IR 05000204/2003029

Insp Repts 50-315/85-07 & 50-316/85-07 on 850204-0329. Violations Noted:Failure to Provide Timely & Effective Corrective Actions Identified in Internal Staff Rept & Personnel Unaware of Procedural Requirements

ML17321A593
Person / Time
Site:	Cook, 05000204
Issue date:	04/29/1985
From:	Hawkins F, Walker H NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
To:
Shared Package
ML17321A591	List: IR 05000204/2003029 ML17321A590
References
50-315-85-07, 50-315-85-7, 50-316-85-07, 50-316-85-7, NUDOCS 8505030536
Download: ML17321A593 (18)

Text

U.S.

NUCLEAR REGULATORY COMMISSION

REGION III

Report No. 50-315/85007(DRS)

50-316/85007(DRS)

Docket No. 50-315; 50-316

,License No.

DPR-58; DPR-74 Licensee:

American Electric Power Service Corporation Indiana 5 Michigan Power Company 1 Riverside Plaza Columbus, OH 43216 Facility Name:

D.

C.

Cook Nuclear Plant, Units 1 and

Inspection At:

American Electric, Power Service'orporation, Columbus, OH, and D.

C.

Cook Site, Bridgman, MI Inspection Conducted:

February 4-7, 25-28, March '1, 4-8, 11-15 and 25-29, 1985 guality Assurance Programs Section Ins ection Summa'r Mzy Bc a

e Ins ection on Februar 4-7 25-28 March 1 4-8 11-15 and 25-29 1985 e ort o.

- 1 DR '1 Y

r 1 i P t fli act>on on previous inspection findings, gA/gC administration, audit program, offsite review committee activities, and corrective action.

The inspection involved a total of 106 inspector-hours onsite and 93 inspector-hours at the corporate headquarters.

Results:

Of the four areas inspected, no violations or deviations were identi-

~fse in one area; two violations were identified in the remaining three areas (failure to provide timely and effective corrective action - sections 4. b.(1)

(b)2, 4.b. (1)(e), 4.d. (1)(b), 4.d. (1)(d),

and 4.d. (1)(e)2; failure to follow procedures

- sections 4.b. (1)(c), 4.c. (1)(b), 4.d. (1)(a),

and 4.d. (1)(e)l)

8~OSoa0'SSS 8S04a9 I

PDR ADOCK 05000315

PD~R

DETAILS Persons Contacted American Electric Power Service Cor oration AEPSC M.

P. Alexich, Vice President Nuclear Operations P.

A. Barrett, Senior Licensing Engineer

~T.

P. Beilman, Station guality Assurance Supervisor J.

A. Bella, Manager, Design Division J.

G. Feinstein, Manager, Nuclear Safety 8 Licensing R.

F. Fering, Vice President Fossil Operations R.

M. Jurgensen, Consulting Engineer, NOD R.

F. Kroeger, Manager of guality Assurance V. A. Lepore, Assistant Manager, Design Division H.

N. Scherer, Jr.,

Seniop Vice President, Electrical Engineering, Deputy Chief Engineer D.

V. Shaller, Staff Engineer, NOD J.

R. Stroyk, Vice President Engineering Administration D.

A. Timberlake, NSDRC Staff Administrator Indiana 8 Michi an Electric Com an I88EC)

~J. Allard, Maintenance Superintendent

"K. R.,Baker, Operations Superintendent

"N. Baker, gC Departmental Assistant

"A. A. Blind, Assistant Plant Manager, Maintenance

"G.

H. Caple, ACC Supervisor

• D. Krause, Operations ACC

"M.

E. Schefers, Assistant Plant Manager

"M. G. Smith, Jr., Plant Manager

• J.

F. Steetzer, guality Control Supervisor

"B. A. Svensson, Assistant Plant Manager

"D. A. Yount, Accounting Supervisor USNRC J.

K. Heller, Resident Inspector

"B. L. Jorgensen, Senior Resident Inspector

"L. A. Reyes, Chief, Operations Branch Other personnel were, contacted as a matter of routine during the inspection.

"In'dicates those attending the exit meeting at D.

C.

Cook on March 29, 198.

Licensee Action on Previous Ins ection Findin s a.

b.

C.

d.

e.

g.

(Closed)

Unresolved Item (315/83-01-02; 316/83-01-02):

Lack of independence of auditors performing site quality assurance audits.

The plant quality assurance supervisor and the quality assurance organization, both who perform audits at D.

C.

Cook, currently report to the AEPSC quality assurance manager and are independent of the plant manager.

V (Open) Unresolved Item (315/83-01-09; 316/83-01-09):

Temporary procedure changes were issued for plant manager instructions (PMIs)

and department head instructions (DHIs) without quality assurance (gA) approval.

gA approval was required on the original issue and subsequent revisions.

Existing procedures require gA approval for temporary procedure changes and this requirement is being imple-mented; however, the inspector noted that a number of.temporary change sheets which were previously issued are still in use without gA approval.

This item will remain open pending satisfactory reso-lution of this issue.

I~

(Closed) Violation (315/83-18-01; 316/83-19-01):

Failure of the NSDRC to review'ondition reports as required by the technical speci-fications.

Review of condition reports is now being performed as required.

(Open) Violation (315/83-18-02; 316/83-19-02):

Failure of the NSDRC to review the audit program, audit reports and audit findings as required.

The inspector determined that the 1984 review of the audit program, audit reports and audit findings were adequate and timely.

However, the inspector noted that the six month audit program i eview, due in January/February 1985, had not been performed.

Results of the review were presented to the NSDRC on March 12, but the written report had not been prepared.

This item remains open pending timely performance and reporting of future gA audit program reviews.

(Closed) Violation (315/83-18-03; 316/83-19-03):

Failure of the NSDRC to review minutes of the Plant Nuclear Safety Review Committee (PNSRC).

This review is presently being conducted as required.

(Closed) Violation (315/83-18-05; 316/83-19-05):

NSDRC audits did not evaluate the effectiveness of the gA program elements which were audited.

NSDRC audits reviewed by the inspector were adequate and gA program effectiveness was addressed.

(Closed) Violation (315/83-18-06; 316/83-19-06):

NSDRC audit reports were not issued within the required 30 days.

Reports for the NSDRC audits, reviewed by the inspector, were issued within the required

days.

~

~

~

~

h.

(Closed) Violation (315/83-18-07; 316/83-19-07):

Licensee procedures did not require responses to corrective action requests (CARs) within 30 days.

The inspector reviewed AEPSC General Procedure 18. 1, Revision 1 ("AEPSC-gA Internal Audit Program" ).

This procedure requires that audited organizations respond to CARs within 30 calen-dar days of the audit report issue date.

For audit records reviewed by the inspector, responses were dated within the 30 day period.

i.

(Closed) Violation (315/83-18-08; 316/83-19-08):

Audits did not examine corporate office quality rel.ated activities.

Audits are now being conducted on AEPSC corporate quality related activities.

j.. (Closed) Violation (315/83-18-10; 316/83-19-10):

The entire NSDRC did not review the safety evaluations relative to request for change (RFC) documents.

As a result of the review of subcommittee minutes and attendance of a subcommittee meeting, the inspector noted that safety evaluation reviews are appropriate.

3.

Ins ection Methodolo This report documents the first in a series of augmented inspections to assess the SALP quality assurance functional area which was assigned a Category 3 rating during the last SALP reporting period.

This report identifies strengths and weaknesses within the quality assurance program.

Weaknesses which violate regulatory requirements are addressed within the scope of the NRC enforcement policy.

Weaknesses which 'do not violate requirements are dealt with in light of their relative significance 'and impact on the assessment's conclusions.

Upon completion, the inspection series will collectively represent a total asse'ssment of performance.

Each report will present a summary of con-clusions, and as necessary, provide a diagnosis of problem areas.

4.

Pro ram Areas Ins ected During this inspection, activities were reviewed to verify compliance with regulatory requirements and quality assurance program commitments.

Specifically, the programs and their implementation for gA/gC administra-tion, offsite review activities, audits, and corrective actions were reviewed.

Special emphasis was given to areas which had been identified during previous NRC inspections in order to verify that effective action had been taken to resolve known problems.

The inspection was performed by observing and reviewing work activities, conducting personnel interviews, and reviewing applicable procedures and records.

a.

A/ C Administration The D.

C.

Cook quality assurance program is written and controlled by the American Electric Power Service Corporation (AEPSC);

however, a

large portion of the responsibility for its implementation rests with the plant owner, Indiana and Michigan Electric Company (I8MEC).

f Beginning in,1984, significant steps were taken to, improve the D.

C.

Cook quality assurance program.

In January 1984, an indepen-dent gA organization was formed which reports to the AEPSC manager of quality assurance.

This organization provides an independent assessment of quality related plant'ctivities by performing audits and surveillances.

At the same time, a quality control organization was formed to provide independent inspection of in process work activities.

Improvements due to these changes continue to be noted as staffing and training continues.

D.

C.

Cook is presently conducting a regulatory performance improve-ment program (RPIP) which provides for a review (and upgrading as necessary)

of procedures which implement the quality program.

This action has resulted in an overall improvement of D.

C.

Cook pro-cedures.

(1)

Ins ection Results The inspector interviewed a number of key personnel and reviewed the methods used for controlling implementing procedures.

Methods for controlling the N List (safety-related list) were also reviewed.

During a review of procedural control at D.

C.

Cook, the inspector noted that the majority of recent changes to plant manager instructions (PMIs) were made using the instruction and Procedure Change Sheet rather than by revising the procedure.

Although the approvals for the two types of changes are identical, the sequence is different.

The change sheet procedure allows implementation of the change sheet prior to review by gA and the PNSRC.

The inspector was informed that the change sheets were used because priorit'ies are given to their approval.

Widespread use of the change sheet appears to be a misuse of the interim procedure change process.

This is an open item pending further review (315/85007-01; 316/85007-01).

(2)

Conclusions/Recommendations

/

Although no serious problems were noted in gA/gC administration, consideration should be given to the following recommendations to improve the administration of the gA/gC program.

(a)

Improve communications and interface between personnel and organizations having quality responsibilities for D.

C.

Cook.

Special attention should be given to commun-ication and interface between D.

C.

Cook plant organizations and offsite support organization (b)

Line supervision of organizations which perform work supporting an activity or another organization should be notified of changes in procedures or other responsibilities which affect them.

(c)

Each individual's responsibilities and duties should be clearly defined and the individual should be aware of them.

(d)

The authority of individuals to take action 'and make decisions should be clearly defined.

b.

~ACht P

The D.

C.

Cook audit program involves five specific audit systems performed by AEPSC gA or outside consultants.

Audits of D.

C.

Cook station activities are performed by the AEPSC site quality assurance organization.

Audits of AEPSC activities at the corporate offices in Columbus, Ohio, are performed by the AEPSC corporate quality assurance organization, which also performs audits of D.

C.

Cook suppliers.

Supplier audits are sometimes performed by other utilities under agreements with AEPSC.

NSDRC audits, to verify compliance with technical specification requirements, are performed jointly by representatives of the NSDRC and the corporate quality assurance organization.

In addition, an appraisal of the D.

C.

Cook station and support activities, which includes both corporate and site quality assurance, is performed by an outside consultant approxi-mately once every two years.

(1)

Ins ection Results During this review, the inspector participated as an observer in a site quality assurance audit at D.

C.

Cook and an internal audit of activities at the AEPSC offices.

Audit and gA manage-ment personnel were interviewed and audit schedules, procedures and records were reviewed for the audited areas.

The May 1984, report of the quality assurance appraisal of D.

C.

Cook and AEPSC support activities performed by LRS Consultants was also reviewed.

Specific observations made during the inspection were as follows:

(a)

While reviewing AEPSC internal audit gAVP-84-01 (conducted June 19 through July 31, 1984) of the Nuclear Material and Fuel Management section, the inspector noted that signifi-cant problems were documented, in the report.

The audit response indicated that action to correct the problems would require either the revision or preparation of 27 procedures.

This action was scheduled to be accomplished over a period of approximately. 18 months and was to be completed by December 31, 1985.

Based on the description

of the problem in the audit report, this length of time for resolution appears excessive.

Pending further review, this item is considered unresolved (315/85007-02; 316/85007-02).

(b)

The. following specifics wer e noted while reviewing site quality assurance audit records:

The five site gA audits reviewed, which were con-ducted prior to August 14, 1984, were conducted without a certified lead auditor assigned as audit team leader.

In reviewing the AEPSC procedure for site gA audits (gAP Number 19, Attachment No. 2),

the inspector noted that the procedure did not address the assignment of auditors.

The D.

C.

Cook gA Program specifies that in certain cases, individuals other than a lead auditor can conduct the actual audit func-tion.

Records indicated that prior to August 14, 1984, the majority of audits were conducted without the benefit of participation by a lead auditor.

gAP Number 19, Attachment No. 2, does not indicate who is assigned lead auditor responsibilities in these cases.

The inspector is concerned that the intent of ANSI N45. 2. 12 is not being met in this area.

Additionally, gAP Number 19, Attachment No. 2, does not clearly address either the requirements of ANSI N18.7-1976 paragraph 4.5 (independence of auditors) or the requirements of ANSI N45.2. 12 paragraph 3.5.3 (scheduling of supplemental audits).

Pending review of gAP Number 19 to verify that the requirements of ANSI N45.2. 12 and ANSI N18.7 are met, this item is unresolved (315/85007-03; 316/85007-03).

2.

gAP No.

19, Paragraph 3.5. 1.(2) of Attachment No, 2, requires that action requests (ARs) be generated for each question that resulted in a deviation or nonconformance unless either adequate corrective or preventative action was completed during the audit or the AEPSC gA Supervisor determines that corrective/

preventative actions would serve no useful purpose.

The inspector noted several instances where corrective or preventative action was necessary and an AR was not issued.

For example, the excessive backlog of condition reports (CR) was identified in Audit Report No. gA-84-16; inappropriately, an AR was not issue ~

II

~

~

(c)

(d)

(e)

This failure to ensure that conditions adverse to quality are promptly identified and corrected in accordance with approved procedures is in violation of 10 CFR 50, Appendix B, Criterion XVI (315/85007-04A; 316/85007-04A).

gAP No. 19, Paragraph 3.4.7 requires that site quality assurance audit rep'orts be issued within 30 days of the exit meeting date.

Reports for Audit Nos. 84-14, 84-16, 84-18, 84-19, 84-20, 84-21, 84-22, 84-23, 85-01 and 85-02 were not issued within the 30 days.

This failure to issue site quality assurance audit reports in accordance with procedure gAP No.

19 is in violation of

CFR 50, Appendix B, Criterion V (315/85007-05A; 316/85007-05A).

The inspector reviewed lead auditor certification files for two lead auditors assigned to plant quality assurance.

Neither of the files contained objective evidence to support some of the points and data on the evaluation form which were used for certification.

Additionally, the four-audits which were used as a basis for certification of the two lead auditors were performed without a certified lead auditor assigned to the audit.

The inspector is concerned whether the two individuals received the necessary guidance and training during the certification audits.

This item is unresolved pending a further review of the auditor certification methods and files (315/85007-06; 316/85007-06).

The inspector reviewed the plant quality assurance

"Open Item - Internal Staff" report issued on March 22, 1985.

This system is used to track due dates 'for gA followup on action requests and open items generated as a result of either audits or surveillances.

The inspector identified that fifty-four items in this report were past the scheduled due dates with due dates from September 1, 1984 through March 15,, 1985.

Additioyally, two items selected from the audit records were not listed in the report.

These failures to ensure that conditions adverse to quality are promptly corrected are in, violation of 10 CFR 50, Appendix B, Criterion XVI (315/85007-04B:

316/85007-04B).

'(2)

Conclusions/Recommendations The audit program appeared to be satisfactory in identifying quality problems.

Audit plans, checklists and verification methods were acceptable, and in most cases audits appeared to be properly conducted and thoroug Existing methods of followup and tracking were sometimes unsuccessful in obtaining timely resolution to a number of quality problems.

Findings documented as a result of audits and surveillances should be reviewed promptly after completion of corrective action.

Due dates for audit and surveillance items should be monitored more closely to ensure they are met.

Failure of audited organizations to meet due dates or provide proper action should be promptly elevated 'to higher management for resolution.

Offsite Review Committee Activities Offsite review activities for D.

C.

Cook are performed by the Nuclear Safety and Design Review Committee (NSDRC) and four sub-committees located at the AEPSC corporate offices in Columbus, Ohio.

A review of the NSDRC activities by the inspector indicated substantial involvement by AEPSC management and technical support personnel.

Four subcommittees perform most of the detailed review work and report the results to the NSDRC for either concurrence or action.

The NSDRC meets monthly with additional special meetings conducted as necessary.

Subcommittees meet as necessary to perform required activities.

(1)

Ins ection Results The inspector interviewed the chairman of the NSDRC and the chairmen of the four NSDRC subcommittees.

Each was knowledgeable of his responsibilities.

One NSDRC meeting and two subcommittee meetings were attended by the inspector.

Records of ten regularly scheduled and two special NSDRC meetings and selected subcommittee meetings minutes were reviewed.

Specific observa-tions were as follows:

(a)

During the review of the NSDRC manual, the inspector noted a number of inconsistencies between the technical specifi-cations, the NSDRC Charter, the implementing procedures, and actual practice.

Examples of these inconsistencies are as follows:

2 ~

Section 6.5.2.3 of the technical specifications states that no more than two alternates shall participate as voting members in NSDRC activities at any one time.

This requirement is neither addressed in the charter nor the implementing procedures.

Enclosure IV - j. of the NSDRC charter requires that proposed changes to the technical specifications and the operating license be prepared by the Nuclear Safety and Licensing Section, and then be presented

to the NSDRC.

Section A-4 of the charter requires that these changes be submitted to the subcommittee on proposed changes, rather than directly to the NSDRC.

3.

The Charters for the subcommittees on proposed changes and audits (Appendices A 8 C) both require the respec-tive subcommittees to perform a semi-annual review of the gA audit program.

This review is actually being performed by the subcommittee on audits.

R Based on these examples, the inspector is concerned whether consistent requirements and guidance exist to ensure proper conduct of the 'NSDRC.

Pending further review by the licensee to ensure consistency between the technical specifications, the charter, the implementing procedures, and actual practice, this matter is considered open (315/85007-07-316/85007-07).

(b)

Paragraph E-1 of the NSDRC Procedure VI ("NSDRC Records" ),

requires that two concurrent files be maintained for NSDRC records.

It further states that both files shall consist of the full inventory of NSDRC records.

The NSDRC working files are maintained by the NSDRC recording secretary and the master file is maintained at the D.

C.

Cook plant.

When reviewing this file at D.

C.

Cook, the inspector noted that 43 of the 48 regular meeting minutes were missing.

This failure to store NSDRC records in accordance with NSDRC Procedure VI is in violation of 10 CFR 50, Appendix B, Criterion V (315/85007-05B; 316/85007-05B).

(c)

Paragraph 6'.2.7.d of the technical specifications requires NSDRC approval of proposed changes to both the technical specifications and the operating license.

Paragraph 5 of Enclosure IV-1 of'he NSDRC manual permits submittal of the change to the NRC prior to its review by the NSDRC.

The inspector is concerned that this lack of prior NSDRC approval does not meet the intent of the technical speci-fication.

This is an open item pending further review (315/85007-08; 316/85007-08).

(2)

Conclusion/Recommendations Substantial improvement has been made in offsite review committee activities.

The reviews and evaluations conducted by the NSDRC and the four subcommittees appear to be accurate and thorough.

Management support and involvement also appear to be good.

Additional management attention should be given to correct procedural inconsistencies and ensure their imple-mentation.

d.

Corrective Action Four methods are used to document quality related problems for D.

C.

Cook:

condition reports are used to document discrepant conditions, procedural violations and certain other items for tracking purposes; nonconformance reports are used to document discrepant conditions and procedural violations at the AEPSC corporate offices in Columbus, Ohio; corrective action requests and action requests are used by AEPSC gA to document findings noted during gA audits and surveillances.

(1)

Ins ection Results The inspector interviewed a number of key personnel associated with the corrective action program and reviewed methods used for control of condition reports, corrective action requests, and action requests, as well as the systems used for tracking, follow-up and close-out of these documents.

Specific items, both open and closed, were reviewed to verify timely processing and appropriate remedial, investigative and preventative action.

The following observations were made during the inspection; (a)

Plant Manager Instruction No.

PMI-7030 provides time limits that should be met in the investigation and pro-cessing of condition reports (CRs).

The procedure also requires that a request for extension of time be submitted to quality control if required action on the CR cannot be completed within the specified time.

In these cases, a

copy of the CR is required to be submitted which specifies the estimated completion date and the reason the extension is necessary.

The inspector identified a February 28, 1985, memorandum which requested the extension of completion dates for 96 CRs.

The memorandum provided neither a copy of the CR which specified the estimated completion date nor the reason the extension was necessary.

These failures to process CRs in accordance with Procedure PMI-7030, are in violation of 10 CFR 50, Appendix B, Criterion V (315/85007-05C; 316/85007-05C).

(b)

The inspector noted that as of February 28, 1985, 2131 CR's were open.

These open CRs dated back several years and the large backlog appeared to be impacting their timely review by the PNSRC and NSDRC.

For example, CR 12-12-83-1342 was submitted to the PNSRC for review on February 14, 1984; PNSRC review had not been completed as of March 29, 1985.

As of February 28, 1985, the PNSRC

had a backlog of 1213 open CRs for review.

In another example, during the February 21, 1985, meeting of the NSDRC subcommittee on corporate and plant occurrences, problems were noted with the action taken to resolve CR 1-'10-82-676.

This CR was sent back for additional action more than two years after it was written in October 1982.'

The number of open CRs increased from 979 in July 1984, (as documented in gA audit report gA-84-16) to the 2131 total open at the end of February 1985.

During the inspection, the inspector not'ed that the number of open CRs was increasing at more than 100 a month.

In reviewing audit reports, the inspector noted that the untimely review of CRs had been documented by the licensee

'in audit NSDRC-95 (December 1983), audit NSDRC"105 (April 1984),

LRC Consultants appraisal of D.

C.

Cook and AEPSC support activities (May 1984),

and audit gA-84-16 (July 1984).

At the time of this inspection, the licensee had not taken appropriate corrective actions to resolve the identified deficiencies.

These fai lures to ensure that deficiencies identified as a result of audits are promptly corrected are in violation of 10 CFR 50, Appendix B, Criterion XVI (315/85007-04C; 316/85007-04C).

Two similar violations were identified by Region III in August and October 1984 (315/84-16-02A; 316/84-18-02A and 315/84-16-02B; 316/84-18-02B).

(c)

During the review of CRs, the inspector identified two concerns regarding their disposition.

Condition Report No. 12-12-83-1342 was written on January 19, 1984, and concerned the installation of incorrect check valves in the diesel generator fuel oi'l transfer:-system for Unit 1.

This CR was submitted to the PNSRC for review on February 14, 1984, after required actions, as determined by responsible organ-izations, had been completed.

Records on this CR contain the following statement'under Preventative A II Pk:

"A 't Eg I t~p d

gttt by tb Agygt g I t

gt According to the results of the evaluation, the heavier valves were acceptable.

....

The valves received have been installed.

No further action.is planned.

This item is closed."

This disposition does not address action to prevent recurrence of the problem.

As of March 29, 1985, the CR had not been reviewed by the PNSRC.

2.

On April 6, 1984, another CR (No. 2-04-84-493)

was written on a similar occurrence when the wrong type check valves were installed.

These valves were in-correctly installed in the RCP seal leak-off lines.

The valves were changed to the proper type and the CR was closed on August 1, 1984, after review by the PNSRC.

The following statement was included under Preventative Action Taken:

"Somewhere in the RFC request or c ange pac age, it should be identified that a special type of check valve, Y200C58, is required.

It is imperative that information of this, nature be placed on the ISO [isometric drawingj.

Apparently the only place this information showed up was on the P.O.

[purchase orderj which I did not rec'ei ve. "

In their review of this CR on November 29, 1984, the NSDRC subcommittee on Corporate and Plant Occurrences noted that additional corrective action was required.

This is a open item pending additional review to ensure that action to prevent recurrence is taken as necessary (315/85007-09; 316/85007-09).

(d)

The AEPSC action item tracking (AIT) system is used to track items pertaining to D.

C.

Cook.

This system includes commitments made as the result of NRC inspection reports, IE bulletins, IE information notices, QA audits, QA sur-veillances, and licensee event reports.

QA audit findings (CARs) are closed when response commitments are entered in the AIT, system.

A bi-weekly report of overdue action items and a monthly report, of open action items are sent to the action assig-nees.

A review of the overdue action items report dated March 14,'985, 'listed 112 past-.due items.

Of these 112

'verdue items, 5 were assigned to the D.C.

Cook plant for action.

The othe)

107 were assigned to AEPSC support organizations.

Thirty-eight of these items were more than 3 months overdue, with 19 of them more than 6 months overdue and 10 of them overdue for more than a year.

Because of the importance of the items included in the AIT system, it is imperative that appropriate corrective actions are taken on items as they become due.

These failures to ensure that conditions adverse to quality are promptly corrected are in violation of

CFR 50, Appendix B, Criterion XVI (315/85007-04D; 316/85007"04D).

(e)

The inspector reviewed trending programs for D.

C.

Cook and the AEPSC corporate offices.

The following specifics

, were noted during this review:

1.

Trending activities being performed in accordance with Procedure PMP-7030 RPT.003 ("Review and Trending of Condition Reports by Shift Technical Advisors"), were reviewed.

This procedure requires that a yearly analysis of CRs be performed and that a yearly report on this analysis be prepared and issued.

The analysis is performed using closed CRs.

The analysis and report for 1982 were reviewed.

No analysis or reports for 1983 and 1984 had been prepared or were in progress.

The inspector was informed that the number of CRs presently being issued prohibited the analysis and the preparation of this report.

This failure to issue the annual repor't on trending and evaluation of CRs as required by Procedure PMP-7030 RPT. 003 is in violation of 10 CFR 50, Appendix B, Criterion V (315/85007-05D; 316/85007-05D).

2.

The inspector also reviewed other trending activities.

The trending of operating parameters is being per-formed by the shift technical advisors.

Also, the NSDRC subcommittee on corporate and plant occurrences prepares graphs of the total numbers of condition

'eports, licensee event reports and personnel error reports.

Upon requests, plant quality control wi 11 perform a search of condition reports for specific types of repetitive occurrences.

None of these activities provide trending by cause, type of failure, manufacturer, or system affected as is necessary to comply with paragraph 4. 1.(4) of ANSI N18.7-1976.

These failures to provide a trending program that will promptly identify repetitive conditions adverse to quality so that the cause can be determined and appropriate action taken is in violation of 10 CFR 50, Appendix B, Criterion XVI (315/85007-04E; 316/85007-04E).

(2)

Conclusions/Recommendations There is a need for improvement in the D.

C.

Cook corrective action program.

Consideration should be given to the following recommendations to improve the corrective action system.

(a)

The responsibility and authority of each person involved in the documentation, followup and resolution of quality problems should be clearly defined.

This is especia11y applicable where both plant and offsite support per-sonnel are involved.

(b)

Communication and interfaces between 'organizations should be carefully reviewed.

'This is especially applicable where both plant and offsite support personnel are involved.

(c)

Management should establish appropriate priorities for followup and action on 'identified quality problems.

(d)

Management should provide a sorting of CRs in order to

, route to both the onsite and offsite review committees only those CRs 'which document discrepancies and procedural violations having nuclear safety significance.

(e)

Personnel should be held accountable for overdue action items.

(f)

Methods for elevating overdue items to appropriate manage-ment should be developed and communicated to personnel.

(g)

A system should be established to require justification if a due date is not met or is extended for all items which require corrective action.

5.

Unresolved Items Unresolved items are matters about which more information is required in order to ascertain whether they are acceptable items, items of noncompli-ance or deviations.

Unresolved items disclosed during the inspection are discussed in Paragraphs 4.b. (1)(a), 4.b. (1)(b)l)

and 4.b. (1)(d).

6.

0 en Items Open items are matters which have been discussed with the licensee, which will be reviewed further by the inspector, and which involve some action on the part of the NRC or licensee or both.

Open items disclosed during the inspection are discussed in Paragraphs 4.a. (1), 4.c. (1)(a), 4.c. (1)(c),

and 4.d. (1)(c).

7.

~E*i M

The inspector met with licensee representatives-'(denoted in Paragraph 1)

at D.

C.

Cook on March 29, 1985, and summarized the purpose, scope and findings of the inspection.

The inspect'or discussed the likely informa-tional content of the inspection report with regard to documents or processes reviewed by the inspector during the inspection.

The licensee did not identify any such documents/processes as proprietary.

~

~

V<

V V

I It V

I'