(A)(1)(i). The organization of license applications varies per licensee, but it generally consists of chapters, sections, and paragraphs. When citing or referencing the CFR or a licensing basis document, inspectors should use the appropriate terminology consistent with the structure of the document.

2.5 Inspection Report 70-1151/2017-005 assigned a tracking number to a minor violation.

Minor violations are not tracked in RPS.

2.6 Acronyms were often defined but not used again. In other cases, acronyms were not defined. This is not consistent with the NRC Editorial Style Guide in NUREG-1379.

2.7 Titles of procedures and documents referenced in the inspection scope were not in quotation marks as suggested by the NRC Editorial Style Guide in NUREG-1379.

2.8 The scope of a Permanent Plant Modifications inspection report lacked clarity because it generically described that modifications were reviewed but did not specify the selected modifications and what was reviewed for each modification. For example, statements like Modifications were reviewed to verify ABC without listing the modifications (or referencing the list of modifications in the report attachment) may not be clear to a reader. Statements such as The inspectors reviewed x, y, and z for the modification packages listed below to verify compliance with, would be more consistent with IMC-0616. Inspector Manual Chapter 0616 states that the inspection scope section details the specific items such as equipment or programs that were inspected to determine if the licensee was in compliance with the regulatory standard.

2.9 A report closing a previous cited violation (VIO) did not clearly describe the corrective actions performed by the licensee to restore compliance and the basis to close the violation. Inspector Manual Chapter 0616 states that, in general, the write-up must summarize the inspector's follow-up actions to evaluate the adequacy of any licensee actions and provide enough detail to justify closing the violation.

2.10 A report discussing a previous cited violation (VIO) did not describe what actions were still pending to close the violation. However, IMC-0616 does not contain specific guidance on the level of details that need to be included for an open violation that is discussed in the report. The IMC directs the staff to follow the documentation guidance for licensee identified violations (LIV) in Section 0616-11. However, it is not clear what aspects of the (LIV) documentation are applicable to open violations discussed in the report.

2.11 Some inspection reports included passive voice statements that could have been expressed in active voice as recommended by the NRC Editorial Style Guide.

2.12 An inspection report section did not contain a 'Scope' and 'Conclusions' as required by IMC-0616.

3 2.13 In one case, No findings of more than minor significance were identified was used instead of No violations of more than minor significance were identified as described in IMC-0616.

2.14 In one case, a violation did not contain a title when the tracking number was assigned in the report details as required by IMC-0616. A title was assigned in the Supplemental Information attachment.

Exit Meeting Summary Section 2.15 Several inspection reports included the statement No dissenting comments were received from the licensee in the Exit Meeting summary. Although this statement is in some of the templates, IMC-0616 Section 14.01(f)(4) states that Licensee responses should not be included in the summary except in cases where the licensee disagrees with the violation. In that case, the summary should state that the licensee took exception to the violation. Inspection reports should not include a statement that no dissenting comments were received and should only be documenting when the licensee dissents.

Documents Reviewed Section 2.16 The document dates listed in the Documents Reviewed section of the Attachment did not always use the format recommended by the NRC Editorial Style Guide, which is May 30, 2007 for example.

General Comments 2.17 Two inspection reports had the wrong ADAMS ML number entered in the Inspection Report Tracking System (IRTS) function of RPS.

• BWXT 70-27/2019002 shows ML19107A164; correct ML is ML19107A163

• GNF-A 70-1113/2017005 shows ML18022A062; correct ML is ML18022A064 3.0 Observations For the purpose of this audit, observations are remarks for consideration to improve the overall quality of inspection reports. Section 4.0 contains recommendations and corrective actions for the observations in this report, but their completion will be left at the discretion of DFFI management.

Cover Letter 3.1 Concurrence blocks contained inconsistent terminology to represent staff signatures such as Via FIT and RA (feeder) which may not be clearly understood by a reader.

3.2 URENCO quarterly reports have a concurrence block for Derivative Classifier (DC) review while Category I resident reports do not.

4 Executive Summary 3.3 One inspection report contained minor inconsistencies on the dates for the date range covered by the inspection.

3.4 There were inconsistencies between reports concerning the use of Section or Paragraph in the Executive Summary when listing the sections of the report (e.g., Paragraph A.2, Section D.1).

3.5 Reports often used inconsistent wording for the summary statements in the Executive Summary. Some reports simply stated that no violations of more than minor significance were identified while others elaborated more on the scope of inspection and the findings.

Report Details 3.6 In some cases, inspection scopes contained observations and statements that were not directly associated with the items inspected to determine if the licensee was in compliance with a regulatory standard. For example, a statement such as The inspectors noted that the ABC program included IROFS 1234 would not be relevant if there are no regulatory requirements to include IROFS 1234 in the ABC program. While IMC-0616 neither allows nor prohibit this type of statements in the scope, their use should be limited to avoid confusion.

3.7 Some reports included the number and title of the IROFS and procedures selected for review while others only included the document number.

3.8 The scope of the Emergency Preparedness (EP) inspection in some reports may imply that the NRC was inspecting offsite facilities for compliance. Statements like: The inspectors verified that the ABC County Emergency Agency had the latest copy of the Emergency Plan may imply that the offsite organization is required by NRC regulations to do so. The EP inspection scope should clearly emphasize that the regulatory requirement is only applicable to the licensee. For example: The inspectors interviewed staff from the ABC County Emergency Agency to verify that the licensee had provided the latest copy of the facilitys Emergency Plan as agreed in the Memorandum of Understanding, dated May 10, 2016.

3.9 Some inspection report sections, like Nuclear Criticality Safety, contained extensive inspection scope and potentially redundant or convoluted statements that could be confusing to a reader. Some inspection reports also contained lengthy sentences. For example:

The inspectors reviewed the licensees generation of accident sequences to determine whether the CSAs systematically identified normal and credible abnormal conditions in accordance with the commitments and methodologies in the LA for the analysis of process upsets. This included the review of accident sequences the licensee determined to be not credible to verify the bases for incredibility were consistent with the commitments, definitions, and methodologies in the LA, and documented in sufficient detail to permit an independent assessment of credibility. In addition, the inspectors reviewed select accident sequences designated as not credible to determine whether the bases for incredibility rely on items which should be identified as formal NCS controls

5 or IROFS. This review was conducted for incredible moderator introduction sequences on the x, y, and z processes.

Exit Meeting Summary None Documents Reviewed Section 3.10 Some inspection reports documented only the number of Corrective Action Program documents and work orders reviewed while others listed document number, titles and/or dates.

4.0 Conclusions and Recommendations Overall, the peer review team did not identify major deviations from the inspection report guidance included in IMC-0616 and the cover letter templates contained in the NRC Enforcement Manual. The team identified the following recommendations for consideration of DFFI management and staff.

Associated Recommendation Lead Finding or (Target Date)

Observation All Discuss peer review findings with DFFI management and J. Rivera staff. (9/30/19)

Finding 2.1 Assess whether is necessary to include the EN number in T. Sippel the upper left corner of the report cover page. (9/13/19)

Recommend revisions to IMC-0616 as needed.

Finding 2.3 Evaluate whether open items should be discussed in the T. Sippel Executive Summary. If discussing open items is (9/13/19) acceptable, recommend the level of details required for the Executive Summary. Recommend revisions to IMC-0616 as needed.

Finding 2.5 Verify that RPS does not have an inspection item assigned T. Vukovinsky to the minor violation documented in Inspection Report 70- (9/30/19) 1151/2017-005. Evaluate if a report errata is necessary.

Finding 2.10 IMC-0616 should contain additional guidance on the level J. Rivera of details required for an open violation that is discussed (9/30/19) in the report. Evaluate if the guidance in IMC-0616 for discussing open violations or open items is adequate.

Additionally, evaluate if the connection that IMC-0616 makes between open violations and licensee-identified violations is logical.

Finding 2.15 Revise all inspection report templates to exclude any G. Goff statements referring to No dissenting comments were (9/30/19)

6 Associated Recommendation Lead Finding or (Target Date)

Observation received from the licensee in the Exit Meeting Summary.

In the meantime, refrain from using such statement in any inspection report.

Finding 2.17 Contact the Region 2 owner of IRTS to correct the ML E. Stamm numbers in the system. (Complete)

Observation 3.1 Consider using consistent terminology to describe the type K. McCurry of approval signature on the concurrence block. (9/30/19)

Observation 3.2 Evaluate whether a DC review is needed for Category I L. Pitts quarterly reports (public reports). (9/30/19)

Observation 3.4 Consider using consistent terms to describe the inspection J. Rivera report elements (e.g. Paragraph vs. Section). Inspection (9/30/19) reports do not typically use numbers or any kind of bullets to identify paragraphs. While not explicitly stated in IMC-0616, the manual chapter refers to the report elements as sections. Thus, the term section seems to be the most appropriate one.

Observation 3.8 Consider revising the scope of the EP inspection template IR Template to clearly emphasize that the interactions with offsite Revision Lead responders are to verify that the licensee is meeting its and SPIs applicable regulatory requirements, not to inspect the (9/30/19) offsite organizations. In the meantime, SPIs should verify that report feeders clearly delineate the difference between licensees and offside responders responsibilities.

Observation 3.9 Consider reviewing the NCS inspection template to identify B. Adkins and lengthy and potentially redundant statements in the scope. NCS Contact (9/30/19)

Observation 3.10 Consider achieving consistency on how Corrective Action IR Template Program documents and Work Orders are described in the Revision Lead Documents Reviewed section. and SPIs (9/30/19)

7 5.0 List of Inspection Reports Selected for Peer Review