Atomic Energy of Canada Limited National Research Universal Reactor Safety System Upgrades and the Canadian Nuclear Safety Commission's Licensing and Oversight Process

VIII. Untimely Installation of the EPS Connections to the Main Heavy Water Pumps P-104 and P-105

AECL specifically requested the Talisman Team to review the reasons why the connection of EPS to MHWPs P-104 and P-105 had not been made as of November 2007. The Talisman Team interviewed most of the individuals who were involved in the NRU safety upgrade program, and reviewed the program documents related to the EPS upgrade - as noted in the sections above. The Talisman Team concluded that the fundamental reason for the long installation time was the AECL site management' beliefs that the connections were not an AECL licence requirement. As a result of those beliefs, the AECL resources available to the safety upgrade program in early 2006 were diverted to responding to the Directives and Actions identified in the CNSC QA audit report, which had to be addressed to support the AECL licence renewal hearings before the CNSC Commission.

The lack of any apparent CNSC concern regarding the missing connections appears to have reinforced the belief that these connections were not considered very important from a safety aspect. Prior to the CNSC Compliance Inspection, and prior to the Licence Condition that required the safety upgrades to be fully operational by the end of December 2005, AECL management was tracking the activities to make these connections as a "Non-REG" item in the AIMS tracking system in the section that was part of the Environmental Program. The initial entry that documented this status was made in the AIMS tracking system in September 2004. It continued to be tracked in the AIMS system until March 2007, when it was removed and was no longer included in any major AECL tracking system, and oversight was transferred to the "environmental panel."

The Talisman Team reviewed the NRU Licence Extension Project Report for July 7, 2006 and the NRU Licence Extension Project meeting minutes for March 2007, to see if the DC Motor Starter connection status was being tracked. It was not identified as an action item being tracked in either system. As a consequence, the connections were being implemented in a non-priority manner. In interviews with key individuals involved, the Talisman Team was informed that the reactor operations group wanted to proceed cautiously with any changes to the power supply of MHWPs P-104 and P-105, since those two pumps were key components of the emergency safety cooling system. The operators viewed the current power supply configuration to the MHWPs as robust and highly reliable and, as a result, they had high confidence in the existing configuration. Consequently, there was no sense of urgency, from any part of the NRU operating organization, to complete the tie-in. The only group that expressed a sense of importance and urgency to the connections was the SRC. In early 2006, when the SRC became aware that the connections were not made as part of the EPS upgrade, it requested the NRU staff to prepare a schedule for implementation. The SRC was unsuccessful in convincing the NRU staff of the safety benefit of the EPS to the MHWPs. As noted above, although plans were developed to connect the pumps, this was never raised as an important safety improvement that had any schedule priority.

The AECL staff had recognized the need for a formal process for managing regulatory commitments, and issued for use procedure CW-508760-PRO-246, Managing Canadian Nuclear Safety Commission Correspondence and Regulatory Commitments, in June 2006. This procedure included many essential components of a good regulatory commitment management and tracking process, but it was not required to be used. Commitments and other actions were still being entered into the AIMS database, and were not always being entered into the "trAK" system, as required by PRO-246.

Observation (21) Enforcement (E)

The CNSC audit inspection of the safety upgrades, which included the EPS upgrades, did not classify the missing connections as a licence violation, or an issue that warranted being identified as a Directive or Action Item. This was not highlighted, even though members of the audit team were aware that the connections were not made. This further supported the NRU site management' belief that the EPS connections to the MHWPs were not a CNSC regulatory requirement. As a result, the NRU reactor staff refocused essentially all available safety upgrade resources to address other significant items that had been identified in the CNSC audit report in order to support the licence renewal.

Recommendation

Recommendation C-E-1 addresses this observation.

Observation (22) - Commitment Management (CM)

The Talisman Team concluded that both the CNSC and AECL staffs were focused primarily on the responses to the ten Directives, five Action Notices and two recommendations, with less attention being given to the eighty-five findings, which appeared to be treated as less important inspection findings. Without a formal commitment tracking system, individuals used their own judgment as to how to track work activities. As of April 1, 2008, AECL made a decision to use a single tracking procedure for managing all AECL responses to CNSC correspondence and regulatory commitments, which, if properly implemented, should significantly improve the management attention to these action items (see CW-508760-PRO-246). This system is also intended to track activities internal to AECL, such as responses to internal safety audits, emergency drills, and AECL inspections. These items are tracked as Non-REG items.

Recommendation

A-CM-6: AECL should revise procedure CW-508760-PRO-246 to include a safety significance evaluation for any Non-REG entry into the system. For those that are considered to be significant from a health and safety perspective, a level of schedule control similar to the one used for regulatory [REG-C, REG-M and REG-I] actions should be adopted and used.

AECL Management Response
AECL' ImpAct process identifies all events, regulatory and non-regulatory, and tracks the requisite corrective actions. Events are rated according to their safety and programmatic significance, and actions to address the more significant events are subjected to increased schedule control.

Observation (23) - Commitment Management (CM)

The NRU commitment tracking system was not effective in tracking and monitoring the EPS connections to the MHWPs. Despite the fact that these connections were part of the EPS safety upgrade planned by AECL, by 2007 this safety upgrade was not tracked in the NRU commitment tracking system at all.

Recommendation

Recommendation A-CM-3 addresses this observation.

Observation (24) - Regulatory Compliance (RC)

During the CNSC Type I Inspection audit of two of the "completed" NRU safety upgrades, the inspectors identified that the commissioning tests of the DC motor starters were not documented. AECL responded to the inspection on two occasions, stating that the starters were not connected, but AECL did not identify the fact that the EPS upgrade modification was commissioned without having been fully implemented, and that the "stream of correspondence" regarding the upgrades was in conflict with the mindset of key NRU project staff, who believed that the tie-in was an enhancement and not part of the original seven upgrades.

Recommendation

A-RC-1: AECL should assess the effectiveness of NRU' regulatory compliance process.

AECL Management Response
AECL will conduct an effectiveness review of regulatory compliance in NRU as part of an upcoming PINO performance-based audit.

Observation (25) - Oversight (O) - Safety Review Committee

The AECL SRC supported the safety upgrades and considered the EPS tie-in to the MHWPs as an important safety upgrade. However, when it became aware that the tie-in had not been made, the SRC was ineffective in ensuring that senior AECL management clearly understood the safety and regulatory significance that the tie-in be made expeditiously. The safety benefit of implementing the modification to connect the MHWPs to EPS was not acknowledged by NRU site management following review by the SRC, and was not elevated to AECL Corporate Management for resolution.

Recommendations:

A-O-1: AECL should include non-AECL safety experts as members of the SRC, to strengthen its independence and objectivity.

AECL Management Response
As part of the mandate revision for the SRC, representation by independent external experts is being sought (see overall recommendation 15).

A-O-2: AECL SRC reports to management should highlight important safety issues as the first part of their quarterly reports.

AECL Management Response
AECL will ensure that guidance on SRC reporting to executive management is included in the revised mandate, including briefings to the executive following SRC meetings (see overall recommendation 15).

A-O-3: AECL management should communicate an expectation that the SRC should be more assertive in requesting and obtaining responses from the line organizations.

AECL Management Response
The SRC mandate revision will ensure that SRC safety concerns are better identified and acted upon (see overall recommendation 15).