Predecisional Enforcement Conference Apparent Violation – Criticality Warning System (CWS) Signal Delay NRC Region II Atlanta, GA April 4, 2012

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• Background and Facts (Holmes)

• Apparent Violation and GNF-A Response (Murray)

• Safety Significance (Murray)

• Event Investigation & Actions (Holmes)

−Technical

−Organizational

• Excellence Plan (Holmes)

• Conclusion (Walsh)

Agenda

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Background and Facts

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Criticality Warning System Functional Diagram

DAM # 1

Detector

Detector

Detector

Detector

Detector

Detector

Detector

Detector

Detector

DAM # 2

DAM # N

Secondary Tones and Amplifiers

Primary Relay Panel

Monitor and Maintenance

Detect Decide Protect

RP ECC Local Panel

RP – Radiation Protection ECC – Emergency Control Center DAM – Data Acquisition Module

Horns

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Simplified Timeline

CWS MORT Root Cause Investigation

Report Issued

Operational Self Assessment

and Readiness Reviews Complete

Fuel

Manufacturing Operations

Authorized to Resume

CWS Requalification

Testing Complete

Full Personnel

Access Granted

Limited Personnel Allowed to Perform

Authorized Activities

CWS Comprehensive System Tests

Complete

Independent Root Cause Team

Initiated Investigation

CWS re-testing to confirm inaudible horn corrected. Management

informed of delay in signal actuation

Fuel

Manufacturing Operations

Suspended – Personnel Evacuated

Initiating Event

Inaudible CWS

Evacuation Signal in

Chemet Lab Discovered

.

CWS Horn Activation System

Component Failure

Identified and Repaired

CWS

Evacuation Signal Delay

Recognized by Radiation Protection Technician

.

CWS Evacuation

Signal Delay Recognized by

Radiation Protection Technician

.

*NRC event notifications

Restricted Access

Employee Training

Week of July 29

Discovered during Extent of Condition Investigation

Apparent Violation & GNF-A Response

NRC Apparent Violation • Delay in CWS alarm signal activation

• Failure to meet license requirement that the system initiates immediate evacuation of the facility

GNF-A concurs.

The delay in the CWS signal activation resulted in a failure to meet the license requirement.

GNF-A Response

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Safety Significance

Actual Significance

• No events occurred that would have resulted in actuation of the CWS.

• No plant upset condition or elevated radiation levels existed.

• Nuclear safety controls remained intact.

• Double contingency was maintained at all times.

Potential Significance

• In the event of a criticality, the automatic evacuation signal would have been delayed ... the manual evacuation signal was available.

Safety Significance

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Corrective Actions

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Immediate Corrective Actions • Fuel manufacturing operations were suspended –

restricted access to the Controlled Access Area (CAA).

• Component failure was diagnosed and repaired.

• Extensive CWS requalification tests performed.

• CWS procedure was upgraded.

• Weekly verification testing was added and area audibility testing was augmented.

Initial actions taken as part of phased restart

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Event Investigation and Actions I. Technical

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Event Investigation and Actions - Technical

Added parallel alarm monitoring Added weekly test of system Enhanced monthly system testing:

– Verification of detector response and calibration – Expanded audibility testing participation – System alarm response time monitoring

Event Investigation and Actions II. Organizational

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• Independent, cross-functional team used Management Oversight and Risk Tree (MORT) methodology to perform root cause analysis (RCA).

• RCA identified four root causes and four contributing factors.

Event Investigation and Actions - Organizational

• Nuclear safety culture • Nuclear safety policy and program

implementation • Controls of equipment and

processes • Policies, programs, and controls

implementation

• Work practices

• Corrective action program

• Standards for procedures

• Oversight

Root Causes Contributing Factors

Excellence Plan

Nuclear Improvement Strategy

• Executive ownership

• Weekly rhythm

• Two-year plan

• Industry excellence • Process excellence • Regulatory excellence • Safety & Security excellence

• Significant event & RCA actions including: Sinter Test Grinder & Criticality Warning System

• Strengthen procedures, training and oversight

• Focused on fuel mfg operations

Raise the bar on nuclear safety and regulatory compliance … #1 focus

Excellence Plan

RCA Action Plan

Raise the Bar

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Raise the Bar (RTB)

Implement compensatory measures

Complete commitments for STG/CWS

Enhance problem identification and resolution

Simplify procedures and improve flow-down

Strengthen process surveillance + HU observations

Improve training program

Engage employees to assure organizational learning

Communicate internally and externally

• RCA actions … 80%+ in ‘12, complete in ‘13

• Problem Identification & Resolution – New CAP system user testing underway – “Go live” in second quarter

• Procedures – Requirements flow-down – Simplified procedure format

• Surveillance program – Staffed program – Completed 60+ surveillances

• Training – Implementing SAT-based program – OJT trainer/evaluator qualification program

• Employee engagement – Completed 2-day employee team feedback session – Employee teams engaged in procedures and training

• Communication – “I am relied on for safety” campaign – Nuclear Safety & Security traits and behaviors

8 Missions Status Update

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• Adopted industry model from NEI … piloted in 2011

• Institutionalized business commitment with policy and procedure … roles and responsibilities at all levels

• Monitoring safety culture traits for trends

• Performing quarterly review meetings with senior leadership team

• Monitoring performance through Nuclear Safety and Security Council

Monitoring our Nuclear Safety Culture

Drive better leading indicators for proactive improvements … monitor and measure culture

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Conclusion

Conclusion

Nuclear safety is #1 priority

• CWS is fully operable with robust surveillance process

• GNF-A continues to address programmatic issues through multi-year Raise the Bar plan with focus on culture, procedures, training and oversight

• Continued focus on nuclear safety culture and behaviors is fundamental to business success

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